This article describes practices in patient blood management (PBM) in 4 countries on different continents that may provide insights for anesthesiologists and other physicians working in global ...settings. The article has its foundation in the proceedings of a session at the 2014 AABB annual meeting during which international experts from England, Uganda, China, and Brazil presented the programs and implementation strategies in PBM developed in their respective countries. To systematize the review and enhance the comparability between these countries on different continents, authors were requested to respond to the same set of 6 key questions with respect to their country's PBM program(s). Considerable variation exists between these country regions that is driven both by differences in health contexts and by disparities in resources. Comparing PBM strategies from low-, middle-, and high-income countries, as described in this article, allows them to learn bidirectionally from one another and to work toward implementing innovative and preferably evidence-based strategies for improvement. Sharing and distributing knowledge from such programs will ultimately also improve transfusion outcomes and patient safety.
Introduction: ABO and Rh are the major blood group systems in Transfusion Medicine, the ABO system based on two red cell antigens (A, B) while the Rh has about 50 antigens of which five are highly ...clinically significant (D, C, c, E, e). These vary among races and ethnic groups. Blood type phenotype incompatibility between mother and fetus may result in antigen mismatch, triggering alloimmunization, and thus causing hemolytic transfusion reaction (HTR), which results in hemolytic disease of fetus and newborn (HDFN). This study aimed to determine the frequencies of ABO and rhesus blood group antigen in the pregnant women in South Western Uganda. Methods: A cross-sectional study was carried out on 1369 pregnant women who were recruited and provided consent to participate during their regular antenatal visits between August 2020 and July 2021. Four milliliters (4mL) of EDTA-anti-coagulated blood samples were collected and ABO and Rh-blood grouping including Rh antigen screening was done using the agglutination technology comprised of glass beads and reagent contained in a column of the Ortho Biovue ID Micro Typing System (Ortho Clinical Diagnostics, New Jersey, USA). The Rh antigen phenotypes and frequencies were then determined. Results: There was percentage distribution of 99.8%, c 99.3%, D 94.3%, C 19.2% and E 15.9%, with Rh cDe/cDe (65.1%) being the most common phenotype followed by cDe/CDe (15%), cDe/cDE (10.8%) and cDE/cDE 0.1% least common. The ABO grouping frequency was obtained as O 49.4%, A 29.5%, B 17.0% and AB 4.1%, with D positivity at 94.3%. Discussion: Population genetic variations result in varied expressions of red cell antigens that may have clinical complications. Knowledge of the presence of these Rh antigen distributions and phenotype frequencies during pregnancy help in rational management of the pregnancy, alloimmunization and better approach to safe blood transfusion. Keywords: ABO, Rh antigens, Rh phenotypes, pregnant women, South Western Uganda
Background: Platelet transfusions play an essential supportive role in treatment of hematologic cancer patients who are predisposed to thrombocytopenia. However, the optimal platelet count threshold ...for prophylactic transfusion is unknown in sub-Saharan Africa. We sequentially lowered thresholds for prophylactic platelet transfusion in Ugandan cancer patients and measured bleeding and adherence to these thresholds.
Methods: We prospectively followed patients admitted to the Uganda Cancer Institute (UCI) with a hematological malignancy from October 2014 to October 2015 in 3 sequential 4-month time-periods using incrementally lower thresholds for prophylactic platelet transfusion: platelet counts ≤ 30 x 109/L in period 1, ≤ 20 x 109/L in period 2, and ≤ 10 x 109/L in period 3. Clinically significant bleeding was defined as WHO grade ≥ 2 bleeding. The number of platelet units that UCI requested and received during the study period was abstracted from the Uganda Blood Transfusion Service records. We used GEE to compare the frequency of clinically significant bleeding, platelet transfusions, and log10-transformed platelet counts by study period, adjusting for age, sex, cancer type, chemotherapy, baseline platelet count, and baseline hemoglobin. Cox regression was used to compare survival by period.
Results: Overall, 188 patients were enrolled. The median age was 18 years (range 1-78), 26 (range 1-80) and 22 (range 2-75) in each period; 56-64% were male. Previous or current chemotherapy use was similar among the 3 periods and ranged from 39-45% of participants. Acute lymphoblastic leukemia, acute myeloid leukemia, and non-Hodgkin lymphoma accounted for most malignancies. Sixty-two patients in period 1 accrued 998 days of follow up, 69 in period 2 accrued 1300 days, and 57 in period 3 accrued 1047 days. The geometric mean platelet count x109/L was 36 (range 0-730) in period 1, 26 (range 0-723) in period 2, and to 21 (range 1-924) in period 3 (adjusted p = 0.55). Platelet transfusions were given to 42%, 55% and 45% of patients and on 65/842 (8%), 154/1268 (12%) and 84/1058 (8%) days for the 3 time periods. In adjusted models, period 3 had significantly fewer transfusions than period 1 (RR = 0.6, 95% CI 0.4-0.9; p = 0.01) and period 2 (RR=0.5, 95% CI 0.4-0.7; p<0.001). Most (54-60%) platelet transfusions were given as prophylaxis for low platelets only. The median pre-transfusion platelet counts x109/L were 10 (range 0-62), 7 (range 0-73), and 5 (range 1-35) for the 3 periods, respectively. The mean number of 60-80mL platelet concentrate units requested for the entire UCI per day was 17 for period 1, 21 for period 2, and 25 for period 3 but the mean platelet units received was only 5.8, 6.4 and 7.7, respectively.
Among all days with platelet counts below the trigger threshold, platelet transfusions were given within 1 day of the low platelet counts on 29 (32%) days in period 1, 76 (46%) days in period 2, and 40 (34%) in period 3. Platelet transfusions were rarely given for prophylaxis when platelet counts were above the threshold, and the overall number of days that transfusions were given according to our defined thresholds was 132 days (68%) in period 1, 241 days (72%) in period 2 and 224 (74%) in period 3.
Eighteen patients (30%), 23 (30%) and 15 (23%) had clinically significant bleeding on at least one day in period 1, 2 and 3, respectively. Of the 559 total days with bleeding assessed, clinically significant bleeding was noted on 45 days (8%) of 559 patient-days in time period 1, 72/809 (9%) days in period 2 and 38/755 (5%) in period 3 (p = 0.41 in adjusted analyses). Thirteen (21%) patients died in period 1, 15 (22%) in period 2, and 11 (19%) in period 3 (p = 0.72 in adjusted analyses).
Conclusion:Platelet counts were low among UCI inpatients with hematological malignancies and platelet transfusions were given to nearly half of patients. Low availability of blood products likely hindered clinicians' ability to provide transfusions when platelet counts dropped below our defined trigger thresholds, but overall adherence was good. Lowering the threshold for platelet transfusion led to fewer transfusions and did not change the incidence of clinically significant bleeding or mortality, suggesting that a threshold of 10 x 109/L platelets used in resource-rich countries may be a safe level for transfusions in Uganda.
No relevant conflicts of interest to declare.
Introduction: Maternal red cell alloimmunization to Rh antigen in pregnant women occurs when the immune system is sensitized by foreign red blood cell surface antigens, in this case fetal red blood ...cells, inducing an immune response. Various antigens of blood group systems may cause alloimmunization, especially the Rh, Kel, Fy, JK, and MNS systems. This study aimed to determine alloimmunization to the different frequencies of Rh antigen among pregnant women in South Western Uganda. Methods: A total of 1369 pregnant women consented and were recruited into a cross-sectional study during their regular antenatal visits during the period August 2020 to July 2021. Samples (4 mL) of anticoagulated and coagulated blood were obtained, and Rh blood grouping including Rh antigen and the indirect antiglobulin test (IAT) was carried out using the agglutination technology of the LISS ID-Card technique in the Ortho Biovue ID-Micro Typing System. Results: Out of 1369 participants recruited to the study, 78 (5.7%) were D.sup.-, 1291 were D.sup.+, and 134 (9.8%) had alloantibodies. Among those with alloantibodies, 115 (85.8%) were D.sup.+ and 19 (14.2%) D.sup.-. The percentage alloimmunization according to the Rh antigens was highest in e (9.72%), c (2.48%), C (2.34%) and E (0.94%) antigens. With the ABO system, alloimmunization was highest in blood group B (10.7%), followed by A (10.6%), O (9.2%) and then AB (7.1%). Alloimmunization was more prevalent in D.sup.- (24%) than in D.sup.+ participants (8.9%). Rhesus antigen e was the most prevalent antigen (99.8%), followed by c. The alloimmunization rate of 9.8% among these participants is high, and appears in both D.sup.+ and D.sup.- women. The other Rhesus antigens are seen to cause alloimmunization, with antigen e causing the highest prevalence. In conclusion, there is a need to identify antibodies and study the outcome for clinical significance, especially in D.sup.+ women, to facilitate proper pregnancy management. Keywords: Rh alloimmunization, Rh antigens, hemolytic disease of the fetus and newborn, pregnant women, Western Uganda
Optimal decision making regarding blood transfusion for patients with cancer requires appropriate knowledge of transfusion medicine among physicians. We assessed blood transfusion knowledge, ...attitudes, and reported practices among physicians working at Uganda Cancer Institute (UCI).
A cross-sectional self-administered survey of UCI physicians on their knowledge, attitudes, and practices regarding blood transfusion was conducted from June to September 2014. In consultation with transfusion medicine experts, 30 questions were developed, including 10 questions for each of the following three domains: knowledge, attitudes, and practices. For the knowledge domain, we created a knowledge score equal to the number of questions correctly answered out of 10.
Of 31 physicians approached, 90% participated. The mean knowledge score was 5.3 (median, 5.5), and 32% correctly answered at least seven of 10 questions. Almost all (96%) understood the importance of proper patient identification before transfusion and indicated identification error as the most common cause of fatal transfusion reactions. More than 60% of physicians acknowledged they lacked knowledge and needed training in transfusion medicine. Most physicians reported sometimes changing their mind about whether to provide a patient with a transfusion on the basis of opinion of colleagues and sometimes administering unnecessary transfusions because of influence from others.
Although UCI physicians have some basic knowledge in transfusion, most reported gaps in their knowledge, and all expressed a need for additional education in the basics of blood transfusion. Transfusion training and evidence-based guidelines are needed to reduce inappropriate transfusions and improve patient care. Greater understanding of peer influence in transfusion decision making is required.
Abstract In November 2014, a 3-day conference devoted to transfusion medicine in sub-Saharan Africa was held in Kampala, Uganda. Faculty from academic institutions in Uganda provided a broad overview ...of issues pertinent to transfusion medicine in Africa. The conference consisted of lectures, demonstrations, and discussions followed by 5 small group workshops held at the Uganda Blood Transfusion Service Laboratories, the Ugandan Cancer Institute, and the Mulago National Referral Hospital. Highlighted topics included the challenges posed by increasing clinical demands for blood, the need for better patient identification at the time of transfusion, inadequate application of the antiglobulin reagent during pretransfusion testing, concern regarding proper recognition and evaluation of transfusion reactions, the expanded role for nurse leadership as a means to improve patient outcomes, and the need for an epidemiologic map of blood usage in Africa. Specialty areas of focus included the potential for broader application of transcranial Doppler and hydroxyurea therapy in sickle cell disease, African-specific guidelines for transfusion support of cancer patients, the challenges of transfusion support in trauma, and the importance of African-centered clinical research in pediatric and obstetric transfusion medicine. The course concluded by summarizing the benefits derived from an organized quality program that extended from the donor to the recipient. As an educational tool, the slide-audio presentation of the lectures will be made freely available at the International Society of Blood Transfusion Academy Web site: http://www.isbtweb.org/academy/.
There are limited published data on the characteristics of blood transfusion recipients in sub-Saharan Africa. This study describes the demographic characteristics of blood transfusion recipients and ...patterns of blood and blood component use in Zimbabwe.
Data on the characteristics of the blood transfusion recipients (age, sex, blood group), blood components received (type, quantity), discharge diagnoses and outcomes following transfusion (discharge status, duration of stay in hospital), were retrospectively collected from four major hospitals for the period from January 1, 2012 to December 31, 2012. Diagnoses were grouped into broad categories according to the disease headings of the International Classification of Diseases (ICD-10). Surgical procedures were grouped into broad categories according to organ system using ICD-9.
Most of the 1,793 transfusion recipients studied were female (63.2%) and in the reproductive age group, i.e. 15-49 years (65.3%). The median age of the recipients was 33 years (range, 0-93). The majority of these recipients (n=1,642; 91.6%) received a red blood cell transfusion. The majority of the patients were diagnosed with conditions related to pregnancy and childbirth (22.3%), and diseases of blood and blood-forming organs (17.7%). The median time spent in hospital was 8 days (range, 0-214) and in-hospital mortality was 15.4%.
Our sample of blood transfusion recipients were fairly young and most of them received red blood cell transfusions. The majority of patients in the reproductive age group received blood transfusions for pregnancy and childbirth-related diagnoses.
Background and Objectives The interface between preparation and use of blood impacts directly on the outcome of hemotherapy. The present study explores the knowledge and opinions of key players at, ...practical realities at, and quality improvement strategies of this interface.
Materials and Methods We surveyed clinicians (n = 81) and blood bank staff (n = 25) to assess their knowledge on key issues in their counterparts’ working domains, the turnaround time on effecting a blood order from a hospital transfusion laboratory and strategies to improve communication of blood needs to blood banks.
Results Out of 81 clinicians, 20 knew the four available blood products while only 17 knew the three uses of these products. Twenty‐three blood bank staff reported the patient’s condition as the main factor on which blood orders are based. Forty‐four (54.3%) clinicians reported reception of a blood product within an hour of placing the order. Addressing infrastructure and human resource were some of the strategies suggested to improve this step of the transfusion chain.
Conclusions The knowledge of staff at the extreme ends of the clinical interface in their counterparts’ working domain is far from adequate. However, they have well formed opinions on strategies to improve this interface.
Background: A number of factors come into play in determining the timing of an elective surgical intervention, particularly in the developing world. The present study explores the factors that ...contribute to the timing of elective surgery and patients' opinions on their quality of life as they wait for surgery. Methods: We followed adult patients with delayed elective surgical interventions (n=204). The causes for the delay and, particularly, the influence of blood shortage on the timing of the procedure were noted. Patients' perceptions on their quality of life as they waited for surgery were also noted. Results: We were able to establish a cause for delayed elective surgery in 133 patients. Shortage of operating space was the leading cause of surgery delay in 44 patients, while blood shortage followed closely in 40 patients. The higher the amount of blood ordered for use in the perioperative time, the longer the delay to surgery (P=0.001). Patients waiting for surgery had a low opinion of their in-hospital quality of life. Here, the key indicators included the threat of losing a job, limited family time, and an increase in day-to-day living costs. Conclusion: Blood shortage is the second most common cause of the delayed performance of elective surgical interventions in our institution. The patients have a low opinion on their quality of life as they wait for surgery.
Musculoskeletal injuries are a common cause of morbidity after road traffic injury (RTI) in motorizing countries. District hospitals provide front-line orthopedic care in Uganda and other sub-Saharan ...African nations. Improving care at the district hospital level is an important component of the World Health Organization's strategy for surgical and trauma systems strengthening, but the data necessary to inform RTI safety and care initiatives has previously been insufficient at the district hospital level. The objective of this study was to provide data on the patient population and patterns of musculoskeletal injury caused by RTI at Ugandan district hospitals.
In this cross-sectional study, all patients with musculoskeletal injuries identified on x-ray presenting to three Ugandan district hospitals from October 2013 to January 2014 were interviewed and examined to obtain data on patient demographics and injury context by road user category. This manuscript is a sub-group analysis of RTI victims from a broader dataset of all musculoskeletal injuries.
Vulnerable road users comprised 92 % of musculoskeletal RTI patients, with 49 % (95 % CI 41-57 %) pedestrians, 41 % (95 % CI 33-49 %) motorcyclists, and 2 % (95 % CI 0-4 %) cyclists. Commonly injured subgroups included student pedestrians (33 % (95 % CI 22-44 %) of pedestrians) and motorcyclists with less than a post-secondary education (74 % (95 % CI 63-85 %) of motorcyclists). The morning hours were the most common time of injury for all RTI patients (37 %%; 95 % CI 30-44 %) and motorcyclists (46 %; 95 % CI 34-58 %), while pedestrians were most commonly injured in the evening (32 %; 95 % CI 21-43 %).
By demonstrating commonly injured demographic groups and high frequency times of day for injury, this surveillance study of musculoskeletal RTI suggests targeted avenues for future road safety research in the districts of Uganda. Compared with previous studies from the capital of Uganda, these results suggest that Ugandan district hospitals care for a disproportionate share of vulnerable road users, a discrepancy which may pertain to other sub-Saharan African nations, as well. Strengthening district hospital orthopedic care should be considered a priority of strategies aimed at improving outcomes for these vulnerable groups.
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