James Burner

Prospective monitoring of plasma and platelet transfusions in a large teaching hospital results in significant cost reduction

BACKGROUND: Plasma and platelets (PLTs) are often transfused to correct mild to moderately abnormal laboratory values. Our objective was to reduce unnecessary plasma and PLT transfusions to nonbleeding patients by prospective triage and education of end users in evidence‐based hemostasis and transfusion medicine practices.

Higher optical density of an antigen assay predicts thrombosis in patients with heparin-induced thrombocytopenia.

Objectives:  To correlate optical density and percent inhibition of a two‐step heparin‐induced thrombocytopenia (HIT) antigen assay with thrombosis; the assay utilizes reaction inhibition characteristics of a high heparin concentration.

Whole Blood in the Management of Hypovolemia Due to Obstetric Hemorrhage

OBJECTIVE: To study the use of blood products including whole blood, for the management of obstetric hemorrhage requiring transfusion. METHODS: This was a population-based, observational study of all women receiving blood for hypovolemia because of hemorrhage at the Parkland obstetrics service between March 24, 2002, and June 12, 2006. Hypovolemia was diagnosed in women who sustained hemorrhages sufficient enough to provoke hemodynamic instability. RESULTS: A total of 66,369 women gave birth during the study period, and 1,540 (2.3%) received a blood transfusion. Six hundred fifty-nine (43%) received only whole blood, 593 (39%) received only packed red blood cells, and 288 (19%) received combinations of blood products, including thawed plasma, platelets, and cryoprecipitate. The number of units transfused was similar in the whole blood and packed red blood cell groups (mean 2 units) and higher in the combination group (mean 5.5 units). Complications attributable to hypovolemia were similar in frequency in the whole blood and packed red blood cells groups, including intensive care unit admission (1%), hypofibrinogenemia (0.3%), and adult respiratory syndrome (0.5% compared with .3%). Acute tubular necrosis was more common in the packed red blood cell group (2% compared with 0.3%, P<.001). All of these outcomes were increased in the combination transfusion group. There were three maternal deaths in the cohort, two in the combination group and one in the packed red blood cells group. CONCLUSION: The risk of acute tubular necrosis is significantly reduced in women receiving whole blood transfusion for hypovolemia due to obstetric hemorrhage. LEVEL OF EVIDENCE: III

Advantages of isovolemic hemodilution‐red cell exchange therapy to prevent recurrent stroke in sickle cell anemia patients

Chronic simple hypertransfusion (every 3 to 4 weeks) effectively prevents secondary stroke in children with sickle cell anemia but leads to iron overload despite chelation therapy. Conventional red blood cell exchange (C‐RBCx) has advantages over simple transfusion: no net iron gain and less frequent hospital visits. However, C‐RBCx requires more red blood cell units, an apheresis instrument and skilled personnel; it is also more expensive. We developed a modified procedure where isovolemic hemodilution precedes RBCx (IHD‐RBCx) to decrease RBC units required and to increase the interval between procedures. Twenty patients underwent IHD‐RBCx over a period of 7 years. IHD‐RBCx required 11% fewer RBC units and increased inter‐procedure interval from 37 to 53 days compared to C‐RBCx. The median number of annual procedures decreased from 9.8 to 7.0 per patient, resulting in estimated savings of more than

Thromboembolic outcomes after use of a four-factor prothrombin complex concentrate for vitamin K antagonist reversal in a real-world setting.

4.5 million over 10 years for 20 patients while providing improved care. Five patients have discontinued chelation therapy; three while on C‐RBCx and two while on IHD‐RBCx. No adverse events occurred related to the isovolemic hemodilution phase and no patients had recurrent stroke. IHD‐RBCx is a safe, efficient, and cost effective therapy for secondary prevention of stroke in patients with sickle cell anemia. J. Clin. Apheresis, 2011.

The HI‐STAR study: resource utilization and costs associated with serologic testing for antibody‐positive patients at four United States medical centers

A four‐factor prothrombin complex concentrate (4F‐PCC) was recently licensed in the United States for urgent vitamin K antagonist (VKA) reversal based on two randomized clinical trials. These studies excluded patients at high risk of thrombosis; therefore, the risk of thrombotic complications in unselected patients remains a concern.

Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach.

Little is known about how the resource utilization and costs of serologic work ups for positive antibody screens vary across subpopulations based on diagnosis, transfusion history, and serologic testing history.

Plasma exchange for the management of refractory pruritus of cholestasis: A report of three cases and review of literature

OBJECTIVES Acute hypertriglyceridemia induced pancreatitis (HTP) presents with a more severe clinical course compared to other etiologies of pancreatitis. Therapeutic plasma exchange (TPE) is a potential treatment option for lowering plasma triglycerides and possibly decreasing morbidity and mortality. However, clinical data regarding its effectiveness are limited. METHODS We retrospectively examined the clinical data and outcomes of 13 consecutive episodes of HTP in which TPE was employed to reduce plasma triglycerides during a 15-month period. RESULTS The TPE was initiated at a median of 19 hours from the time of presentation. We performed 1.2-1.5 volume TPEs with 5% albumin as the replacement fluid. After only one TPE procedure, the mean plasma triglycerides values decreased from 2993 mg/dl to 487 mg/dl with a reduction of 84%. All 13 patients survived with a mean length of hospital stay of 9.5 days. There were no complications related to TPE. CONCLUSIONS One TPE procedure is an effective method for reducing plasma triglycerides and possibly decreases the length of hospital stay in patients admitted with HTP.

Rinseback during red blood cell exchange with COBE Spectra does not affect fraction of cells remaining or post‐exchange hematocrit

Intractable pruritus of cholestasis leads to significant morbidity. Therapeutic plasma exchange (TPE) has been shown to be an effective alternative in the setting of refractory pruritus associated with cholestatic liver disease based on several individual reports. Due to rarity of this approach to intractable pruritus, the literature is sparse and therefore TPE, as a treatment for refractory pruritus is currently not in the apheresis guidelines. We present three additional patients with severe intractable pruritus of cholestasis successfully treated with plasma exchange to add to the mounting literature showing this as an effective and safe adjunctive therapy.

Comparison of a rapid platelet function assay--Verify Now Aspirin--with whole blood impedance aggregometry for the detection of aspirin resistance.

CaridianBCT currently does not recommend rinseback with its COBE Spectra cell separator during red blood cell (RBC) exchange procedure, as the machines software does not take into account the “rinseback” when calculating the fraction of cells remaining (FCR, and therefore target hemoglobin S (HbS) value) and postexchange hematocrit (Hct). To our knowledge, no study has investigated the effect of rinseback on these laboratory values. Therefore, we performed pre‐ and postrinseback evaluations of FCR and Hct in 22 consecutive combined Isovolemic Hemodilution/Red blood cell (IHD‐RBCx) exchange procedures in sickle cell anemia patients with stroke currently enrolled in our institutions chronic RBC exchange program. The pre‐ and‐post rinseback values for HbS were 9.9 ± 4.66 and 10.7 ± 4.83 (P = 0.56) with corresponding FCRs of 22.6 ± 8.57 and 24.7 ± 8.75 (P = 0.44), and for Hct were 32.4 ± 2.93% and 32.2 ± 3.19% (P = 0.79), respectively. Since there was no significant difference in the “pre” and “post” values, we conclude that rinseback can be used during RBC exchange without any concern for significantly affecting Post Exchange HbS and Hct and possibly not waste 53 mL of precious red cell mass in the rinseback. J. Clin. Apheresis, 2010.