Administration Of Blood Components Research Articles

EP186 - Blood transfusion documentation in surgical patients - are we doing it correctly? An audit on the blood transfusion documentation in surgical patients at a district general hospital in the United Kingdom

Abstract Aim Transfusion of blood products is commonly indicated in surgical patients, especially in patients with gastro-intestinal bleeding, gastro-intestinal cancers, and trauma patients. However, the documentation regarding blood transfusion in these patients often does not meet the guidelines. The aim of this clinical audit was to improve the blood transfusion (BT) related documentation in patients of general surgery (GS) at a district general hospital (DGH) in the United Kingdom, in accordance with the national guidelines (Administration of blood components: a British Society for Haematology Guideline) and the local trust guidelines. Method For the 1st-cycle of the audit, we did retrospective study of all adult patients admitted under GS in our DGH from 1st July 2023 to 15th August 2023 (6weeks) who received BT, and their electronic records were assessed with regards to documentation regarding the following criteria: decision to transfuse, patient's consent and understanding, post-transfusion effect and discharge notes. Following this, we had a discussion with the junior doctors in the department, who do these documentation, to make them aware of the BT guidelines, and to improve adherence. The 2nd-cycle included retrospective data collection from 1st September 2023 to 15th October 2023 (6 weeks). Results BT-documentation during the 2nd-cycle showed significant improvement to adherence above 80% in most of the criteria where it needed improvement in the 1st-cycle. Conclusion This clinical audit successfully improved the BT-documentation adherence to the guidelines, showing that through simple educational methods, the documentation practices could be improved significantly. Our plans for subsequent improvement includes posters in the departmental resource room to increase the awareness, and to re-audit in December 2023.

Enhancing clinical insight: Implementing validated questionnaires for comprehensive assessment of clinician expertise in transfusion medicine practices

BackgroundBlood transfusion is a cornerstone of modern healthcare, pivotal in saving countless lives annually. However, inadequate knowledge among healthcare providers can lead to serious complications. Despite the availability of assessment tools like the Biomedical Excellence for Safer Transfusion (BEST) test, there is a need for indigenous-validated questionnaires to address knowledge gaps effectively. This study aimed to evaluate bedside transfusion medicine knowledge among clinical residents using a validated questionnaire, focusing on knowledge gaps. Study design and methodsA cross-sectional study was conducted at a tertiary care referral center in Northern India. The questionnaire, developed based on national and international transfusion guidelines, was validated by an expert panel, and administered to 245 clinical residents. The questionnaire covered six domains related to transfusion medicine: blood component storage, blood bank procedures, transfusion-transmitted infections, administration of blood components, transfusion reactions, and transfusion practices. ResultsThe study revealed varying levels of knowledge across specialties and residency years. Overall, residents scored 61 % in transfusion medicine knowledge, with Pediatrics residents demonstrating the highest scores. The incremental increase in knowledge from first to third-year residents underscores the value of continuous, experience-based learning throughout the residency period. DiscussionStudy highlights significant knowledge gaps in bedside transfusion practices among clinical residents, emphasizing the need for structured educational interventions. Tailored programs, integrated into undergraduate and postgraduate curricula, are essential to improve transfusion safety and patient outcomes. Addressing these gaps can lead to better bedside transfusion practices, reducing risks and improving the quality of patient care.

EVALUATION OF INCOMPATIBLE CROSSMATCHES AT A TERTIARY CARE HOSPITAL IN CHENNAI – A PROSPECTIVE STUDY

Objectives: The primary goal in blood transfusion is that the transfused blood unit be compatible with the patient during crossmatching. This compatibility testing is performed before every administration of blood component. This cross-matching test helps to detect the presence of antibodies in the recipient against antigens over red blood cells of donor. The aim of this study was to evaluate the incidence and causes of in compatible crossmatches in patients by tube agglutination method. Methods: This was a retrospective cross-sectional study conducted by analyzing incompatible crossmatches encountered during routine compatibility testing between January and December 2021 at the Department of Transfusion Medicine, Government Kilpauk Medical College and Hospital, Chennai, Tamil Nadu, India. The analysis was done in March and April 2022. All crossmatches were done by tube agglutination technique. Data were entered in Microsoft Excel and analyzed. Descriptive statistics were given in summary statistics. Results: Out of the total of 12943 crossmatches performed, 0.3% (n=39/12943) were incompatible. About 76.9% (n=30/39) were seen in females while 69.2% (n=27/39) were seen in the age group 20–60 years. About 35.9% (n=14/39) of the incompatible crossmatches were due to autoimmune hemolytic anemia (AIHA). A root cause analysis protocol was formulated to resolve the incompatibility and ensure safe transfusion. Conclusion: AIHA was the most common cause of incompatible crossmatch. The root cause analysis protocol involves a thorough evaluation of the patient’s clinical condition, underlying pathology, and errors during technical procedure to identify the cause of incompatibility. Protocols should be developed in each blood center and a logical stepwise approach will enable the provision of safe transfusion.

Medico-legal and management issues in patient blood management era.

In recent decades, the approach to blood transfusion has changed radically around the world. In the past, transfusion represented the only solution for anemia, today the paradigm has changed: through the implementation of the Patient blood management (Pbm) program it is possible to manage the patient's own blood in order to reduce and, in many cases, eliminate the administration of blood components for transfusion. This approach increases patient safety by reducing clinical risks as well as costs. The implementation of the PBM program in Australia has demonstrated that the use of blood is not strictly necessary but, on the contrary, is largely avoidable. Through change management the traditional attitude of doctors and healthcare facilities can be modified. Law no. 24/2017 focuses on the safety of care by encouraging the necessary implementation of Pbm in hospital settings; the failure to adopt an organized Pbm program may constitute, in the event of an adverse transfusion event, a clear profile of health responsibility on the part of the management and clinicians.

Rotational ThromboElastometry-guided blood component administration versus standard of care in patients with Cirrhosis and coagulopathy undergoing Invasive ProcEdures (RECIPE): study protocol for a randomised controlled trial

BackgroundPatients with cirrhosis often undergo invasive procedures both for management of complications of their advanced liver disease, including treatment for hepatocellular carcinoma, as well as underlying comorbidities. Despite a current understanding that most patients with cirrhosis are in a rebalanced haemostatic state (despite abnormalities in conventional coagulation tests, namely INR and platelet count), patients with cirrhosis are still often given prophylactic blood components based on these conventional parameters, in an effort to reduce procedure-related bleeding. Viscoelastic tests such as Rotational Thromboelastometry (ROTEM) provide a global measurement of haemostasis and have been shown to predict bleeding risk more accurately than conventional coagulation tests, and better guide blood product transfusion in a number of surgical and trauma-related settings. The aim of this study is to assess the utility of a ROTEM-based algorithm to guide prophylactic blood component delivery in patients with cirrhosis undergoing invasive procedures. We hypothesise that ROTEM-based decision-making will lead to a reduction in pre-procedural blood component usage, particularly fresh frozen plasma (FFP), compared with standard of care, whilst maintaining optimal clinical outcomes.MethodsThis is a multi-centre randomised controlled trial comparing ROTEM-guided prophylactic blood component administration to standard of care in patients with cirrhosis and coagulopathy undergoing invasive procedures. The primary efficacy outcome of the trial is the proportion of procedures requiring prophylactic transfusion, with the primary safety outcome being procedure-related bleeding complications. Secondary outcomes include the amount of blood products (FFP, platelets, cryoprecipitate) transfused, transfusion-related side effects, procedure-related complications other than bleeding, hospital length of stay and survival.DiscussionWe anticipate that this project will lead to improved prognostication of patients with cirrhosis, in terms of their peri-procedural bleeding risk. We hope to show that a significant proportion of cirrhotic patients, deemed coagulopathic on the basis of standard coagulation tests such as INR and platelet count, are actually in a haemostatic balance and thus do not require prophylactic blood product, leading to decreased and more efficient blood component use.Trial registrationRECIPE has been prospectively registered with the Australia and New Zealand Clinical Trials Registry on the 30th April 2019 (ACTRN12619000644167).

An Overview of the Identification, Prevention, and Management of Immunological Reactions to Blood Transfusion

lood transfusions are prevalent treatment procedures nowadays for various medical conditions that involve the administration of whole blood or separated blood components alone or in various combinations that can be administered intravenously; these are undertaken with therapeutic or curative goals in mind, they may carry associated risks and complications that must be weighed against the benefits before initiating therapy. A typical subset of complications associated with transfusions includes Transfusion reactions. These include Non-infectious (Acute and Delayed) and infectious complications. Non-infectious transfusion reactions include Immune-mediated reactions to blood components, such as Febrile Non-hemolytic Transfusion reactions (FNHTR), Allergic Transfusion reactions, Hemolytic Transfusion reactions (HTR), Transfusion-related Acute Lung Injury (TRALI), and Transfusion Associated Graft versus Host Disease (TAGVHD), these reactions have different mechanism and complications between them. They can be differentiated for the mechanism of action, presentation time, and clinic. Blood transfusion immunological reactions remain a significant concern in clinical settings, leading to various symptoms. Diagnosing these reactions requires careful monitoring and evaluation of the patient’s clinical status and laboratory parameters. The prevention methods for these reactions include pre-transfusion testing, selecting appropriate blood products, and using leukoreduced blood products. Treatment options may include supportive care, discontinuation of transfusion, and immunosuppressive therapy in severe cases. This article aims to provide an overview of how to identify immune-mediated transfusion reactions, manage them as they occur, and even prevent them if possible.

Guideline on the investigation and management of acute transfusion reactions.

Guideline on the investigation and management of acute transfusion reactions.

SEGURANÇA DO PACIENTE PEDIÁTRICO NA ADMINISTRAÇÃO DE HEMOCOMPONENTES

ABSTRACT Objective: to analyze pediatric patient safety in the administration of blood components. Method: a documentary and retrospective study, developed at a hospital in the Brazilian Midwest region. Data collection took place through medical records and 234 transfusions were identified, performed in 90 patients aged from zero to twelve years old, hospitalized between July and December 2020. An instrument based on good practice guidelines about blood components was used. Descriptive and inferential statistics were used for data analysis. Results: the transfusions were predominantly performed in breastfeeding infants (71.1%). Blood transfusions in critical sectors stood out (86.3%), as well as with indication of a clinical order (87.2%) and prescription of packed red blood cells (75.3%). The Nursing reports identified adverse events (n=05) and incidents (n=13) that were associated with inadequacies between the prescribed and infused volumes and the request and administration time (p<0.001), although no notification was formalized in the institution during the period. Conclusion: the administration of blood components presented nonconformities, which results in risk situations for pediatric patients.

Knowledge of blood transfusion practices among medical students and residents.

A study was conducted to assess and compare the knowledge of blood transfusion practices among medical students and residents in Lebanese and Saudi medical institutions. The online survey consisted of 26 questions: 4 about personal data and experience with transfusion and 22 about knowledge on transfusion practices in the areas of blood donation and donor selection, production and storage of blood components, selection of appropriate blood components, administration of blood components, transfusion reactions, and complications. One hundred and twenty-six students from Saudi Arabia, 84 students from Lebanon, 31 residents from Saudi Arabia, and 23 residents from Lebanon participated in the survey. There were no significant differences between students' and residents' levels of knowledge. Similarly, there was no difference between the students' level of knowledge in the two countries. The correct responses (48% and 46%, for students and residents, respectively) were below the acceptable limit of 60% for both groups. This reflects the need for more vigorous and well-structured education and training for both students and residents.

Do not forget the platelets: The independent impact of red blood cell to platelet ratio on mortality in massively transfused trauma patients.

Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion. Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality. A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT >2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP >2 (1,160 [12.6%]) (p < 0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18-2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37-1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74-4.24]). Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement. Therapeutic/Care Management; Level IV.

A prospective interventional study to assess the impact of a 'structured compact training' on knowledge and skills of safe blood transfusion practices among nurses working in a tertiary care institute.

There is scarce information on the baseline knowledge and practices of nursing officers in relation to administration of blood components. We set out to evaluate the influence of training on their knowledge and skills through Kirkpatrick's levels of Training Evaluation. This interventional cross sectional study of 7months duration conducted in a tertiary care teaching institute involved 200 nursing officers. Hundred were assigned to study/intervention group and 100 were assigned to control/ comparison group by systematic random sampling. Knowledge was tested in different domains-blood components, pre-transfusion checks, transfusion process, post-transfusion process and blood administration practice. The baseline knowledge scores of intervention and control group were similar-15.16 ± 4.11 and 15.02 ± 4.75 (p=0.831). Post-intervention (phase I) after 1 month, the scores improved significantly for domain A, B, C, D and E to 4.3 ± 2.21 (p=0.0001), 3.46 ± 2.15 (p=0.0001), 7.02 ± 3.55 (p=0.0001), 2.51 ± 1.46 (p=0.0012), and 5.86 ± 3.61 (p=0.0018) respectively. In phase II, after 3 months of training, and the scores were significantly better from baseline for all domains except E. For domain A, B, C, D and E, scores were 3.82 ± 2.46 (p=0.0001), 3.53 ± 1.98 (p=0.0001), 7.38 ± 3.87 (p=0.0001), 2.48 ± 1.55 (p=0.0035), and 5.86 ± 3.61 (p=0.95) respectively. Our study showed that baseline scores were low in the nursing officers. No significant difference was found in baseline scores in subject and control population. However, post-intervention, a significant improvement in scores was observed in the study group across all domains.

Role of the nurse in patient blood management and treating anaemia.

Patient blood management has been defined as a patient-focused and evidence-based approach to optimising the management of patients during the transfusion of blood components. This article explores the complex factors that can influence clinical decisions and enhance patient safety in the administration of blood components, particularly red blood cell transfusions in patients with anaemia. The article also explores the nurse's role in acting as a patient advocate and considering alternatives to the use of blood components. While this article focuses on anaemia-related transfusions, the author relates the principles of patient blood management to all transfusion care.

Pediatric resident knowledge of transfusion medicine: Results from the BEST-TEST3 international education needs assessment.

Transfusions are a common intervention within pediatrics and require unique considerations to optimize patient care. Poor knowledge of evidence-based transfusion practice can lead to misuse of transfusion therapy and harm. While there have been assessments of transfusion medicine knowledge of physicians caring for adult patients, there is little data regarding pediatricians. Using a published transfusion medicine knowledge exam for internal medicine physicians as a backbone, pediatric transfusion medicine experts, using an iterative process, developed a pediatric-specific examination. Pilot testing and Rasch analysis, a method used in high-stakes testing, was used to validate the exam. The exam and a previously validated survey on transfusion medicine training, attitudes, and perceived ability were administered to pediatric residents. Analysis consisted of descriptive statistics as well as comparisons of exam scores based on survey responses. 330 pediatric residents from 19 sites in 6 countries participated in the study. The vast majority (91%) of residents had obtained blood product consent. The mean exam score was 37.1% (range 9.5%-71.4%) with no statistical differences based on amount or perceived quality of transfusion medicine education or perceived ability. A rigorously validated exam has now been developed that can be used to assess pediatric transfusion medicine knowledge. A large international group of pediatric residents performed poorly on the exam demonstrating a pressing need for improved transfusion medicine education to ensure safe and appropriate administration of blood components to infants and children.

Nursing care in the transfusion of blood components to surgical patients in the perioperative period

Introduction: blood transfusion consists of the administration of blood components intravenously in clinical or surgical treatments. In the preoperative period, it is performed with the objective of improving tissue oxygenation, as well as promoting hemodynamic and hemostatic balance.&#x0D; Objective: to understand nursing care in the transfusion of blood components to surgical patients in the perioperative period.&#x0D; Method: this is a descriptive and exploratory study with a qualitative approach. Grounded Theory was used, with constant comparative analysis. A total of 18 nurses and 28 nursing technicians from a university hospital took part in the study. Data were collected between October 2019 and February 2020, through a sociodemographic questionnaire and semi-structured interviews.&#x0D; Results: the study resulted in the central category nursing care during transfusion, which gave rise to the categories: caring for before transfusion; caring for during transfusion; and caring for after transfusion, which were discussed according to the standardized nursing methodology.&#x0D; Conclusion: it was understood that nursing care is planned and implemented following an ordering of practices in a logical sequence due to the characteristics of the procedure in the perioperative period. Nurses demand indirect care; in contrast, nursing technicians engage in direct patient care.

Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review.

This narrative review explores the pathophysiology, geographic variation, and historical developments underlying the selection of fixed ratio versus whole blood resuscitation for hemorrhaging trauma patients. We also detail a physiologically driven and goal-directed alternative to fixed ratio and whole blood, whereby viscoelastic testing guides the administration of blood components and factor concentrates to the severely bleeding trauma patient. The major studies of each resuscitation method are highlighted, and upcoming comparative trials are detailed.

The clock is ticking: using in situ simulation to improve time to blood administration for bleeding trauma patients.

Massive hemorrhage protocols are widely used to facilitate the administration of blood components to bleeding trauma patients. Delays in this process are associated with worse patient outcomes. We used in situ simulation as a novel and iterative quality improvement technique to reduce the mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations. We completed monthly, risk-informed unannounced in situ trauma simulations at a Canadian Level 1 trauma centre. We identified three major latent safety threats: (1) massive hemorrhage protocol activation; (2) transport of blood components; and (3) situational awareness of team members. Process improvements for each latent safety threats were tested and implemented during subsequent in situ simulation sessions. We evaluated the effect of this simulation-based intervention on the care of patients before, during and after the intervention. Demographic, clinical and massive hemorrhage protocol data were collected. The primary outcome was mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations as analyzed using a two-sample t test. Each group was similar in demographic and injury characteristics. The time from massive hemorrhage protocol activation to blood administration decreased from 11.6min pre-intervention to 9.1min post-intervention. This represented a significant reduction (2.5min, 95% confidence interval, 0.03-5.08) following the in situ simulation-based quality improvement intervention. A comprehensive, in situ simulation-based quality improvement project was associated with a significant reduction in the mean time between massive hemorrhage protocol activation and blood administration among injured patients. In situ simulation represents a novel approach to the identification and mitigation of latent safety threats during massive hemorrhage protocol activation.

RHD genotyping is recommended for all patients with serological weak-D phenotypes in Asian populations – Cases with coexistence of weak-D and Asia type DEL alleles results in complete expression of D-antigen

Weak D types 1, 2, 3 and Asia type DEL (RHD 1227 G > A) can be treated as D-positive for purposes of Rho(D) immune globulin (RhIG) administration or selection of blood components for transfusion. To confirm these D variants, RHD genotyping can be used as a complementary to serologic tests. While ruling out weak D types 1,2,3 is useful in Caucasian populations, these are extremely rare in the Asian population, while Asia type DEL is relatively common. Distinguishing between true D-negative and Asia type DEL (RHD 1227 G > A) by genotyping has the same utility of distinguishing weak D types 1, 2, 3. The main difference between weak D and Asia type DEL is that the latter appears as D negative in conventional serologic methods, while the former will show positive in indirect anti-human immunoglobulin tests. RHD genotyping in apparent D-negative Asian patients has been established, yet the utility of genotyping in Asian patients with weakened D phenotypes require further investigation. We have observed cases of weak D patients with coexistence of a weak D allele and an Asia type DEL (RHD 1227 G > A) allele, we have found that antigen expression of D is as the weak D in indirect antiglobulin testing, yet all epitopes are detected with adsorption and elution assays. This is indicative of completeness of the D antigen epitope, and thus we suggest that all Asian patients with weakened D phenotypes can benefit from RHD genotyping.

Improving emergency department blood product use through nursing education.

Rapid access to blood products can be lifesaving for hemorrhaging patients, but placing blood components in easily accessible locations in the emergency department (ED) can lead to wasteful patterns of use. Education can lead to improvements in transfusion behavior, but such changes for the better are often short lived. To facilitate the early initiation of balanced resuscitation, an emergency blood refrigerator was placed in our ED in February 2015. Physician education to give blood components in a 1:1 plasma:red blood cell (RBC) unit ratio with the plasma given first was given repeatedly with short-term success. Finally, nurses were trained and empowered to strongly suggest that blood components be given in balanced ratios and that plasma be given first. Plasma:RBC unit ratios were compared in successive years with the chi-square test for trend. A total of 1165 RBC units and 623 plasma units were issued from the ED emergency blood refrigerator over 5 years. Intensive physician education is documented at start, in late 2016 to early 2017, and again in early and late 2018. Ratios of components (U plasma/U RBCs) were 2015, 17%; 2016, 26%; 2017, 61%; 2018, 49%; and 2019, 91% (p < 10-18 chi-square for trend). Higher ratios of plasma use were associated with $40,000+ annual savings. Giving the ED senior nurses formal education about the need for and a policy to give guidance on massive transfusion protocol (MTP) blood component administration sequence has achieved compliance with our MTP's intention. Increasing plasma use reduces group O RBC use and total blood costs.

Embedding best transfusion practice and blood management in neonatal intensive care

BackgroundTransfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best...

Blood component administration to multiple myeloma patients treated with daratumumab: suggesting a novel approach with use of 0.1 M dithiothreitol

Storage of dithiothreitol (DTT)-treated red blood cells (RBCs) leads to hemolysis. The aim of this study was to compare 0.1 M DTT with 0.2 M DTT treatment of RBCs and to share our experience of providing components to seven patients on daratumumab (DARA). This prospective, observational study included patients who required RBC transfusion within 6 months of DARA administration. All patients underwent a baseline serologic evaluation followed by a repeat evaluation after DARA administration. In addition, use of 0.1 M DTT was compared with 0.2 M DTT in terms of concordance of results, hemolysis with storage of treated RBCs, and ease of use. A total of 22 RBC requisitions were received for seven patients. Antibody screen was positive for one patient (anti-C) at baseline; it was panreactive for all patients after DARA. Concordance of results between the two concentrations was 98.5 percent. Laboratory personnel found results obtained with use of 0.1 M DTT-treated RBCs easy to interpret. Supernatant hemoglobin was found to be significantly greater for 0.2 M DTT-treated RBCs at the sixth day of storage. In conclusion, component administration to patients on DARA can be done without delay if adequate policies and procedures are in place. Use of 0.1 M DTT-pretreated RBCs can be used to avoid delay in transfusion and reduce the burden on the laboratory of weekly preparation of 0.2 M DTT-treated RBCs.