Plasma-reduction for Apheresis Granulocyte transfusions in pediatric patients.

Granulocyte transfusion (GT) may be used to treat and prevent infections in patients with severe neutropenia or nonfunctioning granulocytes. For pediatric patients, the volume of granulocyte unit transfused is a crucial consideration given smaller blood volume and increased risk of volume overload compared to adults. There is limited literature on the optimal dosing or the maximum amount of granulocytes that can be tolerated, especially in pediatric patients. Additionally, no consensus exists regarding granulocyte collection method, frequency, or timing of GT initiation. Previous studies have described splitting or limiting collection volume for GT in pediatric patients, but these methods yield lower absolute neutrophil count (ANC) increment. Our blood supplier provides high-volume (0.5-1 L/unit), high-dose apheresis-collected granulocytes from donors stimulated with both granulocyte colony-stimulating factor and steroids. Here, we report cases of two pediatric patients with active infection undergoing bone marrow transplant with dramatic ANC increments (median one-hour ANC increment 5524/µL, interquartile range (IQR) 4417-10087; median 24-hour ANC increment 3880/µL, IQR 2550-5263) after infusing 100 mL plasma-reduced, apheresis collected GT. Our cases indicate that pediatric patients can tolerate 4-6 × 109/kg plasma-reduced GT and have detectable ANC with GT every 3 days.

Critical conversations on patient blood management with clinical colleagues.

Although a subspecialty-trained transfusion medicine (TM) physician brings value to the clinical bedside, hospital transfusion service oversight often falls under the responsibility of pathologists primarily focused on surgical pathology. Yet, pathologists who lack TM fellowship training may not be quite as confident in their role as the TM physician in-charge, especially when the need to communicate with another clinician arises. Given that blood is a resource subject to frequent shortages, there is a need for constant monitoring of blood utilization such that those responsible for transfusion service oversight need to handle challenging clinical interactions when transfusion guidelines are breeched. Generally, the average pathologist is more knowledgeable regarding blood component therapy than other clinician. Yet, disagreements concerning patient transfusion management can arise, in spite of established evidence-based hospital transfusion guidelines. Since authoritative fact stating is not likely to be effective in changing the entrenched practices, pathologists must engage in strategies that will develop meaningful working relationships with their clinical colleagues. Such strategies include being a visible part of direct patient care, such as attendance at patient rounds or provision of mini-consultations by phone regarding transfusion management. Inviting clinicians to attend the hospital transfusion committee meetings and scheduling educational grand rounds are also useful strategies. Clinicians may be more receptive to blood conservation during times of shortages if open communication is established, particularly if hospital leadership is involved in urgent crisis messaging to the clinicians and other hospital staff involved in patient care.

Prepare to adapt: blood supply and transfusion support during the first 2 weeks of the 2019 novel coronavirus (COVID-19) pandemic affecting Washington State.

BACKGROUND: The first coronavirus (COVID-19) case was reported in United States in the state of Washington, approximately 3 months after the outbreak in Wuhan, China. Three weeks later, the US federal government declared the pandemic a national emergency. The number of confirmed COVID-19 positive cases increased rather rapidly and changed routine daily activities of the community. STUDY DESIGN AND METHODS: This brief report describes the response from the hospital, the regional blood center, and the hospital-based transfusion services to the events that took place in the community during the initial phases of the pandemic. RESULTS: In Washington State, the first week of March started with four confirmed cases and ended with 150; by the end of the second week of March there were more than 700 cases of confirmed COVID-19. During the first week, blood donations dropped significantly. Blood units provided from blood centers of nonaffected areas of the country helped keep inventory stable and allow for routine hospital operations. The hospital-based transfusion service began prospective triaging of blood orders to monitor and prioritize blood usage. In the second week, blood donations recovered, and the hospital postponed elective procedures to ensure staff and personal protective equipment were appropriate for the care of critical patients. CONCLUSION: As community activities are disrupted and hospital activities switch from routine operations to pandemic focused and urgent care oriented, the blood supply and usage requires a number of transformations.

Appropriateness of Plasma Transfusion: A College of American Pathologists Q-Probes Study of Guidelines, Waste, and Serious Adverse Events.

CONTEXT: - Plasma transfusion guidelines support patient care and safety, management of product wastage, and compliance; yet, there is little information across multiple institutions about use of and adherence to plasma transfusion guidelines. OBJECTIVE: - To survey multiple institutions regarding their plasma transfusion guidelines and compliance, plasma wastage rates, and incidence of transfusion reactions associated with plasma transfusion. DESIGN: - The College of American Pathologists Q-Probes model was used to collect data from 89 participating institutions. Each site was asked to provide data relevant to its most recent 40 adult patient plasma transfusion episodes, and complete a questionnaire regarding plasma transfusion guidelines, utilization and wastage of plasma, and transfusion reactions related to plasma transfusion. RESULTS: - The participating institutions reported a total of 3383 evaluable plasma transfusion episodes with transfusion of 9060 units of plasma. Compliance with institution-specific guidelines was seen in 3018 events (89%). Pretransfusion and posttransfusion coagulation testing was done in 3281 (97%) and 3043 (90%) of these episodes, respectively. Inappropriate criteria were noted for more than 100 transfusion episodes. Thirty-two plasma transfusion episodes (1%) were associated with a transfusion reaction. Serious and fatal reactions were reported. Median plasma wastage rate for the year preceding the study was 4.5%. CONCLUSIONS: - Most participating institutions are compliant with plasma transfusion guidelines based on published references, supported by appropriate testing. With transfusions for indications that lack evidence of efficacy and incidence of transfusion reactions, there is an ongoing role for transfusion service leaders to continue to update and monitor plasma transfusion practices.

Blood Bank Specimen Mislabeling: A College of American Pathologists Q-Probes Study of 41 333 Blood Bank Specimens in 30 Institutions.

CONTEXT: -Incorrectly labeled patient blood specimens create opportunities for laboratory testing personnel to mistake one patient's specimen for a specimen from a different patient. Transfusion of blood that is typed on specimens that are mislabeled can result in acute hemolytic transfusion reactions. OBJECTIVE: -To assess the rates of blood bank ABO typing specimens that are mislabeled and/or contain blood belonging to another patient (so-called wrong blood in tube [WBIT]), and to compare these rates with those determined in a similar study performed in 2007. DESIGN: -Participants enrolled in this College of American Pathologists Q-Probes study for the first quarter of 2015 tallied the number of mislabeled and WBIT ABO blood typing specimens. Outcome measurements were the number of mislabeled and WBIT instances per 1000 specimens. We also evaluated the effects of various practice characteristics, in particular the use of bar coding, on the outcome measurements. RESULTS: -A total of 30 institutions submitting data on 41 333 ABO blood typing specimens recorded aggregate rates of 7.4 instances of mislabeling (306 specimens) and 0.43 instances of WBIT (10 of 23 234) per 1000 specimens submitted. Mislabeling rates were lower in institutions requiring that specimens be labeled with patients' birth dates than those that did not. The rates of specimen mislabeling and WBIT were otherwise unassociated with any of the other practice variables evaluated. CONCLUSIONS: -The rates of ABO blood typing specimen mislabeling and WBIT are not statistically different from those determined in a similar study performed in 2007 (P = .94 and P = .10). The use of bar coding was not associated with lower mislabeling (P = .80) or WBIT rates (P = .79).

Post-transfusion purpura in an African-American man due to human platelet antigen-5b alloantibody: a case report.

INTRODUCTION: Post-transfusion purpura is a rare immunohematological disorder characterized by severe thrombocytopenia following transfusion of blood components and induced by an alloantibody against a donor platelet antigen. It occurs primarily in women sensitized by pregnancy and is most commonly caused by anti-human platelet antigen-1a antibodies. Here, we describe what we believe to be the first documented case of an African-American man who developed post-transfusion purpura due to an anti-human platelet antigen-5b alloantibody after receiving multiple blood products. CASE PRESENTATION: A 68-year-old African-American man initially admitted with atrial flutter was started on anticoagulation treatment, which was complicated by severe hematemesis. On days 4 and 5 of hospitalization, he received six units of packed red blood cells, and on days 4, 13 and 14 he received plasma. His platelet count began to drop on day 25 and on day 32 reached a nadir of 7 × 109/L. His platelet count increased after receiving intravenous immune globulin. An antibody with reactivity to human platelet antigen-5b was detected by a solid-phase enzyme-linked immunoassay. Our patient was homozygous for human platelet antigen-5a. CONCLUSION: This case emphasizes the importance of including post-transfusion purpura in the differential diagnosis for both men and women with acute onset of thrombocytopenia following transfusion of blood products. The prompt recognition of this entity is crucial for initiation of the appropriate management.

Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study).

Red blood cell transfusion is common in patients with acute myocardial infarction (AMI). However, observational data suggest that this practice may be associated with worse clinical outcomes and data from clinical trials are lacking in this population. We conducted a prospective multicenter randomized pilot trial in which 45 patients with AMI and a hematocrit level ≤30% were randomized to a liberal (transfuse when hematocrit <30% to maintain 30% to 33%) or a conservative (transfuse when hematocrit <24% to maintain 24% to 27%) transfusion strategy. Baseline hematocrit was similar in those in the liberal and conservative arms (26.9% vs 27.5%, p = 0.4). Average daily hematocrits were 30.6% in the liberal arm and 27.9% in the conservative arm, a difference of 2.7% (p <0.001). More patients in the liberal arm than in the conservative arm were transfused (100% vs 54%, p <0.001) and the average number of units transfused per patient tended to be higher in the liberal arm than in the conservative arm (2.5 vs 1.6, p = 0.07). The primary clinical safety measurement of in-hospital death, recurrent MI, or new or worsening congestive heart failure occurred in 8 patients in the liberal arm and 3 in the conservative arm (38% vs 13%, p = 0.046). In conclusion, compared to a conservative transfusion strategy, treating anemic patients with AMI according to a liberal transfusion strategy results in more patients receiving transfusions and higher hematocrit levels. However, this may be associated with worse clinical outcomes. A large-scale definitive trial addressing this issue is urgently required.

Recombinant activated factor VII (rFVIIa) as salvage treatment for intractable hemorrhage.

BACKGROUND: Recently, there has been an increased use of recombinant activated factor VII (rFVIIa) to promote hemostasis in various hemorrhagic conditions. The objective of this study was to determine the outcome of patients treated with rFVIIa who had intractable bleeding associated with cardiac surgery (CSP) or as a result of other causes (OBP). METHODS: The medical records of 40 consecutive patients treated with rFVIIa were retrospectively reviewed for blood product use before and after treatment. In all patients, rFVIIa was given only after all other measures to stop bleeding had failed. The number of transfused units of red cells (R), platelets (P), fresh frozen plasma (F), and cryoprecipitate (C) were determined both before and after administration of rFVIIa, and the results compared. Mortality at 4 hours and 30 days was assessed. Patients dying within 4 hours of rFVIIa administration were not evaluable for response. Patient characteristics were also assessed as risk factors for mortality. RESULTS: Twelve of 24 CSP survived for more than 4 hours. These 12 patients required an average of 17 units (U) of R, 18 U of P, 18 U of F and 15 U of C pre-treatment compared to an average of 6 U, 10 U, 9 U and 4 U of R, P, F and C respectively, post-treatment. These differences were statistically significant. For the OBP, 11 of 16 survived more than four hours. These 11 patients required an average of 10 U of R, 11 U of P, 14 U of F and 10 U of C pretreatment compared to an average of 1 U, 2 U, 2 U and 0 U of R, P, F, and C respectively, post-treatment. With the exception of C, there was a statistically significant decrease in blood product use following treatment with rFVIIa. Of the survivors in each group, 6 of 12 CSP and 2 of 11 OBP died between 3 and 30 days post-treatment from causes other than bleeding. Mortality at 30 days for CSP and OBP survivors was 50% and 18% respectively, whereas overall 30 day mortality was 75% for CSP and 44% for OBP. CONCLUSIONS: rFVIIa is effective in decreasing blood product use and promoting hemostasis in patients with intractable bleeding associated with cardiac surgery and a variety of other causes.

Malignant transformation of "benign" cystic mesothelioma of the peritoneum.

BACKGROUND AND OBJECTIVES: Peritoneal mesothelioma is being diagnosed with greater accuracy as a result of immunocytochemical analysis. The histological type of peritoneal mesothelioma has a great influence on the natural history of the disease. Benign cystic mesothelioma is a definite clinical entity; however, the absence of a uniform approach to treatment and a lack of long-term follow-up of patients seriously hinders an accurate assessment of the disease process. METHODS: The medical history of a patient with a diagnosis of benign peritoneal cystic mesothelioma followed for 10 years is presented. The medical literature of this disease is reviewed. RESULTS: The patient was a 36-year-old woman initially diagnosed with benign cystic peritoneal mesothelioma; however, after six surgical procedures with the aim of reducing the volume of intraperitoneal fluid and cysts, the disease developed into an aggressive, diffuse malignant mesothelioma. Involvement of abdominal incisions, invasion of lymph nodes, and invasion of the viscera occurred. CONCLUSIONS: Peritoneal cystic mesothelioma is a disease in need of careful longitudinal studies in order to better define the clinical course of these patients. This case report along with a literature review suggests caution in the assessment of cystic mesothelioma as a benign process. This patient had a clear malignant transformation of benign cystic mesothelioma to an invasive and potentially lethal process.