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.     

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.     

Hemolytic Transfusion Reactions

After receiving apparently compatible blood three patients suffered hemolytic reactions. The compatibility tests were by saline and indirect Coombs technique including a screening tube of group 0 cells. The antibodies responsible for these reactions were not clearly demonstrable for several days following the transfusion. In two instances the antibody was anti-E.These case reports point up the following. (a) Currently used cross-matching procedures will occasionally fail to demonstrate an incompatibility. (b) In two of the cases the direct Coombs test was negative on an immediate post-transfusion specimen, when it could have been of great aid in diagnosis. (c) When a transfusion reaction of hemolytic type is suspected, a follow-up study several days after the reaction may clarify the diagnosis; when possible, transfusions should be avoided in the interim.     

Blood transfusion effects in kidney transplantation

Within the three decades since the beginnings of the field of clinical renal transplantation there have been four phases in blood transfusion policies, swinging from liberal transfusions to avoidance of transfusions, followed by a repeat cycle of deliberate transfusions and at present turning back to abstinence again. Because of improving skills at the prevention and treatment of rejections, the beneficial effects of random transfusions in the transplant population as a whole is marginal. This comes at a time when community fears of blood-borne infections and the prospects of supporting red cell production by the use of EPO have emerged as new factors in blood banking. Observations on patients at risk for graft loss, namely those having rejection episodes, indicate that a beneficial blood transfusion effect still exists, however. Future application of deliberate HLA antigen exposure in conjunction with novel immunological manipulations may provide a more effective avenue to tolerance induction. The use of blood transfusions matched for one HLA-DR antigen with the recipient has produced major benefits in preliminary trials and represents one starting point in this direction.     

Problems of multiple transfusions

The use of blood infusion in large amounts is increasing sharply. Increased knowledge of blood group antigens has alerted physicians to the possible hazards of hemolytic reactions to subgroups that must be eliminated by proper cross-matching techniques. Multiple transfusions of preserved blood often defeat their purpose in control of bleeding, for thrombocytopenia is enhanced. Careful selection of blood or preparations of plasma concentrates offer increased protection to the recipient.Plastic bag equipment increases the yield of viable platelets and keeps blood in usable condition for longer periods of storage. The use of multiple transfusions has complicated the selection of preserved blood to control pigment metabolism.     

Intrauterine blood transfusions in the treatment of severe serologic conflict]

Efficacy of the intraperitoneal and intravenous blood transfusions guided ultrasonographically was evaluated in severe cases of fetal hemolytic disease due to Rh conflict. It was shown, that survival rate of fetuses without generalized edema is two-fold higher in the group treated with intraperitoneal blood transfusions in comparison with the control group. It was found, that the proportion of erythrocytes containing HbA in umbilical blood of newborn is related to the number of intraperitoneal transfusions. One has to underline the failure of such a treatment in features with generalized edema. In such case intravenous blood transfusion is a method of choice.     

The use of recombinant erythropoietin in the reduction of blood transfusion rates in craniosynostosis repair in infants and children

The vast majority of infants and children undergoing craniosynostosis correction receive a blood transfusion. The risks of blood transfusion include, but are not limited to, acute hemolytic reactions (approximately 1 of 250,000), human immunodeficiency virus (approximately 1 of 200,000), hepatitis B and C (approximately 1 of 30,000 each), and transfusion-related lung injuries (approximately 1 of 5000). This prospective, single-blinded, randomized study was undertaken to examine the safety and efficacy of preoperative single weekly dosing with erythropoietin (epoetin alfa) in reducing the rate of transfusion in infants and small children undergoing craniosynostosis repair. A total of 29 patients (<8 years) undergoing craniosynostosis repair were randomized into two groups: one received preoperative erythropoietin (600 U/kg) weekly for 3 weeks, and the other served as a control. All caregivers responsible for blood transfusions were blinded, and strict criteria for transfusion were established. A pediatric hematologist monitored both groups, and all patients received supplemental iron (4 mg/kg). Fourteen patients were randomized to receive erythropoietin, and eight of these 14 patients (57 percent) required transfusion (mean age, 17 months; mean weight, 10.1 kg). Of the six patients not requiring transfusion, three were younger than 12 months old (mean, 6 months). Fourteen of 15 patients (93 percent) in the control group (mean age, 13 months; mean weight, 9.3 kg) required a blood transfusion during the study. The only control patient not requiring transfusion was the eldest (5 years old). The difference between the two groups was statistically significant (Fisher's exact test = 0.03). The control group showed no change in hemoglobin levels from baseline to preoperative levels, but the erythropoietin group increased their average hemoglobin levels from 12.1 to 13.1 g/dl. There were no adverse effects noted among children receiving erythropoietin, nor were there any surgical complications. The authors conclude that the preoperative administration of erythropoietin significantly raised hemoglobin levels and reduced the need for a blood transfusion with craniosynostosis correction. More suggestions are made that may further reduce the need for blood transfusions, and a cost-benefit analysis is discussed.     

Leukocyte-depleted blood: a comparison of available preparations.

Febrile nonhemolytic transfusion reactions due to leukoagglutinins are frequently seen in patients who have been given multiple blood transfusions. To prevent or reduce the severity of these reactions, leukocyte-poor blood (that containing fewer than 0.3 X 10(9) leukocytes per unit) is frequently requested by clinicians. Four methods commonly used in Canada to produce leukocyte-poor blood were examined for their relative effectiveness and appropriate use. The mean total leukocyte count per unit was reduced to 0.22 X 10(9) in buffy-coat-poor red blood cell preparations produced by centrifugation with the blood bag inverted, to 0.19 X 10(9) by perfusion through an Imugard filter, to 0.21 X 10(9) by the use of an IBM 2991 automated cell washer and to 0.13 X 10(9) with the use of frozen blood. The proportion of red cells recovered varied from 62% with the inverted-spin method to 85% with the use of frozen blood. Comparison of these data and the percentage of leukocytes removed, the shelf life of the product, the cost of supplies and the preparation time indicated that the use of sophisticated machinery, such as the IBM cell washer, or of glycerolization plus washing of frozen cells is not warranted for most patients. Instead, patients who have febrile nonhemolytic transfusion reactions should initially be treated with a leukocyte-poor red cell preparation produced by the inverted-spin method; only if such reactions recur should the blood bank be requested to provide filtered, washed or frozen red cells.     

History of the research on differentiating Hepatitis A and B]

The numerous researches devoted to 'jaundice' during the Second World War have brought to light the existence of an infectious type of hepatic jaundice or 'homologous serum jaundice' following parenteral injection of vaccines containing human serum and blood transfusions, which were carried out on a large scale at the time. This type of serum jaundice was then gradually differentiated from 'catarrhal', contagious or epidemic jaundice by clinical trials along with large series of animal studies. Finally, the epidemiological, clinical and biological data obtained made it possible to establish, between 1944 and 1954, the viral etiology of these two types of jaundice: the A virus, present in the patients' blood and stools, was considered to be the agent responsible for epidemic hepatitis; the B virus, present primarily in the blood, was held to be responsible for serum hepatitis.     

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.     

Blood salvage, proper choice for tumor patients?

Blood transfusion is frequently used in tumor patients, However, allogeneic blood transfusion have been claimed to be associated with an increased risk of negative outcomes, including transfusion reactions, fever, virus transmission, and alloimmunization. Other risks of homologous transfusion specific to the tumor patients are the potential deleterious effects on the recurrence of tumor and indefinite overall survival. On the contrary, autologous blood transfusion offers survival advantages to tumor patients and has been shown to minimize the occurrence of many detrimental allogeneic blood associated effects and complications. It also reduces the volume of banked blood needed and improves the prognosis of patients. However, the quality of salvaged blood is still a matter of debate, because it may contain tumor cells which are associated with potential detrimental effects such as metastasis. So, an advanced technology is needed to remove such contaminants to make autologous blood transfusion safer.     

Blood salvage,proper choice for tumor patients?

Blood transfusion is frequently used in tumor patients, However, allogeneic blood transfusion have been claimed to be associated with an increased risk of negative outcomes, including transfusion reactions, fever, virus transmission, and alloimmunization. Other risks of homologous transfusion specific to the tumor patients are the potential deleterious effects on the recurrence of tumor and indefinite overall survival. On the contrary, autologous blood transfusion offers survival advantages to tumor patients and has been shown to minimize the occurrence of many detrimental allogeneic blood associated effects and complications. It also reduces the volume of banked blood needed and improves the prognosis of patients. However, the quality of salvaged blood is still a matter of debate, because it may contain tumor cells which are associated with potential detrimental effects such as metastasis. So, an advanced technology is needed to remove such contaminants to make autologous blood transfusion safer.     

ALLERGIC IMPLICATIONS OF BLOOD DISORDERS IN INFANCY AND CHILDHOOD

The clinical manifestations of many of the blood disorders are wholly or partially dependent on immunoallergic reactions. A growing body of evidence permits the characterization of antigenantibody mechanisms in connection with hemolytic anemia, purpura and agranulocytosis, and more specifically for each of the blood cell elements and for the vessel wall.These reactions extend to maternal-fetal relationships producing well defined blood disorders manifest at birth or in the neonatal period.Once the effects of the hypersensitive state are set in motion during the course of a blood disorder, therapeutic measures to slow their progress are often futile. Because it is not always possible to identify the potentially allergic child in whom these circumstances will occur, it is extremely important to weigh the advantages of the use of a drug before it is administered especially when its side effects have not yet been thoroughly investigated.Important information has recently been obtained regarding the heightened susceptibility to infection in children with chronic anemia who have had splenectomy to reduce the frequency of transfusions. The hypersensitive responses in children with spleen removed may result in overwhelming and often fulminating infections necessitating rigid criteria in selecting patients of the pediatric age for this operation.     

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.     

Supportive care including growth factors in myelodysplastic syndromes

In spite of recent advances in the treatment of myelodysplastic syndromes (MDS), supportive care remains a very important part of the therapy. Red blood cells transfusions are the most important component of this supportive care. They transiently relieve anemia symptoms and alleviate their effects on quality of life and daily functioning. Platelet transfusion therapy is less frequently needed, at least in low-risk MDS. Dealing with an increased risk of infections linked to neutropenia, mainly by broad spectrum antibiotics, is also needed, more often in advanced stages of [dict: MDS] or when the MDS evolves to acute myeloid leukemia. Chronic red blood cell transfusions expose patients to various side-effects, including blood components intolerance reactions and alloimmunization risks, but also increased frequency of iron overload, a more significant problem in low-risk heavily transfused MDS patients, who have prolonged life expectancy. The use of growth factors is becoming a more and more important part of current supportive care. High-dose erythropoietin is able to reduce or suppress red blood cell transfusions needs in selected subgroups of MDS. The short-term use of granulocyte colony-stimulating factor is also often proposed in infections, although not formally established by prospective trials. Although trials of growth factors with thrombopoeitic activity have been performed with interleukin 11 and are underway with thrombopoeitin, none of them are available for routine use.     

Effect of phototherapy on the frequency of the use of exchange transfusion in the treatment of neonatal jaundice

The authors analysed an incidence of performed exchange blood transfusions at the newborn babies ward prior to and after introduction of phototherapy into practice. This analysis included the causes of jaundice in newborn. The study included the causes of jaundice in newborn. The study involved 8,937 newborn babies delivered between 1981 and 1985. Prior to phototherapy (period between January, 1981 and July, 1980), 45 blood transfusions and 9 retransfusions were performed. During the period II (between July, 1983 and December, 1985), i.e. phototherapy, 30 blood transfusions and 1 retransfusion were effected despite of the higher number of delivered babies. The obtained results have shown favourable effect of the phototherapy in jaundice of perinatal period, especially in jaundice unconnected with blood Rh factor conflict and in premature babies. Phototherapy decreased the number of performed transfusions and retransfusions.     

CRITERIA FOR BLOOD TRANSFUSIONS

A review of the use of blood transfusions used in a small community hospital over a two-year period revealed a high incidence of instances in which the clinical record did not show essential need for the procedure. Educational efforts in hospital staff meetings resulted in some improvement in this respect during the two-year period. Of single unit transfusions given during the first year, 80 per cent were deemed to have been nonessential; during the second year, 52 per cent.Methods which will reduce the use of blood except when it is essential are (1) continuation of staff education; (2) providing the staff with accurate methods of measurement of blood volume and of monitoring blood loss; (3) use of a separate blood transfusion chart in the patient''s hospital record; and (4) establishment of a hospital transfusion committee to review the criteria in all cases in which blood is transfused.     

Clinical use of rHuEPO in bone marrow transplantation

Recipients of bone marrow (BMT) or peripheral blood progenitor stem cells (PBSCT) transplant have in the period following transplantation a frequent need for red blood cell transfusions and therefore an increased risk of blood-transmitted infections. The anaemia is caused mainly by myelosuppression after high-dose chemotherapy, but an impaired erythropoietin (EPO) production and an inappropriate EPO response may also contribute. Since recombinant human erythropoietin (rHuEPO) has been established as a treatment for renal anaemia it has been of interest whether treatment may be of benefit in the transplant setting. This paper gives an overview of the studies conducted to date with rHuEPO treatment in patients receiving bone marrow transplants. Current data donot support any transfusional benefits when rHuEPO is used in patients receiving autologous transplants. However, in patients receiving allogeneic transplants several studies clearly indicate a therapeutic role for rHuEPO with patients showing accelerated erythroid engraftment, increased haemoglobin levels, a reduced requirement for red blood cell transfusions, and a shortened time to transfusion independence. Especially patients with immune haemolysis after transplantation seems to benefit from the treatment. In addition, rHuEPO treatment has been used for lateonset anaemia after BMT and to prevent the need for homologous red blood cell transfusions to the BMT donor. To reduce costs, it is important in future studies to identify not only the optimal dose and route of administration of rHuEPO but also the most effective combination with other haematopoietic growth factors and cytokines that are used before and after transplantation.     

Transfusion strategy for patients in therapeutic aplasia. Experience of the Henri Mondor Hospital apropos of 2 successive protocols

Retrospective analysis of two transfusion protocols applied in our institution to the bone marrow transplanted patients was conducted. Granulocyte transfusions should be only proposed as a therapeutic treatment to patients with severe well documented bacterial infection resistant to an adapted antibiotherapy. Leukocyte-depleted blood products reduce the incidence of HLA-immunization but do not influence the frequency of CMV infections. Random single donor platelet concentrates (obtained by cytapheresis) could decrease the incidence of polyspecific HLA-antibodies in comparison with the use of random standard platelet concentrates. The best transfusion protocol should associate leukocyte-depleted blood products with transfusion of prophylactic single donor platelet concentrates. In our institution, this protocol is less expensive than the protocol with prophylactic white blood cell transfusions and has the same cost than other protocols using standard blood products.     

The Efficacy and Cost-Effectiveness of Cell Saver Use in Instrumented Posterior Correction and Fusion Surgery for Scoliosis in School-Aged Children and Adolescents

Posterior spinal instrumentation and fusion surgery in school-aged children and adolescents is associated with the potential for massive intraoperative blood loss, which requires significant allogeneic blood transfusion. Until now, the intraoperative use of the cell saver has been extensively adopted; however, its efficacy and cost-effectiveness have not been well established. Therefore, the aim of this study is to determine the efficacy and cost-effectiveness of intraoperative cell saver use. This study was a single-center, retrospective study of 247 school-aged and adolescent patients who underwent posterior spinal instrumentation and fusion surgery between August 2007 and June 2013. A cell saver was used intraoperatively in 67 patients and was not used in 180 patients. Matched case-control pairs were selected using a propensity score to balance potential confounders in baseline characteristics. Allogeneic red blood cell (RBC) and plasma transfusions as well as blood transfusion costs were analyzed. The propensity score matching produced 60 matched pairs. Compared to the control group, the cell saver group had significantly fewer intraoperative allogeneic RBC transfusions (P = 0.012). However, when the combined postoperative and total perioperative periods were evaluated for the use of allogeneic RBC transfusion, no significant differences were observed between the two groups (P = 0.813 and P = 0.101, respectively). With regard to the total cost of perioperative transfusion of all blood products (RBC and plasma), costs for the control group were slightly lower than those of the cell saver group, but this variance did not reach statistical significance (P = 0.095). The use of the cell saver in posterior spinal instrumentation and fusion surgery in school-aged children and adolescents was able to decrease the amount of intraoperative allogeneic RBC transfusion but failed to decrease total perioperative allogeneic RBC transfusion. Moreover, the use of the cell saver was not cost-effective.