Investigating the impact of mitochondrial DNA: Insights into blood transfusion reactions and mitigation strategies.

440 Background: Massive Transfusion Protocol (MTP) is a term used to describe a process to deliver blood products rapidly to treat life-threatening hemorrhage. MTPs follow a prescribed algorithm to efficiently replace blood products in set ratios. Three components of MTP include immediate availability of blood products, set types and ratios of blood products, and standardized roles for health care providers. MTP is associated with decreased morbidity and mortality compared to provider-driven decisions on blood transfusion. Methods: The Quality Improvement Assessment Board approved this initiative to standardize and create an MTP process outside of the Operating Room (OR). We assembled a multidisciplinary team to review and adopt evidence-based practices for MTP. A core group of content experts developed the relevant policy and protocol for activation and use of MTP in the Intensive Care Unit (ICU), Pediatric Intensive Care Unit (PICU), Emergency Room (ER), Interventional Radiology (IR) and inpatient floor. Simulations were held in these areas and Plan Do Study Act (PDSA) cycles used to improve the processes. Improvements included adjustment to the quantity and type of emergency release products immediately available, the timing of when platelets were delivered to providers and development of a ‘pull’ process for the Blood Bank to prepare additional blood products minimizing wastage. Following these changes, the MTP process became consistent and could be activated from all of the targeted locations. Each MTP episode was reviewed for outcomes and efficiency metrics. We held multidisciplinary care debriefings to review hemorrhagic events for areas of improvement. The OR had an existing process that was separate from this initiative, but will be aligned June 2023 and included in future analysis. Results: Baseline, from January 2022 to September 2022, 32 massive transfusion events occurred (3.5 per month). After implementation of the MTP protocol, from October 2022 to May 2023, the MTP protocol was activated 36 times (4.5 per month). There were 7 (22%) deaths at baseline and 5 (14%) after implementation. The average length of time from activation to receipt of first blood product was 26 minutes at baseline and 25 minutes with MTP. The average number of units administered at baseline included 7.7 units of red blood cells (RBC), 7.6 units fresh frozen plasma (FFP), 1 unit single donor platelets, and 2 units cryoprecipitate compared to after implementation of 6.9 units RBC, 6 units FFP, 1.6 units single donor platelets, and 3 units cryoprecipitate. The ICU was the most common MTP activation location (44%), followed by ER (19%), PICU (17%), the floor (14%) and IR (6%). Conclusions: It is feasible and safe to deploy an MTP throughout an institution. Preliminary data show a decrease in the percentage of patient deaths with use of MTP. Additional analysis are planned to evaluate the incremental improvements made with each PDSA cycle.

The administration of blood components: a British Society for Haematology Guideline.

Background:Massive transfusion protocols (MTPs) are increasingly used in the transfusion practice and are developed to provide the standardized and early delivery of blood products and procoagulant agents and to supply the transfusion of blood products in a well-balanced ratio.Aim:The aim of this study was to investigate the effect of a hospital-wide introduction of an MTP on blood product ratio and a waste of blood products.Materials and Methods:Retrospective analysis was performed to compare the transfusion practice in massive bleeding patients before and after the introduction of an MTP and between the use of an MTP and transfusion off-protocol. Massive bleeding was defined as an administration of ≥5 units of red blood cells (RBCs) within 12 h.Results:Of 547 massively transfused patients, 192 patients were included in the pre-MTP period and 355 patients in the MTP period. The ratio of RBC to fresh frozen plasma (FFP) and the platelets transfused shifted significantly toward 1:1:1 in the MTP period (P = 0.012). This was mainly caused by a shift in RBC: FFP ratio (P = 0.014). An increase in the waste of blood products was observed, most notably FFPs (P = 0.026). Extending the storage time after thawing reduced the waste of FFPs from 11% to 4%.Conclusion:Hospital-wide introduction of an MTP is an adequate way to achieve a well-balanced transfusion ratio of 1:1:1. This comes at the cost of an increase in the waste of FFPs, which is lowered after extending the duration of storage time after thawing.

Blood transfusions have been the cornerstone of life support since the introduction of the ABO classification in the 20th century. The physiologic goal is to restore adequate tissue oxygenation when the demand exceeds the offer. Although it can be a life-saving therapy, blood transfusions can lead to serious adverse effects, and it is essential that physicians remain up to date with the current literature and are aware of the pathophysiology, initial management and risks of each type of transfusion reaction. We aim to provide a structured overview of the pathophysiology, clinical presentation, diagnostic approach and management of acute transfusion reactions based on the literature available in 2022. The numbers of blood transfusions, transfusion reactions and the reporting rate of transfusion reactions differ between countries in Europe. The most frequent transfusion reactions in 2020 were alloimmunizations, febrile non-hemolytic transfusion reactions and allergic transfusion reactions. Transfusion-related acute lung injury, transfusion-associated circulatory overload and septic transfusion reactions were less frequent. Furthermore, the COVID-19 pandemic has challenged the healthcare system with decreasing blood donations and blood supplies, as well as rising concerns within the medical community but also in patients about blood safety and transfusion reactions in COVID-19 patients. The best way to prevent transfusion reactions is to avoid unnecessary blood transfusions and maintain a transfusion-restrictive strategy. Any symptom occurring within 24 h of a blood transfusion should be considered a transfusion reaction and referred to the hemovigilance reporting system. The initial management of blood transfusion reactions requires early identification, immediate interruption of the transfusion, early consultation of the hematologic and ICU departments and fluid resuscitation.

Background and objectives: Massive postpartum hemorrhage (PPH) is the most common cause of maternal death worldwide. A massive transfusion protocol (MTP) may be used to provide significant benefits in the management of PPH; however, only a limited number of hospitals use MTP protocol to manage massive obstetric hemorrhages, especially in Japan. This study aimed to assess the clinical outcomes in patients in whom MTP was activated in our hospital. Materials and Methods: We retrospectively reviewed the etiology of PPH, transfusion outcomes, and laboratory findings among the patients treated with MTP after delivery in our hospital. Results: MTP was applied in 24 cases (0.7% of deliveries). Among them, MTP was activated within 2 h of delivery in 15 patients (62.5%). The median estimated blood loss was 5017 mL. Additional procedures to control bleeding were performed in 19 cases, including transarterial embolization (18 cases, 75%) and hysterectomy (1 case, 4.2%). The mean number of units of red blood cells, fresh frozen plasma, and platelets were 17.9, 20.2, and 20.4 units, respectively. The correlation coefficients of any two items among red blood cells, fresh frozen plasma, platelets, blood loss, and obstetrical disseminated intravascular coagulation score ranged from 0.757 to 0.892, indicating high levels of correlation coefficients. Although prothrombin time and activated partial thromboplastin time levels were significantly higher in the <150 mg/dL fibrinogen group than in the ≥150 mg/dL fibrinogen group at the onset of PPH, the amount of blood loss and blood transfusion were comparable between the two groups. Conclusions: Our MTP provides early access to blood products for patients experiencing severe PPH and could contribute to improving maternal outcomes after resuscitation in our hospital. Our study suggests the implementation of a hospital-specific MTP protocol to improve the supply and utilization of blood products to physicians managing major obstetric hemorrhage.

Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient

Transfusion-associated graft-versus-host disease.

Fibrinogen concentrate for management of bleeding

CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 49 transfusion-related death in the United States, surpassing deaths caused by ABO incompatibility and bacterial contamination. The actual incidence of TRALI remains unknown in the United States; however, with improved recognition, the number of cases of TRALI reported in the literature has increased significantly since the initial case series was reported in 1985. Nevertheless, much about this clinical syndrome that may complicate blood transfusions remains poorly understood, and TRALI remains an important topic of research in transfusion medicine. In 2006, the AABB (formerly the American Association of Blood Banks) assembled a TRALI task force to develop recommendations for the prevention of TRALI. This article is a summary of AABB actions on TRALI and includes a summary of the recommendations made by the AABB task force.

Blood Substitutes

Massive transfusion (MT) is traditionally defined as transfusion of more than 10 units of red blood cells (RBCs) within the first 24 h after admission. The aim of this study is to analyze the trend of MT in regional trauma center including ratio of fresh frozen plasma (FFP) and packed RBC. Retrospective data were driven from 2014 to 2016. A total of 185 patients who received more than 10 packed RBC units within the first 24 h after admission were included in the study. We analyzed transfusion requirements for each time interval 4 h and 24 h after admission. Moreover, we compared transfusion characteristics between survival and non-survival group, between high FFP: RBC group (≥1: 2) and low FFP: RBC group (<1: 2), and between the first half and latter half period. There was a trend for improvement in the FFP: RBC ratio after applying the MT protocol. The FFP: RBC ratio increased from 1: 1.7 to 1: 1.4 within 24 h after arrival. The time to first transfusion was shortened (137-106 min). Mortality was lower in high FFP: RBC group than that of low FFP: RBC group. In our study, the MT protocol improved the FFP: RBC ratio. A higher FFP: RBC ratio also led to an improvement in the mortality rate in MT patients.

Posterior reversible encephalopathy syndrome following blood transfusion in a patient with factor X deficiency: Is it an unusual systemic manifestation of an adverse transfusion reaction?

Lung Transplant With Cardiopulmonary Bypass: Impact of Blood Transfusion on Rejection, Function, and Late Mortality

Rational use of blood: how to do it?

Background Massive transfusion protocols (MTPs) have been examined in trauma. The exact ratio of packed red blood cells (PRBC) to other blood replacement components in hemostatic resuscitation in obstetrics has not been well defined. Objective The objective of this study was to evaluate hemostatic resuscitation in peripartum hysterectomy comparing pre- and postinstitution of a MTP. Study Design We conducted a retrospective, descriptive study of women undergoing peripartum hysterectomies from January 2002 to January 2015 who received ≥ 4 units of PRBC. Individuals were grouped into either a pre-MTP institution group or a post-MTP institution group. The post-MTP group was subdivided into those who had the protocol activated (MTP) versus not activated (no MTP). Primary outcomes were estimated blood loss (EBL) and need for blood product replacement. The secondary outcome was a composite of maternal morbidity, including need for mechanical ventilation, venous thromboembolism, pulmonary edema, acute kidney injury, and postpartum infection. A Mann-Whitney U test was used to compare continuous variables, and a chi-squared test was used for categorical variables with significance of p < 0.05. Results Of the 165 women who had a peripartum hysterectomy during the study period, 62 received four units or more of PRBC. No significant differences were noted in EBL or blood product replacement between the pre-MTP (n = 39) and post-MTP (n = 23) groups. Similarly, the MTP (n = 6) and no MTP (n = 17) subgroups showed no significant difference between EBL and overall blood product replacement. Significant differences were seen in transfusion of individual blood products, such as fresh frozen plasma (FFP) (MTP = 4, no MTP = 2; p = 0.02) and platelets (plts) (MTP = 6, no MTP = 0; p = 0.03). The use of high ratio replacement therapy for both plasma and plts was more common in the MTP group (FFP/PRBC ratio [MTP = 0.5, no MTP = 0.3; p = 0.02]; plts/PRBC ratio [MTP = 0.7, no MTP = 0; p = 0.03]). There were no differences in the secondary outcome between pre- and post-MTP or MTP and no MTP. Conclusion Initiation of the MTP did result in an increase in transfusion of FFP and plts intraoperatively. At our institution, the MTP is underutilized, but it appears that providers are more cognizant of the use of high transfusion ratios.