Shamee Shastry

Clinical factors influencing corrected count increment

Refractoriness to platelet transfusions is a common clinical problem. The present study was conducted to look into patient characteristics affecting the corrected count increment in a tertiary care referral hospital. A total of 161 aphaeresis platelet units were transfused to 40 patients with varied clinical diagnoses. The mean platelet increment was 17,789/mm(3). Median corrected count increment was 7344 and percentage platelet recovery was 22.82%. Logistic regression analysis revealed significant influence of splenomegaly and anti-platelet drugs on refractoriness. Fever, bleeding, sepsis, disseminated intravascular coagulation and cyclosporine use, though more common in the patients with refractoriness they were not statistically significant.

A rare case of haemolytic disease of newborn with Bombay phenotype mother

We are reporting a rare case of severe hemolytic disease of newborn (HDN) with Bombay phenotype mother. A retrospective study of a case with severe haemolytic disease of newborn with Bombay phenotype mother was done. Blood grouping, antibody screening, and lectin study was done on the blood sample of the baby and mother to confirm the diagnosis. Hematological and biochemical parameters were obtained from the hospital laboratory information system for the analysis. Blood group of the baby was A positive, direct antiglobulin test was negative. Blood group of the mother was confirmed to be Bombay phenotype, Hematological parameters showed all the signs of ongoing hemolysis and the bilirubin level was in the zone of exchange transfusion. Due to the unavailability of this rare phenotype blood unit, baby was managed conservatively. Anticipating the fetal anemia and HDN with mothers having Bombay phenotype and prior notification to the transfusion services will be of great help in optimizing the neonatal care and outcome.

Linear accelerator: A reproducible, efficacious and cost effective alternative for blood irradiation

BACKGROUND The dedicated devices for blood irradiation are available only at a few centers in developing countries thus the irradiation remains a service with limited availability due to prohibitive cost. OBJECTIVE To implement a blood irradiation program at our center using linear accelerator. MATERIALS AND METHODS The study is performed detailing the specific operational and quality assurance measures employed in providing a blood component-irradiation service at tertiary care hospital. X-rays generated from linear accelerator were used to irradiate the blood components. To facilitate and standardize the blood component irradiation, a blood irradiator box was designed and fabricated in acrylic. Using Elekta Precise Linear Accelerator, a dose of 25 Gy was delivered at the centre of the irradiation box. Standardization was done using five units of blood obtained from healthy voluntary blood donors. Each unit was divided to two parts. One aliquot was subjected to irradiation. Biochemical and hematological parameters were analyzed on various days of storage. Cost incurred was analyzed. RESULTS Progressive increase in plasma hemoglobin, potassium and lactate dehydrogenase was noted in the irradiated units but all the parameters were within the acceptable range indicating the suitability of the product for transfusion. The irradiation process was completed in less than 30 min. Validation of the radiation dose done using TLD showed less than ± 3% variation. CONCLUSION This study shows that that the blood component irradiation is within the scope of most of the hospitals in developing countries even in the absence of dedicated blood irradiators at affordable cost.

Barcode error leading to sample misidentification during blood grouping

Patient safety associated with the transfusion process is extremely important due to the propensity of errors to cause catastrophic consequences. To aid blood banks in minimizing these errors, advanced computerized information systems and barcode labeling technology have been introduced. The barcode technology comprises machine readable symbols used to encode information to automate it. It simplifies and improves the patient identification system in laboratory and clinical transfusion practice. Currently barcode technology has become an indispensable advancement allowing the technical staff to bypass the tedious manual check of the sample labels. Our center is a 2032-bed tertiary care facility and administers approximately 30,000 blood components annually. We have a state-of-the-art immunohematology laboratory with fully automated grouping system with an annual load of 54,000 patient samples. Samples are barcoded at the site of reception at the blood bank, using a barcode printer of Zebra Technologies Corporation. Subsequently samples are loaded into automated blood grouping equipment, which has a software into which the patient details are fed manually and the labels are scanned by an built-in scanner. Recently we noticed a blood grouping error (O D1 instead of B D1) and on root-cause analysis it was found to be due to barcode printing error. As visualized in Video Clip S1 (available as supporting information in the online version of this paper), the barcode label printed in the above said barcode printer in our blood bank, for a particular hospital number, was read as a different number belonging to another patient, leading to the blood grouping error. While entering the patient’s blood grouping report to the blood bank software, a discrepancy was noted with the previous grouping report. To resolve the Fig. 1. Possible causes for barcode label error. The fishbone diagram indicates four major categories of causes resulting in a barcode label error. Three examples for such causes are listed per category. The root cause for the error shown in Video Clip S1 was a hardware problem with the printer resolution.

Implication of deferral pattern on the donor pool: Study at a Tertiary Care Hospital

Background and Objectives: Donor screening process is one of the most important steps in protecting the safety of blood supply. Donors who do not meet specified criteria are deferred either temporarily or permanently. These criteria are designed to protect both donors and patient safety. Due to the varied rates and reasons for deferrals in the existing literature, we aimed to evaluate the patterns and prevalence of deferrals in our institution. Materials and Methods: This retrospective study was conducted at a Tertiary Care Hospital, Karnataka, Southern India, to evaluate the various reasons for blood donor deferral from January 2011 to January 2014. Demographic data of blood donors was obtained through the blood bank database and secondary measures such as the type of deferral (permanent/temporary, pathogenic/nonpathogenic, and harmful to donor/recipient) were assessed. Results: A total of 54,653 subjects presented to our blood bank during this period out of which 2935 (5.6%) were deferred. The deferral to donor percentage was higher in females (36.54%) than males (3.64%). Low hemoglobin was the major deferral criterion seen in our participants (48.1%) followed by hypertension (16.4%), underweight (8.9%). Low pulse rate and fasting donor were the least prevalent reasons. A total of 36.8% of reasons for deferral were harmful to donors, 88.2% were nonpathogenic, and 98.1% were temporary causes. Conclusion: Variations in donor deferral may be attributed to different donor selection criteria in different regions and centers. Hence, it is important to know the common causes of donor deferral in a region so that measures may be taken to improve the donor pool.

A rare case of missing antibody due to anti‐snake venom

Immunohematologic tests are influenced by various factors, including patient age, disease condition, and treatment. Solving a case of blood grouping discrepancy is often challenging. Here we report the first case of a missing antibody due to the administration of snake venom antiserum for the management of a child after snake bite. A request for routine blood grouping was sent from the pediatric intensive care unit for a 6-year-old child. She was admitted with a snake bite, suspected to be from a cobra. She had cellulitis and compartment syndrome of right leg that required fasciotomy. On admission, her hemoglobin level was 13.2 g/dL, prothrombin time was 20.5 seconds (control, 14.8 sec), and activated partial thromboplastin time was 37.1 seconds (control, 34 sec). She was discharged from the hospital after 2 weeks with complete recovery. The result of initial blood grouping is shown in Fig. 1. Further testing with anti-A,B done using test tubes was negative. Repeat blood typing gave similar results with a fresh sample. Blood grouping was carried out in an automated blood grouping machine using ABD and reverse diluent cards (AUTO/ VUE, Ortho-Clinical Diagnostics, Inc., Raritan, NJ). To enhance the assay, reverse grouping was done in test tubes and kept at 4°C for 1 hour along with the autocontrol and group O cells. Under these conditions, a weak positive reaction was seen with “A” cells and no agglutination was seen with the autocontrol and group O cells. All laboratory tests were carried out in accordance with the manufacturer’s insert. Parents’ ABO grouping was determined using AUTO/VUE and both the parents were group O. The direct antiglobulin test, the red blood cell antibody screening using gel cards, and the three-cell antibody screening panel (DiaMed AG, Cressier sur Morat, Switzerland) showed negative results. On reviewing the patient’s history, it was found that she was treated with more than 50 vials of anti-snake venom—polyvalent (ASVS-ASIA; Bharat Serums and Vaccines Ltd, Thane, India). To check the effect of anti-snake venom on blood group antibodies, we selected a group O serum sample from a normal blood donor and performed reverse typing in the presence and absence of anti-snake venom. As shown in Fig. 2, there was no reaction with A cells in the presence of anti-snake venom, whereas normally a 4+ reaction is expected. From these observations, it was inferred that the blood group discrepancy is attributable to anti-snake venom and the group was reported as group O D+. According to the manufacturer’s details, each milliliter of anti-snake venom neutralizes not less than the following quantities of standard venom tested in mice by the intravenous route: cobra (Naja naja), 0.6 mg; common krait (Bungarus caeruleus), 0.45 mg; Russell’s viper (Vipera russelli), 0.6 mg; and saw scaled viper (Echis carinatus), 0.45 mg. Because anti-snake venom is a concentrated preparation of serum globulins obtained by fractionating blood from healthy hyperimmunized horses, false positivity during immunohematologic testing can be expected but a false-negative result is unusual. Although anti-snake venom binds to and neutralizes venom, some constituents of equine-derived anti-snake venom may also act as antigens to neutralize anti-A. In an earlier study, A or A-like substances were present in every specimen of horse serum investigated and B substance was not demonstrable. So A substance is a property of horse serum itself, and it is likely that these substances in anti-snake venom neutralized the anti-A. At the time of

Effect of pre-donation fluid intake on fluid shift from interstitial to intravascular compartment in blood donors

BACKGROUND Fluid shifts from interstitial to intravascular space during blood donation helps in compensating the lost blood volume. We aimed to determine the volume of fluid shift following donation in donors with and without pre-donation fluid intake. METHODS We studied the fluid shift in 325 blood donors prospectively. Donors were divided in groups- with no fluid intake (GI) and either water (GII) or oral rehydrating fluids (GIII) before donation. Fluid shift following donation was calculated based on the difference between the pre and post donation blood volume. The influence of oral fluid intake, age, gender and body mass index (BMI) on volume of fluid shift was analyzed. RESULTS The fluid shift was significant between donors without fluids (GI: 127 ± 81 ml) and donors with fluid intake (GII & III: 96 ± 45 ml) (p < 0.05). The difference was not significant between donors with water intake (GII: 106 ± 52 ml) and oral rehydrating fluid intake (GIII: 87 ± 41 ml). The shifted fluid volume increased with increasing BMI and decreased with increasing age in females. The fluid shift increased in females than in males. CONCLUSION The age, gender, BMI and VVR did not significantly contribute to the volume of fluid shift following donation. As per our observation, the oral fluids before donation might not contribute to increase in fluid shift in blood donors after donation.

Cumulative quality assessment for whole blood‑derived platelets: A compliance review

Background and Objectives: Quality control (QC) results of platelet-rich plasma and buffy coat-reduced platelet concentrates (PCs) are presented with the goal to assess their compliance with published guidelines and corrective action taken for any process deviation during their manufacture. Subjects and Methods: Retrospective QC of in-house prepared whole blood-derived platelets (2009–2013) was conducted. Their cumulative results were compared to the published quality standards given by the American Association of Blood Banks, Council of Europe, and Indian guidelines. Data was analyzed using SPSS Statistics version 20. Results: A total of 36,053 PCs were prepared during the study period, and 1.43% (n = 516) was subjected to QC. The aggregate five years mean ± standard deviation (range) of product per bag were volume 58.4 ± 9.5 (37–90) mL, platelet yield 5.89 ± 1.28 (3.1–8.7) × 1010, residual leukocyte count 1.5 ± 1.2 (0.02–5.5) × 107, pH 6.67 ± 0.48 (6.0–7.3), and erythrocyte contamination 0.29 ± 0.2 (0.03-2.0) mL. Swirling was present in all the units. None of the bags showed any microbial growth. Against volume, yield, and erythrocyte contamination 90.0%, 94.3%, and 87.0% units showed compliance to the Indian standards, respectively. All the PCs had pH and leukocyte counts well within the recommended norms. Conclusions: Quality of our platelet product although suboptimal to International standards was well within the national requirements.

A handy chart for the interpretation of sequential differential adsorption-elution procedure

D adsorption and elution procedures are often helpful in separating multiple antibodies in a complex mixture. One of the applications of this procedure is to confirm the presence or absence of anti‐D, anti‐C, and anti‐G in the serum with apparent anti‐D + anti‐C specificities in alloimmunized pregnancies.[1] We performed a modified sequential differential adsorption‐ elution procedure in such patients. Unlike the method described in the literature, to begin with, we used enzyme‐treated red blood cells of DEc phenotype for the adsorption, and the procedure (with the cell to serum ratio of 1:1) was repeated twice to achieve the complete adsorption of the antibody in the serum. The eluate obtained by cold acid elution technique from these cells was used for the second adsorption procedure with dCe cells. Following each step, the adsorbed serum and the eluate were tested against the D+C‐ and D‐C + screening cells. We validated this procedure using the known mixture of antibodies and the samples from five antenatal cases. Baia et al. have explained a simple approach to confirm the presence of anti‐D in sera with the presumed anti‐D and anti‐C specificity.[2] However, it requires two aliquots of serum to rule out all the five possible combinations: anti‐D + anti‐C, anti‐G, anti‐C + anti‐G, anti‐D + anti‐G, and anti‐D + anti‐C + anti‐G. We used only one aliquot (1.5 mL) of serum, and the total turnaround time was 6 h in the protocol mentioned above.

Adding up the evidence: Trigger for prophylactic plasma transfusion

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