Stubbs, James R.

Background The national waste rate for hospital‐issued blood products ranges from 0% to 6%, with operating room–responsible waste representing up to 70% of total hospital waste. A common reason for blood product waste is inadequate intraoperative storage. Study Design and Methods Our transfusion service database was used to quantify and categorize red blood cell ( RBC ) and fresh‐frozen plasma ( FFP ) units issued for intraoperative transfusion that were wasted over a 27‐month period. Two cohorts were created: 1) before implementation of a blood transport and storage initiative ( BTSI )— RBC and plasma waste J anuary 1, 2011‐ M ay 31, 2012; 2) after implementation of BTSI — RBC and plasma waste J une 1, 2012, to M arch 31, 2013. The BTSI replaced existing storage coolers (8‐hr coolant life span with temperature range of 1‐10°C) with a cooler that had a coolant life span of 18 hours and a temperature range of 1 to 6°C and included an improved educational cooler placard and an alert mechanism in the electronic health record. Monthly median RBC and plasma waste and its associated cost were the primary outcomes. Results An intraoperative BTSI significantly reduced median monthly RBC (1.3% vs. 0.07%) and FFP (0.4% vs. 0%) waste and its associated institutional cost. The majority of blood product waste was due to an unacceptable temperature of unused returned blood products. Conclusion An intraoperative BTSI significantly reduced median monthly RBC and FFP waste. The cost to implement this initiative was small, resulting in a significant estimated return on investment that may be reproducible in institutions other than ours.

BackgroundIdentifying antibodies to HLA (anti‐HLA) by solid‐phase assays is used to screen blood donors to mitigate transfusion‐related acute lung injury risk. Various cutoffs for detection assays have been proposed in the literature; however, these do not take into consideration lot‐to‐lot variability of commercially available assays.Study Design and MethodsSamples from 93 nontransfused males were tested using five different lots of a multiplex bead‐based anti‐HLA detection kit. A subset of 17 samples was tested on 5 days using a single lot. An additional 96 samples from donations with varied anti‐HLA levels were tested using kits from two different lots. Results were reported as a normalized background (NBG) ratio.ResultsFor the 93 nontransfused donors, NBG values generated using the reference lot were significantly higher than those obtained with three of the four comparator lots. However, for the 96 samples with low‐, moderate‐, and higher‐level anti‐HLA, Class I (CL‐I) values were 1.4 times lower and Class II (CL‐II) values were 1.2 times lower using the reference versus comparator lot. For CL‐I antibodies the between‐lot standard deviation (SD) was 1.36 (95% confidence interval [CI], 1.19‐1.60), while the between‐day SD was 1.27 (95% CI, 1.08‐1.52). Similarly, for CL‐II antibodies the between‐lot SD was 0.81 (95% CI, 0.70‐0.95), while the between‐day SD was 0.50 (95% CI, 0.43‐0.60).ConclusionsThere is interlot variability in the tested HLA detection assay as well as significant bias between lots. It may be reasonable to develop a new cutoff when a new lot is obtained.

BackgroundThe rapid reversal of warfarin in the setting of traumatic brain injury (TBI) has been associated with improved outcomes. Until now, remote reversal of hypocoagulable states has not been possible in the prehospital environment. This manuscript describes the development and analysis of a prehospital plasma transfusion protocol to reverse warfarin at the earliest possible moment after TBI.Study Design and MethodsA retrospective review of all TBI patients receiving plasma transfusion(s) in the prehospital environment for warfarin reversal between February 2009 and September 2010 was conducted. Thawed plasma was carried on every air ambulance flight centered at the main campus.ResultsA total of 2836 flights carried over 2500 units of thawed plasma throughout the study period. During this time, 16 patients received prehospital plasma resuscitation, five of who were on warfarin with a concurrent TBI. The median Injury Severity Score was 17 (8.5‐27.5) with a median Glasgow Coma Score of 13 (8‐15) and a mortality rate of 40%. A median of 2 (1.5‐2.0) units of thawed plasma and 0 (0‐0) units of RBCs were transfused en route. The pretransfusion point‐of‐care international normalized ratio improved from 3.1 (2.3‐4.0) to 1.9 (1.3‐3.6) upon trauma center admission (serum sample). One hundred percent of the transported, but unused, thawed plasma underwent subsequent transfusion prior to expiration.ConclusionsRemote prehospital plasma transfusions effectively reverse anticoagulation secondary to warfarin administration in TBI patients. It is feasible to transfuse thawed plasma in the prehospital setting via remote damage control techniques without increasing waste. Prospective studies are needed to determine if this practice can improve outcomes in this population.

BackgroundGroup O red blood cell (RBC) units are used for emergency transfusions and are often uncrossmatched when transfused. We sought to determine the risk of alloimmunization and identify acute adverse outcomes of this practice.Study Design and MethodsThe transfusion medicine database was searched for emergency‐release transfusion (ERT) episodes from January 2006 through December 2010. The data collected included age and sex of the recipient, blood bank history, survival after the ERT episode, antibody screen results, antibody identifications, and compatibility of released units.ResultsA total of 1444 ERT episodes took place involving 1407 patients. A total of 4144 RBC units were released. Of the 129 positive antibody screens, 34 had no antibody on further work‐up, 14 had autoantibodies, 48 had a single antibody specificity, and 25 had multiple antibody specificities. Seven patients developed an antibody that could be attributed to the ERT episode, and 15 patients developed an antibody after ERT and additional RBC transfusions. There were 32 reported suspected transfusion reactions. No acute hemolytic transfusion reactions were reported. Seven patients were given a total of 10 incompatible RBC units. Of these patients, one developed a delayed serologic transfusion reaction. The rate of alloimmunization attributable to ERT was 3%. Overall, the rate of incompatible transfusion was less than 0.3% and the rate of a delayed hemolytic transfusion reaction was approximately 0.02%.ConclusionThere is minimal risk associated with the release of emergency uncrossmatched blood in the setting of an acutely bleeding patient. [Correction statement added after online publication 15‐Oct‐2012: the number of patients with autoantibodies, single antibody specificity and multiple antibody specificity has been update.]

The practice of platelet transfusion in the intensive care unit varies, and liberal use may not be associated with improved outcome. This study reviewed the medical records of 117 patients with moderate-to-severe thrombocytopenia and without active bleeding who were admitted to intensive care unit beds during a 6-month period. The primary outcome measures were new bleeding episodes and platelet transfusion complications. Ninety (77%) received a platelet transfusion. Significant new bleeding developed in 1 patient who received a transfusion. Six patients (8%) developed transfusion complications: 2 transfusion-related acute lung injury, 2 allergic, and 2 febrile reactions. Patients who did not receive platelet transfusion had a higher severity of illness than transfused patients. Predictors of platelet transfusion were platelet count and postoperative status, but not invasive procedure. The practice of platelet transfusion in critically ill patients with thrombocytopenia varies. Prospective studies evaluating restrictive versus liberal platelet transfusion strategies are warranted.