Objectives: Although blood transfusion involves many risks, it is a life-saving tissue/organ transplantation. The decision of transfusion, which is a valuable and expensive form of treatment, should ...be taken meticulously, and patients and products should be followed very carefully. The aim of this study is to retrospectively analyze the blood and blood product data used in our hospital between 2016 and 2020. Materials and Methods: Transfusion center data between 2016 and 2020 at our hospital were analyzed retrospectively. Results: Seven thousand two hundred and eighty-two patients, of whom 74.7% were male and 25.3% were female, who were planned for blood component transfusion were included. The mean age of the patients was 60.94±1.4 years. The most common blood groups were determined as A Rh+ and O Rh+. Erythrocyte suspension (65.9%), fresh frozen plasma (22.4%), apheresis platelet suspension (5.8%) were found to be the most commonly used blood components. The cost of supplying 30,435 units of blood components to the transfusion center was determined as 5,563,335 TL while the cost associated with the discard of 643 units of blood products was determined as 29,728 TL. The discard rate was determined as 2.11%. Conclusion: After transfusion, reactions and undesirable effects can be seen, and the use of blood products is an application that should be evaluated in detail in terms of cost. In this context, more detailed cost-effectiveness studies are needed.
Abstract
Current literature supports improved clinical outcomes in the setting of trauma when a Massive Transfusion Protocol (MTP) adheres to transfusion at, or close, to a 1:1 ratio (RBC:Plasma). At ...our institution, between 2008 and 2015, the number of MTP activations increased ten-fold, accompanied by increased wastage of blood products and stress on the transfusion service. In response, in 2016-2018, we undertook an extensive root-cause analysis, and deployed multiple interventions, including clinician education and multiple process changes to the MTP, which succeeded in reining in inappropriate activation of the MTP, as we have previously published.
Heretofore, we have not addressed whether these interventions also affected the ratio of blood products transfused during MTPs activated at our institution. Here, we test the hypothesis that the changes deployed in 2016-2018 were associated with improved adherence to the desired 1:1 ratio.
The study is a retrospective analysis of massive transfusion data collected from 2008 to 2022. We reviewed RBC and Plasma units transfused to all patients receiving blood products through the MTP during this period. All patients transfused seven or more RBC and/or Plasma units following MTP activation were included in the study (total n = 443). Activations were classified by year. For each patient, the (RBC:Plasma) ratio transfused was calculated and assessed for adherence to a 1:1 ratio, with a ratio of 2:1 or greater classified as “suboptimal”. Our institution does not use Whole Blood.
MTP usage at our institution gradually increased from 2008, when the MTP was established, to 2016, when the MTP procedure was revised. Suboptimal transfusion ratios (RBC:Plasma) also increased from 2008-2016. Between 2008 and 2013, 15% of patients received suboptimal ratios following MTP activation. In 2014-2016, suboptimal ratios were observed in 25% of MTPs. Following multiple interventions, the frequency of MTP activation dropped precipitously, as described, and was accompanied by a decrease in the percentage of suboptimal ratios; in 2020 to 2022, 11% of MTPs involving seven or more transfused units had a suboptimal ratio.
In summary, the dramatic increase in activations of the MTP observed between 2008 and 2016 at our medical center was accompanied by an increase in suboptimal RBC:Plasma transfusion ratios. Interventions deployed between 2016 and 2018 led not only to reduced blood wastage, and lower stress of BB staff, but also to improved adherence to best transfusion practices, in the form of appropriate (RBC:Plasma) ratios transfused during MTPs.
Background: Trauma-induced coagulopathy (TIC) is a major contributing factor to worsening bleeding in trauma patients. The objective of this study is to describe the spectrum of coagulation profiles ...amongst severely injured patients. Methods: This is a retrospective study of all patients with complete baseline TEG coagulation parameters collected prior to randomisation in the FIRST (fluids in resuscitation of severe trauma) trial between January 2007 and December 2009. Parameters recorded for this study included patient demographics, mechanism of injury, admission vital signs, lactate, base excess, coagulation studies prothrombin time (PT), international normalised ratio (INR), thromboelastography (TEG) parameters, volume, and type of fluids administered, volume of blood products administered, length of intensive care unit (ICU) stay and major outcomes. Results: A total of 87 patients were included in this study, with a median injury severity score (ISS) of 20 and 57.5% had a penetrating injury mechanism. Coagulopathy was highly prevalent in this cohort, of which a majority (69%) was diagnosed with hypercoagulopathy and 24% had a hypocoagulopathy status on admission. There was no difference in age, gender and amount of pre-hospital fluids administered across the three groups. The median volume of blood products was higher in the hypocoagulopathy group, although not statistically significant. Overall, the 30-day mortality rate was 13%, with case fatalities occurring in only coagulopathic patients: hypercoagulopathy (15%) and hypocoagulopathy (10%). Conclusion: TIC is not an infrequent diagnosis in severely injured patients resulting in increased morbidity and mortality. Determining the coagulation profile using TEG at presentation in this group of patients may inform appropriate management guidelines in order to improve outcome.
BackgroundThe primary cause of preventable trauma-related death is major haemorrhage. Activation of a Massive Transfusion Protocol (MTP) or ‘Code Red’ initiates the rapid and continuous supply of a ...large volume of blood products during life-threatening bleeds1. Activation of the protocol can be life-saving, however, ‘Code Red’ is a resource-intensive activity and significant risk is associated with inappropriate utilisation. An extended MTP can quickly deplete the supply of costly blood products and may lead to waste, thus contributing a significant cost burden to the healthcare system. Locally, the cost per unit of red cell concentrate is €295, plasma €116, platelets €650 and 1gm Fibrinogen €440.In 2018, there were 47 ‘Code Reds’ in University Hospital Galway. A learning opportunity was identified to expand upon basic training in the management of MTPs and use High-Fidelity Simulation (HFS) to enhance staff awareness of deactivation, resource-utilisation and management of challenging MTP cases.Summary of workA multidisciplinary team of midwives, nurses, porters, laboratory and blood bank staff and consultants in obstetrics, emergency medicine, anaesthesia and haematology engaged in addressing staff needs by developing a pilot HFS workshop. Three scenarios were developed targeting:Use of appropriate blood products for previously cross–matched bloodTimely deactivation of a ‘Code Red’ andManagement of a ward–based obstetric MTP (high–risk, low–frequency scenario)Feedback from participants and users was used to assess the feasibility and acceptability of the pilot session.Summary of resultsThe pilot session was run in March 2019 with 15 cross-discipline attendees. Feedback demonstrated that 100% of participants agreed or strongly agreed that the workshop addressed their learning needs, all agreed or strongly agreed that the workshop improved their ability to use skills related to the topic and all agreed or strongly agreed that the knowledge and skills they learned will be useful to them in their clinical job.Discussion, conclusions and recommendationsHFS offers a solution to both training clinical staff in improving the management of MTPs and in optimising the use of blood products so as to limit waste and resource depletion.ReferencesThomasson, R. R., Yazer, M. H., Gorham, J. D., Dunbar, N. M., & MTP Use Study Investigators, on behalf of the Biomedical Excellence for Safer Transfusion (BEST) Collaborative. (2019). International assessment of massive transfusion protocol contents and indications for activation. Transfusion.
Background
Fetal and neonatal exposure to lead is associated with irreversible adverse effects on neural development. There is no reliable threshold for lead effect, so limiting exposure is ...recommended. A significant correlation has been reported between post‐transfusion blood lead level (BLL) in infants and lead levels in transfused RBC units. We measured levels of lead, mercury, and cadmium, in Canadian donor blood to investigate if concerning levels for neonatal transfusion exist.
Study Design and Methods
Whole blood samples from blood donors (n = 2529) were shipped cold within 7 days of donation. All permanent blood donation clinics across Canada were sampled. Twelve of these permanent clinics and 8 mobile clinics with a greater potential for having higher lead or mercury levels were oversampled. Heavy metals were measured by inductively coupled plasma mass spectrometry.
Results
Of all donations, 2.2% (lead) and 0.4% (mercury) had levels higher than the recommended thresholds for safe neonatal transfusion. BLLs were higher in males but there was no significant difference in the blood mercury levels of males versus females. Cadmium levels were higher in females. There was a positive correlation between donor age and levels of heavy metals, with lead having the strongest correlation (r = 0.47, p < .0001). Three clinics in close proximity to two lead‐producing mines were among the clinics with the highest BLLs. Significantly higher blood mercury levels were observed in coastal clinics.
Conclusion
Our data on donor blood heavy metal levels supports considering blood transfusion as an exposure source to heavy metals and encourages informed selection of blood units for transfusion to vulnerable groups.
The COVID-19 pandemic has changed the requirements for new nurses to obtain employment in highly specialized areas, (e.g. ambulatory oncology infusion). The global healthcare system has experienced ...higher levels of turnover in experienced nurses.1 The increased need for nurses has allowed new graduate nurses to receive employment in areas that require nurses to have specialized skills and confidence to succeed. A needs assessment performed at Huntsman Cancer Institute's two infusion rooms and three offsite community infusion rooms revealed a lack of confidence in new nurses administering blood products, caring for central lines, utilizing and accessing oncology resources and managing infusion complications and emergencies. The purpose was to supplement new oncology nurses' orientation with an infusion didactic session after the first two weeks of bedside orientation. The learning session took place in a more structured, less stressful environment to provide knowledge, skills and promote confidence in newly hired infusion room nurses. A five-hour infusion-specific essentials didactic course was developed to promote learner engagement by using innovative learning techniques that included training, discussion and activities on central lines, blood administration, infusion complications/emergencies, and drug education resources. A high fidelity simulation of a new oncology patient who needed drug education, central line care, safe handling and administration of hazardous drugs and experienced a hypersensitivity reaction was conducted for application and solidification of concepts covered in class. Evaluation: Pre and post assessments using a fivepoint Likert-scale were administered to measure nurses' confidence levels in: caring for an infusion room patient independently, administering blood products, managing central lines, responding to infusion complications/emergencies and how to access resources. Nurses' confidence significantly increased on the post-assessment compared to pre-assessment. This program has been implemented into all newly hired oncology infusion room nurses' orientation. In late 2022 this program will be added to the Ambulatory Oncology Transition to Practice Program. The long term goal is to require the class for all newly hired nurses who administer hazardous drugs throughout inpatient and ambulatory areas of Huntsman Cancer Institute and its community sites. This program positively impacted nurses' confidence levels in caring for oncology patients in the infusion room by using creative learning techniques such as "what went wrong" video demonstrations, flipped classroom, group worksheets activities and discussion and a high fidelity simulation.
Professional Development orientees are presented with a hypothetical scenario of a new patient admission. The patient requires a series of nursing skilled tasks and interventions essential for the ...unit's population including central line care, indwelling urinary catheter, administering blood products, and chest tube care. On the final day, the new nurses individually provide the program lead with a list of topics or skills that require further education. This is facilitated through an evidence-based policy review and hands on skill demonstration with patients on the unit. Confidence and proficiency of clinical application systems, central venous catheter care, indwelling catheter insertion, administering blood products, and using clinical resource guides, were measured using a pre and post survey. Since July 2021, 23 new graduate nurses have successfully completed the program and maintained their expected orientation timeline. Preliminary results show improvement in levels of confidence, nursing sensitive indicators rates, and decreased turnover rates. Presentation will include final data review including full statistical analysis, program curriculum, and data collection tools. Implementation of unit specific orientation provides enhanced confidence and skillset for new graduate nurses. Increased confidence in new nurses could be directly linked retention and a return on investment for the organization. The goal of the program is to expand to other nursing units with customization of specific skill sets applicable to diverse patient populations.
Background: Massive transfusion protocols (MTP) have been developed to improve and standardize resuscitation. Delays to activating or receiving blood products as part of an MTP have been associated ...with worse outcomes. The aim of our study was to determine average times for MTP activations in the emergency department at the Montreal General Hospital, a level 1 trauma centre, and compare those times with the distribution, pick-up and transfusion of blood products. Methods: This is a retrospective database and chart review observational study. All patients who required the activation of an MTP from 2014 to 2018 were identified from the institution's blood bank database. Trauma patients who required the activation of an MTP were isolated by cross-referencing the results with the Montreal General Hospital trauma database registry. Further data were subsequently retrieved via chart review from Oacis. Results: A total of 342 patients admitted to the trauma unit required MTP activation and transfusion of blood products between 2014 and 2018. On average, patients who were admitted had a mean age of 45 years (standard deviation 19.6 yr) and were predominantly male (78.7%). Once the MTP requisition was submitted to the blood bank, the average delay was found to be 15.8 minutes (SD 12.5 min, median 13 min). The shortest delay was 0 minutes, while the longest was 108 minutes. Following MTP activation, the average time between the preparation and distribution of blood products, compared with the pick-up time, was approximately 6 minutes for the first cooler. However, this time increased to 15-30 minutes for the second, third, fourth and fifth coolers. We then dichotomized time between MTP activation and first cooler pick-up as greater, and less than, 10 minutes. Approximately 60% of those initial pick-ups were considered to be delayed. There was a small but statistically significant difference whereby the average time to first cooler pick-up following MTP activation was slightly higher for those who survived (mean 17.1 min, SD 13.1 min) relative to those who died (mean 12.5 min, SD 9.42 min; t test 3.32, degrees of freedom 211.15, p < 0.001). Following logistic regression, it was noted that age increased the odds of mortality by 4% (odds ratio 1.04, 95% confidence interval 1.02- 1.06). Glasgow coma scale, a lower pulse and being admitted on the night and evening shifts (relative to the day shift) decreased the odds of mortality. Conclusion: As predicted, the majority of MTP activations from 2014 to 2018 had delayed blood product pick-up times. Although our results did not demonstrate increased mortality relative to the delay, we suspect this finding to be a consequence of MTP preactivation before the arrival of the patient in the emergency. We propose the use of a blood product cooler in resuscitation rooms to further standardize and reduce delays in blood product delivery for trauma patients.
Fibrinogen plays a critical role in achieving and maintaining hemostasis and is fundamental to effective clot formation. There is increasing awareness of the important role of fibrinogen as a key ...target for the treatment and prevention of acquired bleeding. Fibrinogen is the first coagulation factor to fall to critically low levels (<1.0 g/L) during major hemorrhage (normal plasma fibrinogen levels range from 2.0 to 4.5 g/L), and current guidelines recommend maintaining the plasma fibrinogen level above 1.5 g/L. Fibrinogen supplementation can be achieved using plasma or cryoprecipitate; however, there are a number of safety concerns associated with these allogeneic blood products and there is a lack of high‐quality evidence to support their use. Additionally, there is sometimes a long delay associated with the preparation of frozen products for infusion. Fibrinogen concentrate provides a promising alternative to allogeneic blood products and has a number of advantages: it allows a standardized dose of fibrinogen to be rapidly administered in a small volume, has a very good safety profile, and is virally inactivated as standard. Administration of fibrinogen concentrate, often guided by point‐of‐care viscoelastic testing to allow individualized dosing, has been successfully used as hemostatic therapy in a range of clinical settings, including cardiovascular surgery, postpartum hemorrhage, and trauma. Results show that fibrinogen concentrate is associated with a reduction or even total avoidance of allogeneic blood product transfusion. Fibrinogen concentrate represents an important option for the treatment of coagulopathic bleeding; further studies are needed to determine precise dosing strategies and thresholds for fibrinogen supplementation.
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