Robert C. Skeate

Clinical review: Canadian National Advisory Committee on Blood and Blood Products - Massive Transfusion Consensus Conference 2011: report of the panel

In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.

Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload.

Purpose of reviewThe purpose of this review is to provide an overview of concepts recently presented in the literature that impact our understanding of transfusion related acute lung injury (TRALI) and transfusion associated circulatory overload (TACO), and how to distinguish between the two disorders. Recent findingsAn exceptionally clear review article by Brux and Sachs clarified the two-hit model of TRALI pathogenesis. The TRALI definition developed at the 2004 consensus conference helped demonstrate that TRALI is likely underreported. Brain natriuretic peptide can be useful in distinguishing cardiogenic from noncardiogenic pulmonary edema. Blood centers are implementing male predominant plasma programs to limit TRALI, and preliminary evidence suggests that this is a useful intervention. SummaryTACO and TRALI have emerged as important causes of posttransfusion morbidity and mortality. As understanding of their pathogenesis improves, incidence, risk factors, differences, and possible preventive interventions are becoming clearer. There is no sentinel feature that distinguishes TRALI from TACO. Developing a thorough clinical profile including presenting signs and symptoms, fluid status, cardiac status including measurement of brain natriuretic peptide, and leukocyte antibody testing is the best strategy currently available to distinguish the two disorders.

Limiting and detecting bacterial contamination of apheresis platelets: inlet-line diversion and increased culture volume improve component safety

BACKGROUND: Septic transfusion reactions to apheresis platelets (PLTs) continue to occur despite preventive measures. This study evaluated the effect of two operational changes designed to reduce bacterial risk: 1) introducing inlet‐line sample diversion on two‐arm procedures and 2) increasing the sample volume cultured from 4 to 8 mL from all donations.

Reducing Errors from the Electronic Transcription of Data Collected on Paper Forms: A Research Data Case Study

We conducted a reliability study comparing single data entry (SE) into a Microsoft Excel spreadsheet to entry using the existing forms (EF) feature of the Teleforms software system, in which optical character recognition is used to capture data off of paper forms designed in non-Teleforms software programs. We compared the transcription of data from multiple paper forms from over 100 research participants representing almost 20,000 data entry fields. Error rates for SE were significantly lower than those for EF, so we chose SE for data entry in our study. Data transcription strategies from paper to electronic format should be chosen based on evidence from formal evaluations, and their design should be contemplated during the paper forms development stage.

Hemolytic anemia due to passenger lymphocyte syndrome in solid malignancy patients treated with allogeneic natural killer cell products

Allogeneic natural killer (NK) cell products for treatment of solid organ malignancies were prepared by performing T (CD3+)‐cell depletion on nonmobilized apheresis mononuclear cell collections. The products were not B‐cell depleted. This report details two cases of passenger lymphocyte syndrome (PLS) after NK‐cell infusion.

Transfusion medicine data as product

An indication of the success of transfusion medicine is the fact that transfusing physicians expect that they need only place a blood order and a high-quality, safe, properly labeled and documented, and highly effective blood component will be delivered. We have created these expectations with many years of hard work to improve blood product production and maintenance, with progressive process improvements, and with high-quality clinical research. Critical to our success has been the development of effective computerized information systems that gather, store, and make available the information necessary for successful clinical transfusion practice. A recent review article in the Journal of Pathology Informatics by Sharma and colleagues provides a good summary of how advances in information systems have enhanced transfusion medicine. Examples at the blood center include computerized donor questionnaire and records, and systems to facilitate manufacturing, delivery, and tracking of blood products. At the hospital, blood bank–specific laboratory information systems facilitate inventory management, maintain patient records, and ensure that the proper products are released to patients. Relatively recent and maturing systems have facilitated the electronic cross-match, kiosk-based blood delivery systems, and radio frequency systems for ensuring proper match between patient and product at the bedside. As evidence-based medicine and quality improvement concepts have been incorporated into contemporary medical practice, there is the increasing expectation from our clinical colleagues that we provide not only highquality products, but also the high-quality data needed to optimize transfusion practice. An excellent example of an effort to meet this expectation can be seen in an article in this issue of TRANSFUSION by Clifford and colleagues. Using a portion of the extremely well-characterized and vetted transfusion related-acute lung injury (TRALI) and transfusionassociated circulatory overload (TACO) patients from the recent study from Toy and colleagues, the authors demonstrated the utility of a computer-enabled algorithm to screen for patients who likely experienced these reactions. With primarily a few simple variables that are frequently available in electronic medical records (EMRs; e.g., chest X-ray obtained, yes/no; reduced PaO2/FiO2 ratio), the authors were able to identify and classify instances of clinically relevant pulmonary transfusion reactions.Their automated system avoids the pitfalls of passive reporting systems and obviates the need for the technically difficult task of natural language processing. They conclude that “This supports the notion that active electronic surveillance may improve case identification, thereby providing a more accurate understanding ofTRALI/transfused ALI and TACO epidemiology.” As argued by Finlay and coworkers in their 2005 report of an analogous strategy, effective computerized and automated surveillance also would provide opportunities to positively influence clinical practice and, assuming thatTRALI cases are reported to blood centers, to enhance the safety of the blood supply. The increasing importance of more effectively leveraging our data for efforts within and outside the context of immediate patient care was reflected in the content of last year’s AABB annual meeting in Boston. In the introductory remarks for a session titled “Improving Transfusion Practices and Safety with Your Hospital or Laboratory Computer System,” moderator Dr William Savage said the faculty would be describing how they “use every day IT resources at their hospitals to improve blood utilization and patient outcomes.” Higgins, Frank, and Andrzejewski all described computerized tools that display and summarize patient data for use in individual transfusion decisions, as well as for benchmarking transfusion practice. Frank and colleagues have previously published on an anesthesia information management system at Johns Hopkins applied to identify significant variability in transfusion practice between surgical services, and among individual surgeons and anesthesiologists. In his talk he described how these data could be summarized and presented to individual surgeons while comparing their practice to the potentially more conservative practices established in the TRICC and TRACS trials as a way to normalize their transfusion decisions. Andrzejewski and colleagues have previously described efforts at Baystate Health to create an EMR strategy for the therapeutic apheresis service. In his presentation, he stressed the importance of designing an encoding strategy for data retrieval not only for direct patient care but also for hemovigilance, quality management, and utilization studies. He emphasized that these purposes should be in mind as EMR contents are designed so that the most useful variables are captured. While not specifically describing computerized information systems, the session moderated by Denomme titled “Molecular Dry Matching of Red Cells” included a TRANSFUSION 2013;53:1153-1156.

Platelet transfusion reactions do not occur more often in recipients transfused with apheresis versus buffy coat platelet concentrates: LETTERS TO THE EDITOR

not evident whether amino acid alignments were identical. The identification of small numbers of amino acid substitutions in both strains, especially if they are located in conserved regions of sequence, could compromise the hypothesis of post-TT ZIKV infection. Available data on ZIKV confirm that genome variation during outbreaks is low; a comparison of seven complete ZIKV coding region sequences from samples collected from unrelated patients during the Brazilian outbreak yielded nucleotide sequence homology ranging from 99% to 100%, and comparison with previously published Brazilian strains revealed a maximum of nine nucleotide changes across the coding region. Similarly, the sequences of 19 West Nile virus strains isolated from blood donors in 2012 in the United States were genetically closely similar. In the case reported by Barjas-Castro and colleagues and in agreement with the authors, it seems likely that ZIKV infection in the recipient probably resulted from transfusion, because the recipient lived in a non-ZIKV-endemic area. However, when both donor and recipients live in the same endemic area, nucleic acid sequencing can only provide suggestive evidence of posttransfusion transmission. Nevertheless, significant differences in nucleotide and amino acid sequences can exclude posttransfusion transmission.

A Second Case Report of Lleuprolide Acetate for Depot Suspension-Induced Mania

This is the second published case report of Lleuprolide acetate for depot suspension (LD)-induced mania. Both reports detail a patient with a prior psychiatric history of both depressive and hypomanic episodes. While depression is a predictable and documented side effect of LD and menopause (especially in those with a previoushistory of symptoms), manic reactions are rare and unexplained. Possible causative mechanismsbehind the LD-induced manic episodes are discussed, and we suggest that patients with a single previous hypomanic episode are at risk for LD-induced mania.

A Study of Results Generated Using the Abbott LCx-GC Assay Fails to Reveal a Performance-Based Rationale for the 2002 Level 1 Recall

To establish the effect of a quality control failure on the performance of the LCx-GC nucleic-acid amplification assay for Neisseria gonorrhoeae (Abbott Laboratories, Abbott Park, IL) in the field, we conducted a retrospective analysis comparing the clinical and analytic performance of the recalled lots with those not implicated in the recall. Our analysis revealed no statistically significant differences between recalled lots (n = 8,686 tests) and nonrecalled lots (n = 8,699 tests) with respect to multiple parameters of assay performance, including frequency distribution of patient results (P = .575), prevalence of indeterminate results (P = .245), mean positive control signals (P = .26), and within-run calibrator precision (P = .68). The LCx-GC systems lack of an electronic data storage and retrieval capability prevented assessment of the impact of the quality control failure on the clinical performance of recalled lots, such as the one described herein, from being conducted in real time.

Cardiac stress biomarkers after red blood cell transfusion in patients at risk for transfusion-associated circulatory overload: a prospective observational study: CARDIAC BIOMARKERS IN PATIENTS AT RISK FOR TACO

Transfusion‐associated circulatory overload (TACO) is a leading cause of serious reactions. In regard to TACO, little is known regarding biomarkers as a predictor, their most informative timing, or thresholds of significance or differentiation from other reactions.