Transfusion Medicine

Massive transfusion needs during war or other casualties Sangeeta Pathak Global Journal of Transfusion Medicine 2019 4(1):1-5

Review of existing legislative instruments for blood systems of Countries in the WHO Eastern Mediterranean Region Cees Theodoor Smit Sibinga, Yetmgeta Eyayou Abdella, Frank Konings Global Journal of Transfusion Medicine 2019 4(1):6-15 Blood transfusion is an essential part of health-care systems; contributes to saving millions of lives; improves patient expectancy and quality of life; and supports medical and surgical procedures. Blood and blood products-whole blood, red blood cells, platelets, and plasma were added to the WHO Model List of Essential Medicines (EMs) in 2013. Effective blood regulation is crucial for establishing blood products as EMs which requires countries to implement an appropriate regulatory framework and functioning regulatory authority (RA). There are numerous situations, for example, in the less developed world, where these prerequisites have barely been implemented. Existing legislative tools of the Eastern Mediterranean Region countries were collected, analyzed for relevance and appropriateness for the regulation of blood products, associated substances and relevant medical devices. Literature search on matching combinations of regulatory system/framework, legislation, regulation, with production and use of blood products resulted in few references on national and international legislation. The WHO recommendations and EU Directives were used as reference. Formal legislative and regulatory documents issued by nine countries from 1960 to 2017 were reviewed. Most are descriptions of RA, operational establishments, and specific requirements. None comply with the WHO/EU recommended format and contents; will not support effective regulatory oversight to promote and enhance the quality, safety, and availability of blood and blood products. National authorities should provide effective leadership and governance in developing a national blood system (NBS), fully integrated into the national health system. Essential functions of NBS include an appropriate regulatory framework; legislation, regulations, and nonlegislative instruments administered by an RA. These should spell out ethics, principles and boundaries, standard setting, and organization of NBS to ensure and sustain an adequate supply of quality-assured blood products and safe clinical use.

Application of flow cytometry in transfusion medicine Rajesh B Sawant Global Journal of Transfusion Medicine 2019 4(1):16-20 Flow cytometry-based testing approaches have no longer remained restricted to the research laboratories. With widening of its horizons in the field of diagnostics in oncology and transplantation medicine, the flow cytometer-based testing approach is now relevant to many aspects of the field of transfusion medicine. Two of the most important applications of flow cytometry in transfusion medicine are the enumeration of CD34-positive cells in the peripheral blood and stem cell product and the enumeration of residual white blood cell counts in blood product as a quality control measure. The flow cytometer-based crossmatch for detection of donor-specific anti-human leukocyte antigen antibodies is also gaining popularity in the field of histocompatibility and immunogenetics. The utility of this platform in the field of immunohematology is also increasing and looks promising for clinical decision-making in the near future.

Comparative analysis of platelet storage lesion in whole-blood-derived platelets stored in autologous plasma versus platelets stored in platelet additive solution using flow cytometric assay of CD62 and Annexin V Subhashish Das, M L Harendra Kumar Global Journal of Transfusion Medicine 2019 4(1):21-27 Background: Platelets storage lesions remain a challenge in regular blood transfusion services. Flow cytometric study based on the expression of platelets activation markers in the stored platelets is a good method to study such lesions. Materials and Methods: Buffy-coat-derived platelet concentrates were stored under standard conditions for 7 days. The expression of activation antigens CD62p and Annexin V on total platelets and populations of small, medium-sized and large platelets was analyzed by flow cytometry during storage on days 0, 5 and 7. Results: There was significant difference in Annexin V expression between PAS and non- PAS group on Day 0, Day 5 and Day 7. The same observation was noted with regard to CD62 estimations. Conclusion: Our study confirm the beneficial effects of platelet additive solution as highlighted by the flow cytometric assay of CD62 and Annexin V. Evaluation of the level of expression of various activation markers on different platelet populations could be an additional valid tool in quality control of platelet concentrates, and could be a novel approach towards better platelet inventory management.

On-site and off-site adverse donor reactions in voluntary whole blood donors: A study from a tertiary care oncology center Priti D Desai, Anisha A Navkudkar, Sunil B Rajadhyaksha Global Journal of Transfusion Medicine 2019 4(1):28-32 Aim: The aim of this study was to analyze the frequency of on-site and off-site adverse donor reactions and its correlation with contributory factors if any. Materials and Methods: A prospective observational study was conducted from October 2016 to November 2016. A total of 1000 voluntary whole blood (WB) donors who consented to participate in the study were contacted telephonically the next day of donation. Donors were asked a structured questionnaire and information was documented. Results: Of the 1000 voluntary WB donors, 948 responded to the phone calls. Of these 948, 79 (8.33%) donors experienced adverse reactions. Of the 79 donors, 33% (26/79) reactions occurred on-site, whereas 67% (53/79) reactions occurred off-site (P < 0.05). Of the total on-site reactions, 92% (24/26) were vasovagal reactions (VVRs) and 8% (2/26) were hematomas (P < 0.001). Of the total off-site reactions, 47% (23/53) were vasovagal and 53% (30/53) were hematomas. Of the 79 donors, 60% (47/79) experienced VVR and 40% (32/79) experienced hematomas. Of the 32 hematoma reactions, 94% (30/32) were noticed off-site, whereas 6% (2/30) occurred on-site (P < 0.001). Majority of hematomas took more than 7 days to resolve. Conclusion: Maximum reactions occurred off-site, and hence donor follow-up after the donor has left the donation site is important. Postdonation follow-up proves to be an efficient tool to acquire information about adverse donor reactions. The next day telephonic follow-up was helpful as donor recall of the off-site reactions was better, which otherwise would have gone unreported.

Surrogate markers and their correlation to bacterial contamination and other quality parameters in random-donor platelets by platelet-rich plasma method Priyatesh Dwivedi, Abhishekh Basavarajegowda, Apurba Sankar Sastry Global Journal of Transfusion Medicine 2019 4(1):33-38 Introduction: Bacterial contamination in platelet concentrates (PCs) occurs more frequently than other blood components because of several factors such as storage in oxygen permeable blood bags at 20°C–24°C with continuous agitation which facilitates bacterial growth compared to other blood components which are kept frozen or refrigerated which inhibits bacterial proliferation in them. The purpose of the study was to assess the incidence of bacterial contamination of random-donor PCs and factors associated with its contamination and see how well the surrogate markers such as pH and swirling correlate with the same. Methodology: This was a cross-sectional study which included randomly chosen 500 random-donor platelets (RDPs) in blood bank prepared by platelet-rich plasma method. The samples chosen for the study were from the RDPs on the 5th day of storage after their preparation. pH, platelet count, and swirling in platelets, which act as surrogate markers for bacterial contamination, were checked on the RDP units. About 1–3 ml of PCs was inoculated from the RDP units into labeled culture bottles (BD Bactec Peds Plus/F). Results: Among a total of 499 random-donor PCs that were cultured in the automated BACTEC system for the study, none of them were culture positive. Thirty RDP units in the study were visibly lipaemic whereas 93 RDP units were visibly reddish in appearance. PCs having volumes <40 ml or >70 ml did not affect the swirling, pH, and platelet counts. There was a statistically significant difference between mean pH with RDP units having swirling Grade 2 and 3 and platelet counts with RDP units having swirling Grade 1 and 2. Conclusion: Bacterial contamination though poses a significant risk is a very rare event in a meticulously prepared and stored PCs. Surrogate markers though useful in resource-constrained settings does not correlate optimally with the quality indicators.

Spectrum of alloimmunization among multitransfused beta-thalassemia major patients Usman Waheed, Muhammad Arshad, Muhammad Saeed, Akhlaaq Wazeer, Ahmed Farooq, Abida Arshad, Hasan Abbas Zaheer Global Journal of Transfusion Medicine 2019 4(1):39-44 Introduction: The development of alloantibodies is a major problem among thalassemia major individuals due to periodic blood transfusions. The current study assessed the frequency and specificity of erythrocytes alloimmunization and also the variables affecting the extent of alloimmunization in repeatedly transfused thalassemia patients. Materials and Methods: This prospective, cross-sectional study was conducted at the Department of Blood Transfusion Services and Thalassemia Centre of Pakistan Institute of Medical Sciences from August 2017 to February 2018. Of the 475 thalassemia major patients, alloantibodies were screened and identified by 3-red cell antigen panel and afterward by an extended 11-cell antigen panel. The data analysis was done through SPSS version 20.0. Chi-square test was employed. Results: Alloantibodies were detected in 77 (16.2%) patients, 5 (6.5%) patients were found with double alloantibodies. Anti-D (31.1%) and Anti-E (29.9%) antibodies had the highest incidence and were found in 24 and 23 patients, independently. Anti-K antibody was observed in 11 (14.3%) and Anti-C in 3 (3.9%) patients. Anti-C (2.6%), Anti-E (2.6%), and Anti-Kpa (2.6%) all were found in two patients, individually. Similarly, Cw (1.3%), k (1.3%), Jka (1.3%), Anti-Fyb (1.3%), and Anti-s (1.3%) antibodies were detected in one patient each. Alloantibodies were common in males, splenectomized patients, in those who initiated their transfusions before 2 years of age, in patients receiving nonleukoreduced blood and in B and O blood group patients. Conclusion: The proper management and prudence are needed for thalassemia patients due to hemolytic nature of these alloantibodies. New techniques should be introduced to reduce the incidence of red blood cell alloimmunization.

Slump of trends in transfusion-transmissible infectious diseases: Is syphils alarming in Pakistan? Maqsood Ahmad, Muhammad Saeed, Aamir Hanif, Usman Waheed, Muhammad Arshad, Noor Ul Ain, Farhan Rasheed, Shahida Hussain Global Journal of Transfusion Medicine 2019 4(1):45-51 Aims: This study was planned to evaluate the trends of transfusion-transmissible infectious diseases (TTID). Setting and Design: This cross-sectional retrospective study was conducted on donor community attending Transfusion Medicine Department, Punjab Institute of Cardiology, Lahore, Pakistan from January 1, 2012, to December 31, 2016. Subject and Methods: A total of 79,774 blood donors were processed for HbsAg anti-HCV, anti-human immunodeficiency virus (HIV), syphilis, and malaria detection by rapid immune chromatographic technique. Statistical Analysis: The data analysis was done through SPSS 20.0. Chi-square test was employed. Results: Males and females were 91% and 9%, respectively. The mean age was 44 ± 10 years, the prevalence of TTID was 4.0%, and year-wise decreasing trends were observed as 4.4%, 4.2%, 3.7%, 3.9%, and 3.9%, respectively, in 2012–2016. Overall Co-infection was 0.36%, HBV+HCV co-infection was most common. The seroprevalence of HBV, HCV, syphilis, malaria, and HIV was 0.9%, 1.7%, 1.1%, 0.1%, and 0%, respectively. Year-wise seroprevalence of HCV was 2.1%, 1.8%, 1.7%, 1.7%, and 1.3%; HBV was 1.2%, 0.8%, 0.8%, 1.0%, and 1.0%, syphilis was 0.8%, 0.8%, 0.9%, 1.4%, and 1.5%, and malaria was 0.1%, 0.03%, 0.1%, 0.1%, and 0.05% in 2012–2016, respectively, and no single case of HIV was detected. Conclusion: Raising trends for syphilis among blood donors underscore the concern about growing infection of this disease in the community as these blood donors represent the highly selective community. The zero prevalence of HIV in Pakistani population supports the growing awareness of this life-threatening disease. HBV and HCV infections still continue to be a menace to the society because, in spite of decreasing trend, burden of the disease is still high in general community.

Revisit of efficiency of blood usage – Need for continuous audit Soumee Banerjee, Parimala Puttaiah, Sitalakshmi Subramanian Global Journal of Transfusion Medicine 2019 4(1):52-57 Background: The most common indices assessing blood usage are crossmatch-to-transfusion (C/T) ratio, transfusion probability (%T), Transfusion Index (TI), nonusage probability (NUP), and wastage as percentage of issue (WAPI). This study, in a South Indian tertiary care hospital, audits blood utilization efficiency and revisits it after implementing corrective measures for deficiencies identified by the first audit highlighting the importance of continuous surveillance and proper measures in efficient blood utilization. Materials and Methods: Blood utilization over 6 months, assessed by C/T ratio, TI, %T, and NUP indicated inefficient blood usage (high C/T ratio). After initiating appropriate measures, reaudit over 1 month assessed effect on blood usage. The total duration was from December 2017 to November 2018. Request forms packed red blood cells provided patient demographics, number of units requested, and indication. Blood bank records provided number of units crossmatched and issued against each request. Results: Initial audit: total requests- 4450, C:T ratio-3.6, TI-0.5, %T- 32% and NUP- 72%. Reaudit: Total requests-948 (medical 52%, surgical 48%), Overall monthly WAPI- 0.1%, C:T ratio-2.4 (medical 1.3, surgical 3.5), %T-63.5%(medical 84%, surgical 43%), TI-1 (medical 1.4, surgical 0.6), NUP- 24% (medical- 11%, surgical 37%) C/T ratio – no subspecialty crossed the highest acceptable value (2.5) except gynecology and obstetrics (4.1) and pediatric surgery (2.75). All departments met the lowest acceptable %T (30%) except G&O (25.2%). All departments met minimum TI (0.5) except G&O (0.3), pediatric surgery (0.47), and surgical super specialties (0.3). Conclusion: Initial audit showed inefficient blood utilization. Appropriate steps taken to improve this included the establishment of standard protocols. Reaudit showed efficient blood utilization in medical departments and the need for further revision in practices for surgical departments. Hence, continuous monitoring is vital in ensuring effective blood usage.

To evaluate hemoglobin thresholds of elective surgical patients and blood typing policy for reducing the erythrocyte transfusion in a hospital setting Sankalp Sharma, Dhananjay Prasad, Saurabh Lehre Global Journal of Transfusion Medicine 2019 4(1):58-64 Introduction: The existing methods to quantify blood requirement in elective surgical procedure are the baseline hemoglobin (Hb) and hematocrit of patients. The risk-based scoring systems available are maximum allowable surgical blood loss and maximum surgical blood ordering schedule employ retrospective data evaluation or patient-specific variables, respectively. The aim of the present study was to evaluate a single institutional data for analyzing red blood cell (RBC) requirement among various surgical diagnoses. The study also evaluated RBC threshold for blood transfusions and efficacy of blood typing policy toward reducing unnecessary transfusions in an institution. Study Design and Methods: This study is a retrospective data evaluation from a single institution of blood transfusion patterns among elective surgical patients. Results: The blood transfusions in surgical diagnoses (n = 259) got integrated under 16 categories. The overall crossmatch-to-transfusion ratio was 1.4, average Hb before transfusion was 9.0 g/dl across the surgical categories, and average erythrocyte transfusion per patient for the various clinical diagnoses was 0.4 blood units. The effective Blood usage was 73.2% of requisitions received and blood typing was performed in 46.3% of total requisitions. Blood typing policy showed a statistically significant improvement in the blood transfusion of crossmatched units in the hospital. A per-unit reduction of blood cost in patients was also observed. Conclusions: The blood transfusion across the surgical categories showed similar Hb thresholds before transfusion. Blood typing policy improved EBU and reduced unnecessary crossmatches and transfusion costs among the patients.