Mark T. Friedman

Patient inclusion in transfusion medicine: current perspectives

License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php International Journal of Clinical Transfusion Medicine 2015:3 7–16 International Journal of Clinical Transfusion Medicine Dovepress

Blood Transfusion in the 21st Century

Blood transfusion is a common procedure in the hospital setting, and the safety of the blood supply has been vastly improved over the past few decades largely due to improvements in screening for viral transmissible diseases, especially human immunodeficiency virus (HIV) and viral hepatitis. However, more recent efforts to improve blood safety have focused on non-transmissible disease risks such as transfusion-related acute lung injury (TRALI), non-viral transmissible diseases such as bacterial contamination of blood products (especially platelet components which are stored at room temperature) and Chagas disease (a parasitic disease caused by Trypanosoma cruzi), and prion transmissible agents (e.g., variant Creutzfeldt-Jakob disease, also known as the agent of mad cow disease) as well as more recently-recognized transmissible viral disease risks such as West Nile virus. Appropriate blood utilization has also come under more intense scrutiny in recent times due to healthcare costs and the recognition that many blood transfusions are given under circumstances in which the benefit to the patients is unclear and may be potentially harmful due to the above risks as well as the emerging concept that blood transfusions may cause long-term damage to the immune system resulting in worse patient morbidity and mortality outcomes. Toward that end, accreditation agencies such as the Joint Commission and the American Association of Blood Banks (AABB) are advocating for healthcare organizations to implement appropriate patient blood management strategies. This review will examine these issues along with newer blood safety technological innovations and further highlight contributing studies from our institutions.

Hot and Cold

A 5-year-old boy presents to the emergency department (ED) with 2 days of fever (temperature 100.7 °F), fatigue, jaundice, and dark urine. The parents note that the child had symptoms of a viral upper respiratory illness 2 weeks before presentation and that he was previously healthy with no history of blood transfusion. In the ED, the child weighs 21.3 kg, and laboratory workup reveals severe anemia with hemoglobin (Hgb) 5.4 g/dL, elevated total bilirubin 5.1 mg/dL, aspartate aminotransferase (AST) 357 U/L (normal range, 8–60 U/L), and lactate dehydrogenase (LDH) 8126 U/L. Serum haptoglobin is undetectable. Urinalysis results are as follows: color, dark; red blood cells (RBCs), 0–3 per high-power field; and urine Hgb, 3+ positive. Notably, the onset of symptoms (fever, fatigue, jaundice, dark urine) was associated with eating a bowl of ice cream. An ethylenediaminetetraacetic acid (EDTA) anticoagulant type and screen sample is submitted to the blood bank along with a request for RBC transfusion.

Adequacy of physician documentation and correlation with assessment of transfusion appropriateness: a follow-up study in the setting of prospective audits and patient blood management

A previous study in our hospitals correlated suboptimal documentation and failure to justify transfusions. In light of implemented blood‐conservation strategies, including patient blood management (PBM) and prospective audits (PAs), we performed a follow‐up study.

Are You Kidding

A 72-year-old male with myelodysplastic syndrome, multiply transfused with a known history of anti-E and anti-c antibodies, presents to the outpatient transfusion service. He was transfused with 2 units of red blood cells (RBCs) 5 weeks ago. The patient’s hematocrit (Hct) is now 22 % and 1 unit of RBCs is requested for the patient. A type and crossmatch sample (ethylenediaminetetraacetic acid, EDTA anticoagulant) is submitted to the blood bank.

The “Unfraction” Reaction

An 8-year-old boy with congenital heart disease is admitted to the hospital for a planned mitral valve repair and revision. The patient has had multiple admissions to the hospital for surgery and complications relating to the congenital heart condition, most recently 1 month ago, and has required support with multiple transfusions of blood products over the years. His prior blood bank tests show that he is group A-positive with a negative antibody screen. A type and screen sample (ethylenediaminetetraacetic acid [EDTA] anticoagulant) is submitted to the blood bank along with a request for crossmatch of two units of red blood cells (RBCs).

I “Pitty” Thee

A 74-year-old man is admitted to hospital for workup of gastrointestinal (GI) bleeding; he is scheduled for colonoscopy the following day. An ethylenediaminetetraacetic acid (EDTA) anticoagulant sample is submitted to the blood bank for type and screen.

How “Dara” You!

A 73-year-old man with immunoglobulin (Ig)G kappa multiple myeloma is referred for outpatient transfusion due to severe anemia with hemoglobin (Hgb) of 6.6 g/dL. The patient has a history of red blood cell (RBC) transfusion at your hospital 2 years ago at which time the antibody screen was negative. An ethylenediaminetetraacetic acid (EDTA) anticoagulant sample is submitted to the blood bank for type and screen along with a request for two units of irradiated RBCs.

Of Wind and Water

A 65-year-old man with a history of obesity, type 2 diabetes mellitus, chronic anemia, and renal insufficiency is admitted to the hospital for evaluation of worsening renal failure, a drop in the hemoglobin (Hgb) level, dyspnea on exertion, and fatigue. The patient’s Hgb is 6.2 g/dL (his baseline is 8.0 g/dL), and the creatinine is 4.4 mg/dL on admission. The patient is tachypneic (respiratory rate is greater than 20 breaths/min) and hypoxic (oxygen saturation is 88% on room air). He is treated with supplemental oxygen 2 L/min by nasal cannula and normal saline by slow intravenous (IV) infusion (125 mL/h). A consult is called for evaluation of gastrointestinal bleeding. In the meantime, a type and screen sample (ethylenediaminetetraacetic acid [EDTA] anticoagulant) is submitted to the blood bank along with a request for two units of red blood cells (RBCs). The patient received RBC transfusion of two units 3 years ago at the hospital; the antibody screen was negative at that time.

Thromboelastography, My Dear Doctor

A 63-year-old man with a history of myocardial infarction and unstable angina is scheduled for coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). A preoperative ethylenediaminetetraacetic acid (EDTA) anticoagulant sample is submitted to the blood bank for type and screen along with a request for crossmatch of four units of red blood cells (RBCs) in preparation for the surgery.