Update on massive transfusion Pham, H.P.; Shaz, B.H.
British journal of anaesthesia : BJA,
12/2013, Letnik:
111, Številka:
suppl_1
Journal Article
Recenzirano
Odprti dostop
Massive haemorrhage requires massive transfusion (MT) to maintain adequate circulation and haemostasis. For optimal management of massively bleeding patients, regardless of aetiology (trauma, ...obstetrical, surgical), effective preparation and communication between transfusion and other laboratory services and clinical teams are essential. A well-defined MT protocol is a valuable tool to delineate how blood products are ordered, prepared, and delivered; determine laboratory algorithms to use as transfusion guidelines; and outline duties and facilitate communication between involved personnel. In MT patients, it is crucial to practice damage control resuscitation and to administer blood products early in the resuscitation. Trauma patients are often admitted with early trauma-induced coagulopathy (ETIC), which is associated with mortality; the aetiology of ETIC is likely multifactorial. Current data support that trauma patients treated with higher ratios of plasma and platelet to red blood cell transfusions have improved outcomes, but further clinical investigation is needed. Additionally, tranexamic acid has been shown to decrease the mortality in trauma patients requiring MT. Greater use of cryoprecipitate or fibrinogen concentrate might be beneficial in MT patients from obstetrical causes. The risks and benefits for other therapies (prothrombin complex concentrate, recombinant activated factor VII, or whole blood) are not clearly defined in MT patients. Throughout the resuscitation, the patient should be closely monitored and both metabolic and coagulation abnormalities corrected. Further studies are needed to clarify the optimal ratios of blood products, treatment based on underlying clinical disorder, use of alternative therapies, and integration of laboratory testing results in the management of massively bleeding patients.
The natural history of heparin‐induced thrombocytopenia (HIT) in the absence of thrombosis was previously established using functional assays for confirmation of diagnosis (e.g. 14C serotonin release ...assay). An enzyme‐linked immunosorbent assay (ELISA) that detects the presence of antibodies directed against the heparin–platelet factor‐4 (PF4) complex has largely replaced functional assays in many medical centers. Although the ELISA is highly sensitive for detecting HIT antibodies, its usefulness for predicting thrombotic outcomes has not been clearly established. We performed a retrospective chart review of all hospitalized patients at a university hospital who tested seropositive for HIT by a commercial ELISA during 2001 and 2002. A total of 63 inpatients were identified as HIT positive by ELISA. Forty‐eight patients had no apparent HIT‐associated thrombosis at the time of HIT seropositivity (i.e. isolated HIT) and only one was treated prophylactically with a direct thrombin inhibitor. The 30‐day thrombosis rate for patients with isolated HIT was 17% (eight of 48). Higher ELISA optical density (OD) measurements correlated significantly with thrombosis (1.41 ± 0.87 vs. 0.79 ± 0.46, P < 0.001). Patients with isolated HIT and an OD measurement of ≥ 1.0 demonstrated nearly a 6‐fold increased risk of thrombosis compared with those with OD values between 0.4 and 0.99 (odds ratio 5.74, 95% confidence interval 1.73, 19.0; absolute rate of thrombosis, 36% vs. 9%, respectively, P = 0.07). We conclude that in hospitalized patients with isolated HIT, the presence of heparin–PF4 antibodies detected by ELISA was associated with a significant risk of subsequent thrombosis and higher ELISA values were observed among patients suffering thrombotic events.
BACKGROUND: In the United States, African Americans donate at approximately half the rate of whites and therefore are underrepresented in the volunteer blood donor pool. The goal of this study was to ...identify motivators and barriers to African Americans donating blood.
STUDY DESIGN AND METHODS: A consortium of 15 predominantly African American churches of varying denominations in metropolitan Atlanta, Georgia, participated in an 81‐item self‐administered survey. The questionnaire was designed to assess participant's demographic background, blood donation frequency, motivators and barriers to donation, knowledge and beliefs regarding donation, and overall health status.
RESULTS: A total of 930 participants completed the survey: 72% female, 55% age 40 or older, 99% African American, and 58% college‐educated. The most frequent reported motivators were donating to help save a life (96%) and donating because blood is needed (95%), while the most frequent barriers were that they rarely think about it and they were afraid, nervous, or anxious to give blood (35%). The association of barriers with donation status, age, gender, and education level was stronger than for motivators. Fear was more common in nondonors than lapsed and current donors, youngest compared to older adults, and women than men and less in those with higher income.
CONCLUSION: Motivators and barriers to blood donation in African American church attendees differ depending on the respondents' demographics. To increase the effectiveness of church drives, donor recruitment should focus on addressing these barriers and motivators.
Massive transfusion is an essential part of resuscitation efforts in acute trauma patients. The goal is to quickly correct trauma-induced coagulopathy and replace red blood cell (RBC) mass with the ...minimal number as well as the appropriate choice of blood components to minimize the possible adverse effects of transfusions. Early trauma induced coagulopathy (ETIC) is present in about 20% of patients upon hospital admission and predicts for decreased survival. The mechanism of ETIC is still being elucidated; however, most theories of ETIC's pathophysiology justify the early use of plasma. Most massive transfusion protocol (MTP) ratios deliver blood products in a ratio of 1:1:1 for RBCs:plasma:platelets, which is supported by the majority of the literature demonstrating improved patient survival with higher ratios (>1 plasma and platelet for every 2 RBCs transfused). Indeed, formula-driven MTPs allow trauma services to react quickly to ETIC and provide coagulation factors and platelets in these ratios without having to wait for the results of coagulation assays while the patient's coagulopathy worsens. New MTPs are being created which are adjusted according to an individual's coagulation laboratory values based on point-of-care laboratory tests, such as thromboelastography. When creating an MTP, product wastage due to inappropriate activation and improper product storage should be considered and closely monitored. Another area of discussion regarding transfusion in trauma includes the potential association of prolonged storage of RBCs and adverse outcomes, which has yet to be confirmed. Significant progress has been made in the transfusion management of trauma patients, but further studies are required to optimize patient care and outcomes.
BACKGROUND: Presenting blood donors are screened to ensure both their safety and that of the recipients of blood products. Donors with identified risks are deferred from donating blood either ...temporarily or permanently. Minorities are underrepresented as donors in the United States and this may in part be a result of increased donor deferral rates in minorities compared to white individuals.
STUDY DESIGN AND METHODS: Data consisted of deferred and successful blood donor presentations to the American Red Cross Southern Region in the metropolitan Atlanta area in 2004 to 2008. Bivariate and multivariate analyses were conducted by race/ethnicity, age group, and sex.
RESULTS: A total of 586,159 voluntary donor presentations occurred in 2004 to 2008, of which 79,214 (15.6%) resulted in deferral. In the age 16 to 69 years subset (98.3% of the presentations), deferred presentations were mostly women (78.2%). The most common reason for donor deferral was low hemoglobin (62.6%). The donor deferral rate varied by race/ethnicity, age, and sex: whites (11.1%), Hispanics (14.1%), and African Americans (17.9%); 16‐ to 19‐year‐olds (17.0%) and 50‐ to 59‐year‐olds (11.7%); and females (20.0%) and males (6.2%). Compared to whites and Hispanics, African American females had the highest deferral rate in each age group.
CONCLUSIONS: Minorities are disproportionately impacted by blood donor deferrals. Methods to decrease blood donor deferral rates among African Americans are needed.
Introduction
In vitro qualitative differences exist in red cell concentrates (RCCs) units processed from whole blood (WB) depending on the method of processing. Minimal literature exists on ...differences in processing and variability in quality data. Therefore, we collected information from blood manufacturers worldwide regarding (1) details of WB collection and processing used to produce RCCs and (2) quality parameters and testing as part of routine quality programmes.
Methods
A secure web‐based survey was developed, refined after pilot data collection and distributed to blood centres. Descriptive analyses were performed.
Results
Data from ten blood centres in nine countries were collected. Six blood centres (60%) processed RCCs using the top‐and‐top (TAT) method which produces RCCs and plasma, and eight centres (80%) used the bottom‐and‐top (BAT) which additionally produces buffy coat platelets. Five of the centres used both processing methods; however, four favoured BAT processing. One centre utilized the Reveos automated system exclusively. All centres performed pre‐storage leucoreduction. Other parameters demonstrated variability, including active cooling at collection, length of hold before processing, donor haemoglobin limits, acceptable collection weights, collection sets, time to leucoreduction, centrifugation speeds, extraction devices and maximum RCC shelf life. Quality marker testing also differed amongst blood centres. Trends towards higher RCC unit volume, haemolysis and residual leucoctyes were seen in the TAT compared with BAT processing across centres.
Conclusion
Methods and parameters of WB processing and quality testing of RCCs differ amongst surveyed blood manufacturers. Further studies are needed to assess variations and to potentially improve methods and product quality.
Red blood cell (RBC) transfusion remains an important treatment for patients with sickle cell disease (SCD), and the majority of patients receive transfusions by adulthood. However, patients with SCD ...are at a high risk of alloimmunization, which can cause life‐threatening complications. The high rate of alloimmunization can in part be explained by chronic inflammatory condition in SCD characterized by significant immune and inflammatory activation. Heightened immune effector cell responses and/or impaired regulatory networks are likely to drive alloantibody production in alloimmunized SCD patients. In support of this, altered T‐cell immunoregulation, known to control antibody responses, has been reported in alloimmunized SCD patients. In addition, stronger follicular helper T‐cell responses that help antibody production by B cells were described in alloimmunized as compared to non‐alloimmunized SCD patients. Furthermore, several innate immune abnormalities have been identified in alloimmunized SCD patients, including a compromised anti‐inflammatory response against extracellular cell‐free haeme. The data support a model in which alloimmunized SCD patients are unable to switch off their proinflammatory state in response to the ongoing haemolytic state characteristic of SCD, placing this patient subset at a higher risk to develop a strong immune response against allogeneic determinants on transfused RBCs, thus increasing the risk of further alloimmunization. A detailed mechanistic understanding of innate immune abnormalities that can contribute to pathogenic T‐cell responses in alloimmunized SCD patients will lay the foundation for identification of biomarkers of alloimmunization with the goal that this information will ultimately help guide therapy in these patients.
Background and Objective In the United States, approximately 15 million whole blood products are collected each year from 10 million volunteer donors. African Americans are underrepresented in the ...donor pool. In 2008, 7% of white versus 4% of African American and Hispanics adults donated in the previous year. The donor rates vary by region in the United States: 77–93% for whites, 1–16% for African Americans and 1–13% for Hispanics. In the Atlanta metropolitan area whose donor pool is 77% white, 16% African American and 4% Hispanic, the blood donor rate (number of blood donors per population) was 11/1000 population for whites, 6/1000 for African Americans and 3/1000 population for Hispanics; and the blood donation rate (number of units donated by population over the total population) was 77 donations/1000 population for whites, 22/1000 population for African Americans and 10/1000 population for Hispanics. Thus, African Americans and Hispanics represent half of the donors as whites when adjusted for their percentage of the population and more strikingly donate a significantly fewer number of units per each donor.
Materials and Methods Literature on reasons for racial/ethnic differences in donation rates and methods to address these differences was reviewed.
Results The reasons for these differences are multifactorial. First, although 41% of the total US population is estimated to be eligible to donate, African Americans and Hispanics have lower eligibility rates (whites 46%, African Americans 36%, and Hispanics 41%). Second, donor deferral rates are higher for minorities: whites 11%, African Americans 18%, Hispanics 14% and Asians 16%. Deferral is most commonly secondary to temporary deferral reasons such as low hemoglobin level, yet donors are less likely to return once deferred, and thus deferral affects donor and donation rates. Third, minorities may have different motivators and barriers. The most cited motivators to blood donation are more convenient place and times, and being asked; and the most cited barriers are fear of catching a disease and feeling faint/dizzy, and not have time or knowing where to donate. Racial differences in motivating factors identified include African Americans are more likely than whites to donate to receive an item/gift and be tested for infectious disease, and if assured that donating is safe. Notably, these motivators are not the primary cited motivators. African Americans compared with whites more commonly cite fear, difficulty finding veins and not knowing where to donate as deterrents. In addition, African Americans have distrust in the healthcare system, which is correlated with lower donation rates. Fourth, different racial/ethnic groups may have different preferred marketing strategies, including methods of contact, as well as culturally specific motivators for behavioural change.
Conclusion Thus, with an improved understanding of these differences as well as accurate tools to measure the outcomes, culturally targeted recruitment programs can be developed to increase donation rates.
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