Immediate adverse reactions to platelet transfusions: whole blood derived versus apheresis platelets.

The transfusion of whole blood derived platelets (WBDPs) or apheresis platelets (APs) is standard support for cancer patients. However, disputes remain about which type of platelets are ideal in terms of efficacy, cost, and the risk of adverse reactions. This cross sectional study included 141 cancer patients who underwent chemotherapy or hematopoietic progenitor cell transplantation and received platelet transfusions at The University of Texas M.D. Anderson Cancer Center between 2002 and 2003 were retrospectively evaluated. A total of 141 patients who did not differ significantly in terms of age or sex had a reaction to transfusions (WBDPs, n=123; APs, n=18), for a frequency of 0.66% in patients who received WBDPs and 0.45% in patients who received APs, but this difference was not statistically significant (p=0.13). More WBDP-related reactions occurred in patients transfused with older platelets (>2 days old) than in patients transfused with fresh platelets, but the difference compared with AP-associated reactions was not statistically significant. However, the rate of reactions to WBDP may increase if WBDPs are stored for a prolonged time (>2 days). Until evidence becomes available that clearly refutes this; the more fresh platelets as possible may be used.

The ethics of blood management.

Blood transfusion practices have evolved empirically, with few or no research data supporting them. In the past several decades, fuelled by fears of infection and reports of mistakes, patients have increasingly demanded their rights to choice, both in the components given to them as well as to refuse to receive these therapies based on religious convictions. In parallel, episodic blood unavailability and growing awareness of the need to apply evidence-based methods have caused physicians to begin re-evaluating traditional practices and to focus on minimizing or eliminating unnecessary transfusions while learning and applying methods that permit reuse of the patient's autologous blood or rely on pharmacologic agents. Ethical principles of autonomy, beneficence, non-maleficence and justice provide a rational basis for decision-making when a new blood management programme is instituted. By proactively considering the ethical dilemmas posed by the juxtaposition of patient needs with clinical judgement at the outset, institutions may devise workable programmes that improve patient safety and quality outcomes.

Transfusion errors: scope of the problem, consequences, and solutions.

For more than 25 years, ABO transfusion errors in the United States have caused more noninfectious transfusion deaths each year than any other cause. The US ABO error rate is between 1:12,000 and 1:19,000, with a fatality rate between 1:800,000 and 1:1.3 million. In the past 15 years, international research has increased to determine the frequency and nature of the slips and mistakes that result in transfusion errors and possible solutions to reduce them. Solutions include changes in human processes, introducing technologic improvements, and involving professional societies to create national or international performance standards to serve as benchmarks for comparison.

Pretransfusion compatibility testing for red blood cell administration.

The purpose of pretransfusion compatibility testing is to prevent incompatible red blood cell transfusions that could lead to immune mediated hemolytic transfusion reactions. Some hemolytic transfusion reactions may have serious sequelae including hemoglobinemia, disseminated intravascular coagulation, renal failure, and death. This article reviews the most comprehensive recent analyses of the laboratory methods used during pretransfusion compatibility testing in the United States. Most of the laboratory practice data have been published in the College of American Pathologists Transfusion Medicine Survey Sets and in a national survey called the Pre-Transfusion Testing Survey. This article couples and trends the data of these comprehensive surveys with an assessment of the literature to present the current practice of pretransfusion compatibility testing.

The changing relationships in transfusion medicine.

Maintaining quality in provision of transfusion services in the face of mergers, acquisitions, affiliations, and risk-sharing relationships between organizations that formerly conducted business in a traditional vendor-purchaser model is the ultimate challenge. Publications, both lay and professional, highlight the speed and nature of the impetus for change, especially in the United States, where managed care philosophies are driving a bottom-line mentality. Blood collection and transfusion organizations are developing new relationships, including entry of for-profit entities into a formerly virtually exclusively not-for-profit environment, provision of transfusion services by formerly exclusive blood collection entities and vice versa, outsourcing of selected portions, and other innovative relationships, with significantly more competitive marketing strategies. Measures of quality of transfusion services should benchmark current practices, if possible, before entering into new relationships to ensure that the quality of patient care remains high. Concerns about the fiscal viability of organizations should not minimize safety and availability of blood for transfusion when needed.

Interactions between science, government and media on selection and testing of donors.

The international media attention to "bad blood" has fueled governmental action in countries around the world. Donor selection criteria continue to expand, focusing most recently on the possibility of exclusion due to intranasal cocaine use and, in the US, due to incarceration for more than 72 hours. As newer methods of testing evolve, more deferrals will occur due to improved testing. An emerging area of concern is the non-standardized notification of donors who are ineligible to donate and lack of a centralized listing of such deferred donors. Because of the consequences to recipients, improvements in both donor questioning and testing are necessary. Further studies are needed to understand and improve these processes.

Monitoring heparin therapy: APTT results from partial- vs full-draw tubes.

Results of the activated partial thromboplastin time (APTT) test can be influenced by biologic, preanalytic, and analytic variables. When a patient is being treated with unfractionated heparin, the correct interpretation of the APTT test result is essential. Laboratories should evaluate all variables influencing this result, particularly when determining the "therapeutic" range for heparin treatment. This study compared the APTT results assayed on specimens drawn into 2 different types of evacuated blood collection tubes. A statistically significant difference was seen in the results when the APTT was outside the reference interval, including results in the therapeutic range for unfractionated heparin. When the therapeutic range is determined by the laboratory, the evacuated blood collection tube system must be standardized.

Practical issues in informed consent for transfusion.

Because patients are knowledgeable and have concerns about the risks of proposed therapies, including transfusion, and are interested in possible alternatives, they are becoming more involved in their own health care. Legal decisions support the patient's interest. Since 1996, the Joint Commission on Accreditation of Healthcare Organizations has specifically required that institutions document informed consent for transfusion. These regulations emphasize the need to establish a practical approach to achieving this process so that physicians and institutions appropriately inform patients and adequately document the patient's choice.

Current good manufacturing practices for transfusion medicine.

Transfusion medicine is most tightly controlled in the US by CGMPs that are written as regulations, guidances, and quality management documents. Because the US regulatory scheme requires that each unit of human blood donated for transfusion (and other purposes) be documented from the moment of donor registration until the last component of that donation is finally disposed of, there is precious little that remains solely within the discretion of the treating physician who orders transfusions for her or his patients. An additional complication for transfusion medicine specialists is that the search for the requirements must extend to all possible areas of information, including the possibly unexpected source within the private sector.

Existing problems in the testing for infectious diseases.

Current methods for testing donated blood for presence of infectious viral agents in the USA differ from those used in other countries because of the USA Food and Drug Administration's (FDA) control which inhibits rapid introduction of testing methods or improvements. Delays in FDA approval may occur because of concerns about methodology or the state of knowledge about the disease it is intended to detect as well as due to variability between manufacturers. Despite strict FDA control, testing problems continue to occur in the USA. No approved method detects infectious agents during the "window period," and variations in detection, i.e., false positives and false negatives (even with confirmatory testing), continue to occur. The effect of physical and chemical changes (e.g., various anticoagulants) on samples has not been thoroughly evaluated. Test performance problems include lapses in sample identification, failure to use routine laboratory controls, improper calculation and reporting of results, improper acceptance of test runs and failure to properly detect and retest samples when carryover from very reactive samples occurs. For these reasons, transfusion-related disease transmission continues to occur. The current USA emphasis on good manufacturing practices should provide continuous improvements.

Bacteria in blood for transfusion. A review.

OBJECTIVE: To summarize reports of bacterial contamination of blood components for transfusion during this century, considering implicated microorganisms and patient outcomes, with identification and discussion of recommended methods to reduce or eliminate this problem. DATA SOURCES: Articles published in the English-language literature from which summary tables of all reported bacterial infections were prepared by collating published case reports, including fatalities, emphasizing recent concerns about Yersinia contamination. STUDY SELECTION: All case reports and related review articles relevant to issues about bacteria implicated in transfusion-associated sepsis were included. DATA EXTRACTION: The author personally extracted all data. DATA SYNTHESIS: With the exception of Yersinia species and Campylobacter jejuni in red blood cells and Salmonella heidelburg in platelets, the majority of bacteria implicated continue to be those found in the environment and as normal skin flora. Existing measures to identify contaminated components before transfusing them are inadequate. Manufacturing efforts to sterilize these components by various methods may result in greater benefit than those directed toward preventing contamination during collections. CONCLUSIONS: Bacterial contamination remains a problem for transfusion medicine. Active research should continue to focus on elimination of contaminants by filtration, chemical additives, or irradiation, as well as innovative measures to detect and exclude infected units from transfusion.