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BACKGROUND: Using algorithms based on point of care coagulation tests can decrease blood loss and blood component transfusion after cardiac surgery. We wished to test the hypothesis that a management algorithm based on near-patient tests would reduce blood loss and blood component use after routine coronary artery surgery with cardiopulmonary bypass when compared with an algorithm based on routine laboratory assays or with clinical judgement. METHODS: Patients (n=102) undergoing elective coronary artery surgery with cardiac bypass were randomized into two groups. In the point of care group, the management algorithm was based on information provided by three devices, the Hepcon, thromboelastography and the PFA-100 platelet function analyser. Management in the laboratory test group depended on rapidly available laboratory clotting tests and transfusion of haemostatic blood components only if specific criteria were met. Blood loss and transfusion was compared between these two groups and with a retrospective case-control group (n=108), in which management of bleeding had been according to the clinician's discretion. RESULTS: All three groups had similar median blood losses. The transfusion of packed red blood cells (PRBCs) and blood components was greater in the clinician discretion group (P<0.05) but there was no difference in the transfusion of PRBCs and blood components between the two algorithm-guided groups. CONCLUSION: Following algorithms based on point of care tests or on structured clinical practice with standard laboratory tests does not decrease blood loss, but reduces the transfusion of PRBCs and blood components after routine cardiac surgery, when compared with clinician discretion. Cardiac surgery services should use transfusion guidelines based on laboratory-guided algorithms, and the possible benefits of point of care testing should be tested against this standard.
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The management of patients requiring a damage control approach taxes the abilities of the best equipped trauma center. These patients present with severe metabolic abnormalities, most notably characterized by a deadly triad of hypothermia, coagulopathy, and acidosis. Using volumetric, oxymetric pulmonary artery catheters, hypothermia and any ongoing cardiovascular abnormalities can be identified quickly and treatment can be monitored. External, forced air rewarming is a valuable technique in treating the patient with hypothermia, as are more invasive modalities, including body cavity lavage. Although there is no shotgun approach to blood component transfusion therapy, the coagulopathy shown by these patients has a time course that is more rapid than stat laboratories can presently keep up with. Given the fulminant nature of this coagulopathy, the authors feel justified in empirically initiating platelet and plasma or cryoprecipitate transfusion on identification of visible coagulopathy. The willingness of trauma surgeons to push the envelope in treating these most severely afflicted patients has allowed patients who once would have certainly died to lead meaningful lives.
The GBV-C/HGV (HGV) virus was discovered a few years ago. This virus is known to be parenterally as well as sexually transmitted. However, no study has found some pathogenic roles for HGV so far. In the present study, we aimed to investigate the transmission of HGV by blood components transfused to 284 patients hospitalized in surgery unit in 1995. We tested two parameters of infection in blood components transfused to infected recipients: viral RNA by PCR and anti-E2 antibodies by ELISA. We tried to suspect some potent hepatocyte impacts by assessing the levels of two enzymes in serums: alanine aminotransferase (ALT) and alpha-glutathion S-transferase (alpha-GST). We found that HGV-RNA was detectable in 3.6% of recipients prior to transfusion and 7.5% post-transfusion. For each infected recipient, we retrospectively did a search for HGV-RNA in each transfused blood component, and we found at least one blood component as HGV-RNA-positive for each transfusional infected recipient. Anti-E2 antibody prevalence standing for a former and cured infection was 39.6% in all the recipients. In viremic recipients, ALT levels were mostly normal, while alpha-GST levels were found more commonly elevated than in non-viremic recipients although non-significantly (20% vs. 6.3%; P = 0.07). The present study underlines that HGV transmission is mostly transfusional in surgery units, and that infectiosity of blood components can be anticipated by detection of the viral RNA by PCR. Furthermore, the possible relationship between the serum activity of alpha-GST and the hepatotropism of HGV, although non-admitted as pathogenic, should be investigated.
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BACKGROUND: This study evaluated the quality of WBC-reduced platelets, RBCs, and plasma collected on a new system (Trima, Gambro BCT) designed to automate the collection of all blood components. The study also evaluated donor safety and suitability of these components for transfusion. STUDY DESIGN AND METHODS: In Phase I, the quality of the components collected on the new system was evaluated by standard in vitro and in vivo testing methods. Results were compared to those from control components collected by currently approved standard methods. In Phase II, additional collections were performed to evaluate the acceptability of the new system and the safety of platelets collected. RESULTS: In vivo 24-hour RBC recovery was 76.8 +/- 3.1 percent for the test RBC units and 77.1 +/- 4.4 percent recovery for whole-blood (control) RBCs. The differences between test and control platelet results in the in vivo and in vitro assays were not clinically significant. Plasma clotting factors and fibrinogen levels met international standards. The system was well accepted by donors, and no major adverse donor reactions were reported for the 68 procedures performed. No problems were reported with transfusing the blood components collected. CONCLUSION: Blood components collected with the Trima are equivalent to currently available components, and they meet the applicable regulatory standards. This system provides consistent, standardized components with predictable yields. It provides the option of fully automating the collection of all blood components.
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To evaluate the effect of blood transfusion on incidence of postoperative hepatitis and prognosis of gastric cancer, the data of 493 patients having been operated on curatively in our hospital were divided into two groups: those who received transfusion before the beginning of components transfusion and those who received transfusion after that. The data indicated that the incidences of postoperative hepatitis increased from 3.7% to 5.4% after the beginning of transfusion of blood components, but the 5-year survival rates did not differ significantly. The 5-year survival rates of transfused patients and non-transfused patients were 57%, 84%, respectively (p less than 0.001) and the rates decreased according to the dose of whole blood and/or packed red cells. The same results were obtained when limited to stages I + II, But they were not deteriorated by fresh frozen plasma significantly. The result suggests that it is better to refrain from unnecessary blood transfusion and transfuse whole blood in the case of massive transfusion to decrease the incidence of postoperative hepatitis and more better to transfuse leucocyte-free blood to avoid immunological effect.
Totally 86 patients with multiple transfusions were followed up regularly for more than six months. Their sera were screened for HLA antibodies every two to four weeks. Subsequently 28 (33%) of them developed HLA antibodies. The specificities of identified antibodies were anti-A2, All, B16 and B60. However, most of the antibodies were either multiple or undetermined. The panel reactive activity (PRA) was correlated with the amount of blood components transfused. We concluded that about one third of the patients will develop HLA antibodies after multiple transfusions and the reactivity of the antibodies is correlated to the amount of blood components transfused.
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Neonatal blood component transfusion practices during 1989 were surveyed via a questionnaire developed by the Pediatric Hemotherapy Committee of the American Association of Blood Banks. Of 1790 questionnaires mailed, 452 were selected to form the database for this analysis because they were from institutions in which neonates were transfused. Nearly all institutions contained intensive care units directed by neonatologists and were involved in the management of high-risk infants. Results from institutions serving as the primary pediatric teaching hospital of a medical school were compared with those with no medical school affiliation. Thirty-six percent of primary pediatric teaching hospitals and 52% of hospitals with no medical school affiliation performed pretransfusion testing in excess of that required, resulting in additional blood loss in neonates. Sixty-six percent of primary pediatric teaching hospitals used fresh frozen plasma to adjust the hematocrit of red blood cell concentrates prior to transfusion (a practice increasing donor exposure), compared with only 29% of hospitals with no medical school affiliation. The usual indication for small-volume red blood cell transfusions in severely ill neonates was to maintain a desired hematocrit level, whereas for stable infants, red blood cell transfusions were given to treat symptomatic anemia, rather than to maintain a predetermined hematocrit. As found in 1985, neonatal transfusion practices in 1989 were variable. However, improvements have occurred since 1985 to suggest that further research and educational efforts may serve to promote even better neonatal transfusion therapy.
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For modern acute poisoning management there are several therapeutic transfusion-induced methods (forced diuresis, haemodialysis, peritoneal dialysis, haemoperfusion, plasmapheresis, exsanguino-transfusion, blood and blood component transfusion, intravenous solution infusion etc), each of them having their advantages, disadvantages and limitations. No one of these methods is so efficacious enough that its application could be justified in all poisonings. However, some of them are considered to be method of choice in the treatment of certain acute poisonings.
Neonatal transfusion practices during 1989 of 452 institutions involved in transfusing infants were surveyed by questionnaire. Most respondents (77%) transfused fresh frozen plasma appropriately (ie, primarily to treat coagulation disorders). However, 11% stated that their most frequent use of fresh frozen plasma was solely to treat hypovolemia, a practice generally not recommended. Seventy-eight percent of respondents transfused platelets to treat bleeding infants with blood platelet counts of less than 50 x 10(9)/L; 84% gave platelets to sick, premature neonates with counts of less than 50 x 10(9)/L whether or not bleeding was evident. Only 35% of respondents transfused granulocytes for neonatal sepsis; most institutions used buffy coats isolated from units of blood--a product readily available, but of questionable efficacy when compared with leukapheresis granulocytes. Ninety-three percent of respondents provided blood components with low risk of transmitting cytomegalovirus: components from seronegative donors were used by 84%, leukocyte-reduced products by 6%, and a combination by 10%. Thirteen percent of respondents gave gamma-irradiated blood components to all and 46% gave them to some neonates to prevent graft vs host disease. Forty-one percent did not routinely irradiate. Ten percent of respondents used leukocyte reduction instead of gamma irradiation to prevent graft vs host disease, a practice currently not advocated. Thus, national transfusion practices for neonates are variable, controversial, and, occasionally, other than those usually recommended. Additional research and educational efforts are needed to ensure optimal transfusion therapy.