Post-Transfusion Hepatitis—A Serious Clinical Problem

Serum hepatitis and infectious hepatitis may have a common pathogen and their few clinical differences the result only of a difference in portal of entry.The risk of serum hepatitis from transfusions derived from prison and Skid Row populations is at least 10 times that from the use of volunteer donors. For every 100 patients receiving a single transfusion, the attack rate is 0.3 per cent when the donor is of the family or volunteer type and 3.2 per cent when the donor is from a prison or Skid Row population.The most practical methods of reducing the hazard of serum hepatitis from blood are to limit the use of blood by giving one transfusion instead of two, two instead of three, etc., and especially by excluding, if possible, all prison and Skid Row donors.It is urged that state and federal control of the quality of blood used for blood transfusions be studied with the possibility that measures may be taken to increase its safety. If it is necessary that blood from prison and Skid Row donors be used to meet the demands, such blood should be labeled as carrying a significantly increased hazard of transmitting serum hepatitis in order that the physician prescribing blood may take the necessary precautions.     

Prevalence of hepatitis B antibodies in hospital personnel.

Of 426 hospital staff tested for hepatitis B surface antibody (anti-HBS) by the radioimmunoassay method 57 (13.4%) had positive results. Laboratory staff had the highest prevalence, followed by nurses, and both values were significantly higher than that of administrative staff. Clerical staff working in laboratories were at the same risk for hepatitis B as general-duty nurses. Significantly more staff with anti-HBS had a history of hepatitis (19.3%) compared with staff without anti-HBS (79%), and significantly more staff with a history of hepatitis had anti-HBS (25.6%) compared with staff without such a history (12.0%). History of blood transfusions was not related to prevalence of anti-HBS. The risk for hepatitis B is greater in hospital staff who are in direct contact with patients or handle patients'' blood and other specimens. However, contact with patients is less important than contact with patients'' blood and other specimens.     

Evaluation of red blood cell transfusion practices with the use of preset criteria.

OBJECTIVE: To assess current red blood cell (RBC) transfusion practices and to determine the potential impact of implementing recently published guidelines on RBC transfusion from the American College of Physicians (ACP). DESIGN: Medical chart review. SETTING: A 219-bed teaching hospital in Kingston, Ont. PARTICIPANTS: All patients over 12 years of age who received RBC transfusions in March 1992. MAIN OUTCOME MEASURES: Need for transfusion according to the ACP guidelines and the number of blood units ordered for each transfusion. RESULTS: A total of 55 patients received 170 RBC units. According to the ACP guidelines 94 (55.3%) of the units were judged unnecessary. The departments of Surgery and Internal Medicine did not differ significantly in the number of unnecessary units (56.4% v. 52.8%). Among the surgical subspecialties, unnecessary transfusion was most common in the orthopedics service (73.5%, p < 0.05). Blood was most frequently ordered 2 units at a time (51.8% of units). Transfusion in normovolemic, hemodynamically stable patients with anemia and unnecessary multiple-unit transfusions were the most common violations of the ACP guidelines. CONCLUSIONS: According to the ACP guidelines, there was significant unnecessary blood use in the hospital surveyed. The guidelines provide a useful framework for assessing transfusion practices but may require further refinement to apply to a broader spectrum of clinical settings.     

Where does blood go? Prospective observational study of red cell transfusion in north England

ObjectiveTo collect population based information on transfusion of red blood cells.DesignProspective observational study over 28 days.SettingHospital blood banks in the north of England (population 2.9 million).ParticipantsAll patients who received a red cell transfusion during the study period. Data completed by hospital blood bank staff.ResultsThe destination of 9848 units was recorded (97% of expected blood use). In total 9774 units were transfused: 5047 (51.6%) units were given to medical patients, 3982 (40.7%) to surgical patients, and 612 (6.3%) to obstetric and gynaecology patients. Nearly half (49.3%) of all blood is given to female recipients, and the mean age of recipients of individual units was 62.7 years. The most common surgical indications for transfusion were total hip replacement (4.6% of all blood transfused) and coronary artery bypass grafting (4.1%). Haematological disorders accounted for 15.5% of use. Overall use was 4274 units per 100 000 population per year.ConclusionIn the north east of England more than half of red cell units are transfused for medical indications. Demand for red cell transfusion increases with age. With anticipated changes in the age structure of the population the demand for blood will increase by 4.9% by 2008.

What is already known on this topic

There have been no systematic population based surveys on use of red cells in the United KingdomStudies in France and the United States have shown that more than half of transfused red cells go to surgical patients

What this study adds

In the north of England over half of red cells are given for medical indicationsRates of red cell transfusion rise steeply with advancing ageSmall increases in the number of elderly people will have large effects on demand     

Autologous versus allogeneic transfusion: patients' perceptions and experiences

BACKGROUND: Preoperative autologous donation is one way to decrease a patient''s exposure to allogeneic blood transfusion. This study was designed to determine patients'' perceptions about the autologous blood donation process and their experiences with transfusion. METHODS: To assess patient perception, a questionnaire was administered a few days before surgery to patients undergoing elective cardiac and orthopedic surgery in a Canadian teaching hospital. All patients attending the preoperative autologous donation clinic during a 10-month period were eligible. A convenience sample of patients undergoing the same types of surgery who had not predonated blood were selected from preadmission clinics. Patient charts were reviewed retrospectively to assess actual transfusion practice in all cases. RESULTS: A total of 80 patients underwent cardiac surgery (40 autologous donors, 40 nondonors) and 73 underwent orthopedic surgery (38 autologous donors, 35 nondonors). Of the autologous donors, 75 (96%) attended all scheduled donation appointments, 73 (93%) said that they were "very likely" or "likely" to predonate again, and 75 (96%) said that they would recommend autologous donation to others. There was little difference in preoperative symptoms between the autologous donors and the nondonors, although the former were more likely than the latter to report that their overall health had remained the same during the month before surgery (30 [75%] v. 21 [52%] for the cardiac surgery patients and 30 [79%] v. 18 [51%] for the orthopedic surgery patients). When the autologous donors were asked what they felt their chances would have been of receiving at least one allogeneic blood transfusion had they not predonated, the median response was 80%. When they were asked what their chances were after predonating their own blood, the median response was 0%. The autologous donors were significantly less likely to receive allogeneic blood transfusions (6 [15%] for cardiac surgery and 3 [8%] for orthopedic surgery) than were the nondonors (14 [35%] for cardiac surgery and 16 [46%] for orthopaedic surgery). They were, however, more likely to receive any transfusion (autologous or allogeneic) than were the nondonors (25 [63%] v. 14 [35%] for cardiac surgery and 31 [81%] v. 16 [46%] for orthopedic surgery). INTERPRETATION: Patients who underwent preoperative autologous blood donation were positive about the experience and did not report more symptoms than patients who did not donate blood preoperatively. Autologous donors overestimated their chances of receiving allogeneic blood transfusions had they not predonated and underestimated their chances after they had predonated. They were less likely to receive allogeneic transfusions, but more likely to receive any type of transfusion, than were patients who did not predonate.     

Association of sex, age and ABO-Rh(D) type with unexpected antibodies among multitransfused thalassemia patients in Bikaner, Rajasthan, India

The thalassemia has become a sensitive issue for clinical and public health owing to the morbidity and mortality caused and potential risks associated with multiple transfusions. Here, a blood bank based cross sectional analytical study was carried out during the period of three months from January 2017 to March 2017, among transfusion dependent beta thalassemia major patients. ABO-Rh(D) blood grouping and screening for unexpected red cell antibodies (other than anti-A and anti-B antibodies) were performed on a Immucor Galileo Neo System (fully automated immunohematology analyzer). Out of 56 patients, 37 (66%) were males and 19 (34%) were females with a male to female ratio of 1.95:1. Two cases (3.6%) were detected positive by antibody screening. Alloimmunization was statistically analyzed on the basis of age, sex and subjects'' ABO-Rh blood group. This study underlines the need for unexpected antibody screening among thalassemic patients receiving blood transfusion therapy.     

Incidence of Uraemia and Requirements for Maintenance Haemodialysis

The biochemistry laboratory records of a 400-bed general hospital serving a population of about 120,000 showed that during the three-year period 1966-8 inclusive 487 patients had at some stage during their admission a blood urea of 100 mg/100 ml or more. Ninety per cent. were aged 50 or over, 79% were 60 or over, and 52% were 70 or over.The case notes of all patients with renal failure admitted during 1966 and 1967 were examined together with those of patients under 60 admitted during 1968. Three observers agreed about the most likely cause of the renal failure in 90% of patients whose case notes were available, or 74% of the total. The raised blood urea was thought to be due to “prerenal” factors in 60% of the patients, to acute tubular necrosis in 80%, to obstructive uropathy in 12%, and to “intrinsic” renal disease in 20%. Renal failure precipitated by such factors as cardiac failure, chest infections, cerebrovascular accidents, and shock was particularly common in old people.The hospital survey and replies to a questionnaire sent to all general practitioners in the area suggest that in the three-year period 14 patients may have been suitable for treatment by maintenance haemodialysis or renal transplantation. This represents a rate of about 39 per million per year under the age of 60 and 28 per million per year under 50.     

基于医疗数据信息集成系统的输血科信息化对临床用血管理的效果评价

目的：评价基于医疗数据信息集成系统的输血科信息化对临床用血管理的效果。方法：选取2015 年1 月至2015 年10 月本 单位输血科进入医疗数据信息集成系统的输血病例400 份为研究组。2014 年1 月至2014 年10 月输血科传统方式输血病例400 份为对照组。输血后对临床输血效果进行分析和评价。结果：对照组年龄18 ~ 77 岁,平均年龄(50.1± 9.2)岁;研究组年龄21 ~ 75 岁,平均年龄(52.3± 8.2)岁。研究组中有效病例共371 份,占总数的92.75 %;对照组中有效病例共330 份,占总数的82.50 %。2组 间有效病例存在统计学差异(P<0.05)。结论：基于医疗数据信息集成系统的输血科信息化对临床用血管理的具有一定优势。     

Editor's preface

OBJECTIVE: To describe the process used to notify pediatric patients who received transfusions of blood or blood products at our institution before donor blood was routinely screened for antibodies to HIV (1985) and hepatitis C virus (1990), and to evaluate the effectiveness of the notification program. DESIGN: Patients who had received transfusions were identified through the hospital''s medical records and the records from the Transfusion Medicine Laboratory. Patients were contacted by registered mail to provide notification of transfusion. A questionnaire was included with the notification to obtain information about the patient''s awareness of the transfusion and whether he or she had undergone or planned to undergo testing for HIV and hepatitis C virus. SETTING: Tertiary care university-affiliated teaching hospital in Hamilton, Ont. PATIENTS: Patients 16 years of age or younger who had received blood products between February 1978 and November 1985. Patients who had received only albumin or immune serum globulin were not included as these products were not associated with viral transmission in Canada. RESULTS: Notification letters were sent to 1546 patients. Of these letters 522 (33.8%) were returned undelivered. Of the 1024 patients contacted 493 (48.1%) responded to the questionnaire, of whom 157 (31.8%) were not aware of their transfusion. A total of 130 (26.4%) of the respondents had already undergone testing for HIV, and 342 (69.4%) indicated that they would undergo such testing as a result of the notification. In contrast, only 30 (6.3%) of 474 respondents had undergone testing for hepatitis C virus, but 425 (89.7%) indicated that they would undergo such testing. Overall, the patients'' response to the notification was neutral or positive; however, a number of patients expressed dissatisfaction and anxiety. CONCLUSIONS: The high proportion of patients who were unaware that they had undergone transfusion and who decided to undergo testing for HIV and hepatitis C virus as a result of notification supports the use of notification programs such as this one.     

Effect of a flow chart on use of blood transfusions in primary total hip and knee replacement: prospective before and after study

Problem A suspected high proportion of unnecessary blood transfusions occur in patients undergoing total joint replacement.Design Prospective before and after study evaluating the impact of a one page flow chart aimed at reducing the use of blood transfusions.Setting Orthopaedic tertiary care centre in Winterthur, Switzerland. 208 patients underwent primary total joint replacement of hips or knees during the control period (October 1998 to September 1999) and 217 during the intervention period (October 1999 to September 2000).Key measures for improvement Proportion of patients receiving allogeneic blood transfusions.Strategies for change A simple one page flow chart, which summarised graphically the perioperative decision pathways for anaemic patients, was placed in all charts of patients undergoing total joint replacement and handed out to medical staff from 4 October 1999 onwards. The implementation of the flow chart focused on its endorsement by chief physicians and the development of a sense of “ownership” among physicians and nurses.Effects of change The proportion of patients receiving allogeneic blood decreased from 35.0% to 19.8% (absolute difference -15.2%, 95% confidence interval -23.3 to -7.0%). The percentage of patients donating and receiving autologous blood also decreased. This led to overall savings of about £23 000 ($42 470; €34 441) (£103.50 per patient undergoing total joint replacement). Differences became more pronounced after adjustment for confounding factors.Lessons learnt Allogeneic blood transfusions in primary hip and knee replacement surgery may be reduced cost effectively by implementing a one page flow chart. Five key elements may have contributed: simplicity; wide distribution; no requirement for major changes; endorsement by local opinion leaders; and development of a sense of ownership. These elements may be used in other contexts to achieve sustained change of clinical practice.     

Trends in incidence of AIDS associated with transfusion of blood and blood products in Europe and the United States, 1985-93.

OBJECTIVE--To quantify patterns and trends in incidence of AIDS associated with transfusion of blood and its products in 14 European countries and the United States. DESIGN--Data were derived from the World Health Organisation''s European non-aggregate AIDS dataset and, for the United States, from the Centers for Disease Control AIDS public information dataset. Rates were standardised by using the world standard populations and adjusted for reporting delays in each country. SUBJECTS--Cases of AIDS in patients with haemophilia and recipients of transfusions. RESULTS--Overall, between 1985 and 1993 almost 6000 cases of AIDS associated with transfusions were registered in the 14 European countries considered and over 8000 in the United States between 1985 and 1992. Most European countries had annual age adjusted rates lower than 0.5 per million children aged 12 or less and between 1 and 2 per million adults. The United States had rates around 1 per million children and 5 per million adults in the most recent period. For children, the highest rates were generally reached in 1985-7, whereas in adults the highest rates were in the late 1980s. France had the highest overall incidence of AIDS related to transfusion in Europe (3.3 per million). Romania had a major epidemic in children (over 30 cases per million children in 1988-90). Incidence rates of AIDS associated with transfusion were still increasing in some southern European countries in the early 1990s. CONCLUSIONS--Apart from in France and Romania it is clear that rates of bloodborne AIDS in European countries are lower than those registered in the United States.     

Concerns of patients,MDs are transforming transfusion medicine.

Fear of HIV and AIDS has been the driving force in reducing physicians'' use of blood and blood products. Nancy Robb interviewed doctors across the country to determine steps they are taking to lower the number of transfusions and discovered that transfusion medicine in Canada has undergone a sea change.     

Blood Transfusion: Use and Abuse of Blood Components

Transfusion of whole blood and some blood components may result in serious or fatal complications, among which hepatitis is most frequent (20,000 to 30,000 cases and 3,000 deaths a year). Although hepatitis B virus (HB Ag) sometimes is implicated in posttransfusion hepatitis, non-A non-B. virus(es) (hepatitis “C” virus) probably accounts for most posttransfusion hepatitis.Half of all blood transfusions may be unnecessary.Responsible transfusion practice requires use of appropriate blood components for which there is adequate justification. Transfusion of red blood cells should be given as packed cells in most instances and whole blood should seldom be used.     

Hydroxyurea Use and Hospitalization Trends in a Comprehensive Pediatric Sickle Cell Program

Background

A decline in hospitalizations and pain episodes among those with sickle cell disease (SCD) who take hydroxyurea (HU) has been shown when compared to pre-HU patterns but paradoxically, when compared to those who have never been treated, HU recipients often have more frequent hospitalizations. This analysis evaluates the impact of increasing usage of HU on trends in hospitalizations and blood transfusions within a large SCD treatment program.

Methods

Eligibility was restricted to patients with Hb SS or Hb Sβ⁰-thalassemia who were 2–18 years old between 2006–2010 and received care at St. Jude Children''s Research Hospital (N = 508). Hospitalizations and blood transfusions were calculated for each of the years under study for those exposed and never exposed to HU. Differences in number of hospitalizations before and after HU initiation were compared.

Results

The proportion of patients receiving HU increased by 4% per year on average. In the HU exposed group, a modest decline in mean per-patient hospitalizations and per-patient hospital days occurred, while those never exposed to HU trended toward a slight increase over time. Rates of blood transfusions declined among those on HU but not in patients never exposed to HU. Patients on HU had a median of one fewer hospital admission in the year after initiation of HU, compared to the year prior. Two deaths occurred in the patient population, both of whom were not exposed to HU.

Conclusions

Increasing usage of HU was concurrent with decreased hospitalization rates and blood transfusions. Our results support the utility of HU on decreasing hospitalizations and transfusions for patients with SCD outside of the clinical trial setting.     

Chronic hemorrhagic iron deficiency. Sources of hemorrhage, blood loss and systematic iron substitution

In only 121/436 (28 per cent) patients with chronic haemorrhagic iron deficiency bleeding sources could be removed by appropriate management or healed spontaneously. In 61 per cent of all cases the disease lasted from 1 year to greater than 20 years. The fall of haemoglobin per month correlated closely with blood losses per month as calculated by determinations of 59Fe whole body iron loss. Over prolonged periods estimations of the magnitude of blood loss (range 1- greater than 721 per year) based on changes of the iron status under normal diets and under systematic iron substitution. Oral iron administration with appraisable bioavailability was able to compensate blood losses up to 151 and with increasing doses up to 361 per year with maintenance of normal or borderline haemoglobin values. However, side reactions increased considerably after years and with rising doses. Under such circumstances combinations of i.v. iron, oral iron and blood transfusions were successful over prolonged periods.     

BLOOD TRANSFUSIONS AND THE Rh FACTOR

When Rh-negative persons are given transfusions of Rh-positive blood, more than 50 per cent are sensitized to the Rh₀ factor. Such sensitization of female children may be the cause of hemolytic disease in their offspring many years later, while severe hemolytic reactions may follow a second transfusion of Rh-positive blood in either sex.The gross hemolysis of transfused blood may be entirely asymptomatic, however. In one case a pint of blood was completely hemolyzed within two hours without producing symptoms. The only signs were hemoglobinuria, low grade jaundice, urobilinogenuria and a rising Rh antibody titer. The patient had previously been sensitized by a single pint of Rh-positive blood.The dangers of Rh sensitization can be avoided by routine Rh typing of all prospective recipients of transfusion, whether male or female, and by giving only Rh-negative blood to those who are Rh-negative.     

MENINGITIS—A Review of One Year's Cases from an Active Children's Hospital Service

Fifty-six cases of bacterial meningitides, other than tuberculous, observed in a period of one year on an active children''s hospital medical service were reviewed. All age groups were involved but most commonly infected were patients in the first year of life. There was no inordinate incidence of infection with any one kind of organism in any specific age bracket, except possibly for infection with enteric organisms which in the present series occurred preponderantly in infants less than six months old. Meningococcus and H. influenza type B were the most common organisms; they were the infecting agents in 71 per cent of cases. Of the immediate complications noted, subdural effusions were the most common (23 per cent of this series). In all except two cases, effusion was resolved by multiple aspirations. In two cases craniotomy was done with good results. Ten electroencephalograms were made and all were abnormal. In most of the patients, multiple antibiotic and chemotherapeutic drugs were used, parenterally during the first few days of hospitalization and then orally as tolerated. Intraspinal therapy was not given. Four of the 56 patients died.     

Use of platelet concentrate in eastern Ontario.

To better understand the reasons for the increasing use of platelet concentrate in Canada, we undertook a 4-month study of platelet concentrate transfusion in six eastern Ontario hospitals in 1985. A total of 4801 units of platelet concentrate were transfused on 687 occasions to 303 patients; the average number of transfusions per patient was 2.3, the average number of units per transfusion 7.0 and the average number of units per patient 15.8. The cardiovascular service used the largest proportion of units (28%), aortocoronary bypass grafting being the most common procedure. The mean pretransfusion platelet count for the medical and oncology services was about 30.0 X 10(9)/L, compared with 155.5 X 10(9)/L for the cardiovascular service. An increment in platelet count 1 hour after transfusion was noted with 238 (75%) of the transfusions for which the data were available; the average increment was 3.4 X 10(9)/L per unit of platelet concentrate transfused. When the data for patients who did not respond were excluded, the average increment was 6.9 X 10(9)/L. Single-donor platelet concentrate was requested for only half of the transfusions to which no response was detected. The current medical literature supports the appropriate use of platelet concentrate in patients with thrombocytopenia due to chemotherapy, but prophylactic platelet transfusion for patients undergoing cardiovascular bypass procedures is being questioned. We advise continued surveillance of the use of these products and re-evaluation of the aims of platelet transfusion therapy.     

The use of blood at a large Red Cross center; an evaluation of various aspects of utilization

During the past ten years over 1,000,000 pints of blood have been collected at the Los Angeles Regional Red Cross Blood Center. In addition to the progressive increase in the number of whole blood transfusions there has been a greater use of specific blood elements which results in purposeful and economical hemotherapy. With the increased use of blood there has also been a growing awareness of transfusion reactions and dangers. Serious transfusion complications reported have been due to bacterial contamination, to hemolytic reactions, to homologous serum jaundice, and to a mistake in cross-matching. Surgeons and anesthetists must pay strict attention to the use of blood since anesthesia masks severe hemolytic transfusion reactions. At present there is no way of eliminating the danger of the transmission of virus disease (infectious hepatitis and homologous serum jaundice) in blood transfusions.     

CONGENITAL SYPHILIS IN CALIFORNIA

Routine serologic tests for syphilis (as required by California law governing prenatal examination) and penicillin therapy during pregnancy for infected mothers have been major factors in the prevention of congenital syphilis in California during the past ten years. In 1940 one of each 822 infants had the disease, as indicated by morbidity reports of congenital syphilis in infants under the age of one year. In 1950 the ratio was one in 8,148. To determine why congenital syphilis continues to occur, a study of the 134 cases reported over a two-year period was made with the cooperation of local health officers and practicing physicians. It showed that in 76 per cent of cases the mother did not consult a physician prior to delivery or reported so late in pregnancy that the infant was born before adequate penicillin therapy could be given. In another 15 per cent syphilis developed in the mother during pregnancy after a negative reaction to a prenatal serologic test. The other 9 per cent of cases were due to various factors, such as infectious relapse or reinfection in previously adequately treated mothers. The study indicated that most cases occur in the lower socioeconomic population groups. Seventy-four per cent of cases were in infants delivered in county hospitals.