Donor Exposure Research Articles

Comparison of Haemonetics MCS Plus and Baxter CS 3000 Plus for Platelet Apheresis: Experienceat a Tertiary Care Hospital

<p><strong>Background and Objective:</strong> Platelet transfusion is one of the most crucial therapeutic approaches in medicine. Single Donor Platelets (SDP) are being preferred because of higher platelet count per unit,leukocyte reduction during collection and fewer donor exposures thus reducing the risk of infection and alloimmunization. This study was conducted to compare Haemonetics MCS plus with Baxter CS3000 plus cell separator in terms of processing time, quality of platelet concentrates, donor experience and individual choice.<br /><strong>Methods:</strong> Two hundred platelet pheresis procedures performed on Haemonetics MCS plus during a period from January 2018 to August 2019 were compared with the same number of procedures performed using Baxter CS3000 plus cell separator from July 2015 to April 2019.<br /><strong>Results:</strong> The mean platelet count of the product was higher with Baxter, 1741.6 ± 347 x 103/μL as<br />compared to1676 ± 301 x 103/μL with Haemonetics. No significant difference between the two instruments was observed regarding processing time, product volume and yield.<br /><strong>Conclusion:</strong> The two instruments are comparable in terms of time, volume and yield of the product but Haemonetics is better because of donors’ comfort and for being operator friendly.</p>

Impact of Ambient Particulate Matter (PM) Exposure of Lung Donors and Recipients on Bronchiolitis Obliterans Syndrome (BOS) and Mortality after Lung Transplant (LT)

A Belgian study found proximity to a motorway increased risk of BOS after LT. Using zip codes as a surrogate for habitat location we investigated the impact of PM2.5 concentration (conc) (PM≥ 2.5 μm/m3) exposure of donors and recipients on BOS and mortality after LT in the US. UNOS Standard Transplant Analysis and Research (STAR) database (June 30, 2017) identified adult LT recipients and their donors between 2005 and 2015, and their zip code of residence at LT. Average ambient PM2.5 conc (PM≥ 2.5 μm/m3) associated with donor and recipient residencies 1 year prior to LT were estimated by mapping each zip code to a census tract, using a crosswalk from HUD, downscaled from a 12 × 12-km sq grid resolution detailed chemistry - transport model application using a Bayesian space-time downscaler, and then fused with surface observations. PM2.5 conc was classified into low (<8 μg/m3), medium (8-12 μg/m3) and high (>12 μg/m3) exposure categories. Cox proportional hazards regression and Kaplan-Meier curves assessed the impact of PM2.5 on 1 year and long term incidence of BOS and all cause mortality. 17,760 LT were analyzed. Median followup was 1101 days (IQR 511-2073, range 1-4448). 25% of LT had high donor exposure and 24% had high recipient exposure. Recipient exposure to PM2.5 had no impact on 1-year survival. However, higher PM2.5 donor exposure appeared to increase risk of early death, although estimates were imprecise (Table). Higher concentration of recipient or donor PM2.5 did not increase long-term mortality risk, and curiously higher recipient PM reduced BOS incidence (Table). PM2.5 is only one aspect of air quality and does not appear to increase long term risk of BOS or death after LT. Donor PM. exposure may have a small impact on 1 year survival after LT. Additional research on other air quality measures including isolating primary and secondary components of PM2.5 and focusing on traffic-related air pollutants is needed.

Coronavirus disease 2019: Implications of emerging infections for transplantation.

The recent identification of an outbreak of 2019- novel Coronavirus is currently evolving, and the impact on transplantation is unknown. However, it is imperative that we anticipate the potential impact on the transplant community in order to avert severe consequences of this infection on both the transplant community and contacts of transplant patients.

Early erythropoiesis-stimulating agents in preterm or low birth weight infants.

Early erythropoiesis-stimulating agents in preterm or low birth weight infants.

Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants.

Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia. Darbepoetin (Darbe) and EPO are currently available ESAs. To assess the effectiveness and safety of late initiation of ESAs, between eight and 28 days after birth, in reducing the use of red blood cell (RBC) transfusions in preterm or low birth weight infants. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 5 June 2018), Embase (1980 to 5 June 2018), and CINAHL (1982 to 5 June 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised controlled trials of late initiation of EPO treatment (started at ≥ eight days of age) versus placebo or no intervention in preterm (< 37 weeks) or low birth weight (< 2500 grams) neonates. We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of the evidence. We include 31 studies (32 comparisons) randomising 1651 preterm infants. Literature searches in 2018 identified one new study for inclusion. No new on-going trials were identified and no studies used darbepoetin. Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of one or more RBC transfusions (21 studies (n = 1202); typical risk ratio (RR) 0.72, 95% confidence interval (CI) 0.65 to 0.79; typical risk difference (RD) -0.17, 95% CI -0.22 to -0.12; typical number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66%; RD I² = 58%). The quality of the evidence was very low. We obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (mL/kg) of blood transfused per infant (typical mean difference (MD) -1.6 mL/kg, 95% CI -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92%). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants; typical MD -0.22, 95% CI -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94%). Three studies including 404 infants reported on retinopathy of prematurity (ROP) (all stages or stage not reported), with a typical RR 1.27 (95% CI 0.99 to 1.64) and a typical RD of 0.09 (95% CI -0.00 to 0.18). There was high heterogeneity for this outcome for both RR (I² = 83%) and RD (I² = 82%). The quality of the evidence was very low.Three trials enrolling 442 infants reported on ROP (stage ≥ 3). The typical RR was 1.73 (95% CI 0.92 to 3.24) and the typical RD was 0.05 (95% CI -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18%) but high heterogeneity for RD (I² = 79%). The quality of the evidence was very low.There were no significant differences in other clinical outcomes including mortality and necrotising enterocolitis. For the outcomes of mortality and necrotising enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. Late administration of EPO reduces the use of one or more RBC transfusions, the number of RBC transfusions per infant (< 1 transfusion per infant) but not the total volume (mL/kg) of RBCs transfused per infant. Any donor exposure is likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO does not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. Further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing one unit of donor blood into many smaller aliquots) may reduce donor exposure.

Pumping O2 with no N2: An Overview of Hollow Fiber Membrane Oxygenators with Integrated Arterial Filters.

The advancement of cardiac surgery benefits from the continual technological progress of cardiopulmonary bypass (CPB). Every improvement in the CPB technology requires further clinical and laboratory tests to prove its safety and effectiveness before it can be widely used in clinical practice. In order to reduce the priming volume and eliminate a separate arterial filter in the CPB circuit, several manufacturers developed novel hollow-fiber membrane oxygenators with integrated arterial filters (IAF). Clinical and experimental studies demonstrated that an oxygenator with IAF could reduce total priming volume, blood donor exposure and gaseous microemboli delivery to the patient. It can be easily set up and managed, simplifying the CPB circuit without sacrificing safety. An oxygenator with IAF is expected to be more beneficial to the patients with low body weight and when using a minimized extracorporeal circulation system. The aim of this review manuscript was to discuss briefly the concept of integration, the current oxygenators with IAF, and the in-vitro / in-vivo performance of the oxygenators with IAF.

Red blood cell transfusion in preterm neonates: a huge debate on tiny patients

Preterm infants are more liable to suffer from anemia, as 90% of extremely low birth weight infants receive red blood cell transfusion. When to receive red blood cell transfusion is not well defined until now, even the complications and hazards resulting from the transfusion of adult red blood cell into the premature circulation is still a matter of debate. In this review, fetal erythropoiesis and the unique pathophysiology of anemia of prematurity is discussed, different meta-analysis studies are presented regarding liberal (high hemoglobin threshold) or restrictive (low hemoglobin threshold) transfusion protocols, early or late transfusion preferences. To clarify the picture of this, everyday decision neonatologists need to take, whether or not to give this premature infant a red packed cell transfusion, which may affect the life of this infant indefinitely. Until now, no fixed guidelines are present regarding when to transfuse anemia and still dependent on expert opinion and center experience. In conclusion the decision of RBCT is a multifactorial expert needing opinion but may be the only treatment option when the preterm neonate reaches a critical oxygen point beyond their ability to cope. So, a judicious use of blood transfusions is recommended, by unit specific guidelines. One can limit donor exposure by using multiple small packs from a single donor to multi transfuse a preterm infant, thus reducing donor exposure.

Immunogenicity of red cell alloantigens in the Japanese population

Aims: To elucidate transfusion-related blood group antigen immunogenicity among Japanese, a retrospective single center study was done. Methods: For 49,884 transfusion recipients from late 2006 to early 2018, antibodies were tested with two techniques: saline immediate spin test and polyethylene glycol-enhanced indirect antiglobulin test. From male recipients with an average of 4.2 donor exposures, we calculated the immunogenicity of blood group alloantigens with a mathematical model. Results: Indirect antiglobulin test detected 638 alloantibodies, 391 (1.53%) among 25,563 women and 247 (1.02%) among 24,321 men. Anti-E (489.1 per 100,000), followed by anti-Lea (238.6 per 100,000) and anti-Fyb (100.2 per 100,000) were most frequently found in the whole. Immunogenicity calculations among male recipients based on 4-donor exposure revealed Jra (67.4 per 1000, 95% CI: 1.7–323.3) as the possibly highest potency antigen, followed by: Lea (23.5 per 1000, 95% CI: 17.4–29.6), Dib (20.1 per 1000, 95% CI: 0.5–109.3), E (11.9 per 1000, 95% CI: 9.4–14.4), and Jka (5.7 per 1000, 95% CI: 1.7–9.6) among Japanese male recipients. Conclusion: Jra and Diego blood group antigens might be highly immunogenic in the Japanese population, but more recipients would need to be investigated to establish statistical significance.

Mercury, lead, and cadmium exposure via red blood cell transfusions in preterm infants.

Mercury, lead, and cadmium are developmental neurotoxicants. We predict that preterm newborns requiring packed red blood cell (PRBC) transfusions may be exposed to neurotoxic doses. We explored the relationship between donor concentration, number of donors, number of transfusions and mercury, lead and cadmium exposure. Single-donor PRBCs were analyzed for mercury, lead and cadmium concentration. Dose per transfusion was calculated and compared to intravenous reference doses (IVRfDs). Linear regression analyses were performed to correlate donor and infant exposure. Thirty-six infants received 268 transfusions from 94 donors. Number of donors and transfusions were significantly correlated with birthweight and gestational age. All three metals were detected in ≥95% of donor PRBCs. Number of donors was significantly associated with cumulative dose, and there was a significant correlation between mercury and lead doses/transfusion. IVRfDs were exceeded for mercury and lead in 8.6% and 38% of transfusions, respectively. None exceeded the IVRfD for cadmium. For lead, infants exposed to three donors had more transfusions exceeding IVRfD than those exposed to 1-2 donors. Preterm infants are exposed to heavy metals via transfusions. Doses exceeded the IVRfDs for mercury and lead. Cadmium did not pose a risk. Prescreening donor blood could reduce exposure risk.

Fresh Frozen Plasma and Platelet Transfusion Practices in Neonatal Intensive Care Unit of a Tertiary Care Hospital.

Blood transfusion is an indispensable part of modern medical and surgical practices. More than 35% of critically ill patients receive transfusion of blood components during their intensive care unit stay. The aim of study is to obtain an information regarding the relationship of platelet concentrate (PC) and fresh frozen plasma (FFP) transfusion on clinical outcome of neonates admitted in neonatal ICU (NICU). This prospective cohort study was conducted from 1st November 2011 to 30th April 2013. The clinical history, blood component details and laboratory parameters were evaluated with clinical outcome. The neonates requiring PC and FFP transfusion were followed up in blood bank for laboratory parameters. Clinical parameters were noted from case file. During the study period, 291 neonates were admitted in NICU. 2 neonates had congenital malformations and thus, were excluded from the study. Of the remaining 289 neonates, 49 neonates received transfusion of platelets and/or FFP. The combined mean donor exposure for all components was found to be 1.48. The mean volume of PC and FFP transfused was 20ml and 30ml respectively. The mean pre- and post-transfusion platelet count was 34,000µl and 42,000µl respectively. The mean pre- and post-transfusion INR was 2.37 and 1.53 respectively. There was a significant increase in platelet count and decrease in INR in transfused neonates. However, no clinical benefit of PC and FFP transfusion seen on bleeding. Transfusion of PC and FFP has significant effect on laboratory parameters as compared to clinical parameter.

Comparison of efficacy of low and high dose prophylactic platelet transfusion therapy in thrombocytopenic haemato-oncology patients

IntroductionTo determine an optimal platelet dose in thrombocytopenic patients is important for their judicious use. Transfusing platelets in different doses and comparing their post transfusion response can achieve this. AimTo compare the efficacy of low and high dose single donor apheresis platelets (SDAP) with standard dose transfusions in terms of Corrected Count Increment (CCI), Percent Platelet Recovery (PPR) and transfusion free interval. MethodIt was a prospective case control study done from January 2016 to April 2017. Twenty-eight hemato-oncology patients with CCI ≥5000 at 20–24 hours after standard dose (3 × 1011/unit), received low dose (1.5 × 1011 platelets/unit) and high dose (>4 × 1011 platelets/unit) SDAP. CCI and PPR were calculated after 20 to 24 hours of transfusion. Transfusion free interval and bleeding episodes were also noted. Grading was done according to WHO bleeding scale. ResultThere was no statistical difference in CCI and PPR when standard dose was compared with low dose (CCI: p = 0.92, PPR: p = 0.89). When standard and high dose was compared, standard dose gave better results than the high dose in terms of CCI (p = 0.006) and PPR (p = 0.008) although the post transfusion increments were comparable (p = 0.938). High dose gave better (p = 0.005) platelet count increments than low dose but CCI (p = 0.04) and PPR (p = 0.05) was significantly less than the low dose. The difference in transfusion free intervals after three doses was not significant. Donor exposure to the patients was significantly (p = 0.000) reduced to 17.5%. ConclusionPossibility of low dose as an alternative to standard dose can be considered in view of comparable platelet response indicators and significantly reduced donor exposure.

Association of Blood Donor Sex and Prior Pregnancy With Mortality Among Red Blood Cell Transfusion Recipients

Evidence regarding associations of blood donor sex with mortality among red blood cell transfusion recipients is conflicting. To study associations of donor sex and prior pregnancy with mortality of transfusion recipients. Data from 3 retrospective cohorts of transfusion recipients (the Kaiser Permanente Northern California [KPNC] and Recipient Epidemiology and Donor Evaluation Study-III [REDS-III] databases of data from January 2013 to December 2016 and the Scandinavian Donations and Transfusions [SCANDAT] database with data from January 2003 to December 2012) were analyzed. Final dates of follow-up were December 31, 2016, for the KPNC and REDS-III cohorts and December 31, 2012, for the SCANDAT cohort. Stratified Cox regression models were used to estimate associations between donor exposure groups with risk of mortality, adjusting for the number of red blood cell unit transfusions. The number of transfused red blood cell units from female donors, previously pregnant donors, and sex-discordant donors (male donor and female recipient or female donor and male recipient). In-hospital mortality. The study population included 34 662 patients (mean age, 69 years; 18 652 [54%] women) from the KPNC cohort, 93 724 patients (mean age, 61 years; 48 348 [52%] women) from the REDS-III cohort, and 918 996 patients (mean age, 72 years; 522 239 [57%] women) from the SCANDAT cohort. The median number of red blood cell transfusions per patient was 3 in the KPNC cohort, 2 in the REDS-III cohort, and 3 in the SCANDAT cohort. The percentage of transfusions from previously pregnant or parous donors was 9% in the KPNC cohort, 18% in the REDS-III cohort, and 25% in the SCANDAT cohort. The percentage of transfusions in the 3 cohorts from female donors ranged from 39% to 43%, from previously pregnant or parous donors ranged from 9% to 25%, and from sex-discordant donors ranged from 44% to 50%. There were 3217 in-hospital deaths in the KPNC cohort, 8519 in the REDS-III cohort, and 198 537 in the SCANDAT cohort. There were no statistically significant associations between any of the 3 donor exposures and in-hospital mortality in the 3 cohorts. Hazard ratios for in-hospital mortality per transfused unit from female donors were 0.99 (95% CI, 0.96-1.03) for the KPNC cohort, 1.00 (95% CI, 0.99-1.01) for the REDS-III cohort, and 1.00 (95% CI, 0.99-1.00) for the SCANDAT cohort. For units from previously pregnant or parous female donors, hazard ratios were 1.00 (95% CI, 1.00-1.01) for the KPNC cohort, 1.01 (95% CI, 0.98-1.03) for the REDS-III cohort, and 1.00 (95% CI, 1.00-1.01) for the SCANDAT cohort. For units from sex-discordant transfusions, hazard ratios were 1.02 (95% CI, 0.99-1.05) for the KPNC cohort, 0.99 (95% CI, 0.98-1.00) for the REDS-III cohort, and 1.00 (95% CI, 0.99-1.00) for the SCANDAT cohort. Among red blood cell transfusion recipients, transfusions from female, previously pregnant, or sex-discordant donors were not significantly associated with increased mortality.

Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants.

Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia. Darbepoetin (Darbe) and EPO are currently available ESAs. To assess the effectiveness and safety of late initiation of ESAs, between eight and 28 days after birth, in reducing the use of red blood cell (RBC) transfusions in preterm or low birth weight infants. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 5 June 2018), Embase (1980 to 5 June 2018), and CINAHL (1982 to 5 June 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised or quasi-randomised controlled trials of late initiation of EPO treatment (started at ≥ eight days of age) versus placebo or no intervention in preterm (< 37 weeks) or low birth weight (< 2500 grams) neonates. We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of the evidence. We include 31 studies (32 comparisons) randomising 1651 preterm infants. Literature searches in 2018 identified one new study for inclusion. No new on-going trials were identified and no studies used darbepoetin.Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of one or more RBC transfusions (21 studies (n = 1202); typical risk ratio (RR) 0.72, 95% confidence interval (CI) 0.65 to 0.79; typical risk difference (RD) -0.17, 95% CI -0.22 to -0.12; typical number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66%; RD I² = 58%). The quality of the evidence was very low. We obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (mL/kg) of blood transfused per infant (typical mean difference (MD) -1.6 mL/kg, 95% CI -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92%). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants; typical MD -0.22, 95% CI -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94%).Three studies including 404 infants reported on retinopathy of prematurity (ROP) (all stages or stage not reported), with a typical RR 1.27 (95% CI 0.99 to 1.64) and a typical RD of 0.09 (95% CI -0.00 to 0.18). There was high heterogeneity for this outcome for both RR (I² = 83%) and RD (I² = 82%). The quality of the evidence was very low.Three trials enrolling 442 infants reported on ROP (stage ≥ 3). The typical RR was 1.73 (95% CI 0.92 to 3.24) and the typical RD was 0.05 (95% CI -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18%) but high heterogeneity for RD (I² = 79%). The quality of the evidence was very low.There were no significant differences in other clinical outcomes including mortality and necrotising enterocolitis. For the outcomes of mortality and necrotising enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. Late administration of EPO reduces the use of one or more RBC transfusions, the number of RBC transfusions per infant (< 1 transfusion per infant) but not the total volume (mL/kg) of RBCs transfused per infant. Any donor exposure is likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO does not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. Further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing one unit of donor blood into many smaller aliquots) may reduce donor exposure.

Predictors of transfusion outcomes in pediatric complex cranial vault reconstruction: a multicentre observational study from the Pediatric Craniofacial Collaborative Group.

Pediatric patients undergoing complex cranial vault reconstruction (CCVR) are at risk of significant perioperative blood loss requiring blood product transfusion. Minimizing allogeneic blood product transfusion is an important goal because of the associated risks and cost. The impact of patient and surgical variables on transfusion is unknown in this population. Our primary aim was to examine relationships between demographic and perioperative variables and blood product transfusion outcomes in CCVR. The multicentre Pediatric Surgery Perioperative Registry was checked for children undergoing CCVR between June 2012 and September 2016. Univariable and multivariable analyses were performed examining patient, procedure, and blood conservation variables and their relationship to three outcomes: intraoperative red blood cell-containing product (RBC-CP) transfusion, total perioperative blood donor exposures, and transfusion-free hospitalization. The registry search returned data from 1,814 cases. Age and surgical duration were the only variables significantly associated with all three outcomes studied. Predictors of reduced RBC-CP transfusion included lower American Society of Anesthesiologists (ASA) physical status and antifibrinolytic administration. Total cranial vault reconstruction, intraoperative vasoactive infusion, and presence of a tracheostomy predicted increased donor exposures. Increased body weight, higher preoperative hematocrit, and utilization of intraoperative cell saver and transfusion protocols were associated with transfusion-free hospitalization. Clinical factors associated with increased allogeneic blood product transfusion in pediatric CCVR include: age ≤ 24 months, ASA status ≥ III, preoperative anemia, prolonged surgical duration, lack of intraoperative antifibrinolytic use, lack of intraoperative cell saver use, and the lack of transfusion protocols.

Intraoperative Management by a Craniofacial Team Anesthesiologist is Associated With Improved Outcomes for Children Undergoing Major Craniofacial Reconstructive Surgery.

The benefits of using a dedicated team for complex surgeries are well established for certain specialties, but largely unknown for others. The aim of this study was to determine whether management by a dedicated craniofacial team anesthesiologist would impact perioperative outcomes for children undergoing major surgery for craniosynostosis. Sixty-two children undergoing complex cranial vault reconstruction were identified. Fifty-four patients were managed by the craniofacial anesthesia team, while 8 patients were not. Primary outcome measures were calculated blood loss, red blood cell transfusion volume, blood donor exposures, extubation rate, and postoperative complication rate. Secondary outcome measures included intraoperative opioid administration, crystalloid and colloid administration, intraoperative complication rate, and intensive care unit (ICU) and hospital length of stay. Children cared for by the craniofacial team had significantly lower calculated blood loss, reduced red blood cell transfusion volume, fewer blood donor exposures, less crystalloid administration, higher rate of postoperative extubation, fewer postoperative complications, and decreased ICU and hospital length of stay than patients who were managed by noncraniofacial team anesthesiologists. There were no significant differences in demographics, opioid administration, colloid volume administration, or intraoperative complication rates between the 2 groups. Management by a craniofacial team anesthesiologist was associated with improved outcomes in children undergoing major craniofacial reconstructive surgery. While some variability can be attributed to provider-volume relationship, these findings suggest that children may benefit from a subspecialty anesthesia team-based approach for the management of craniofacial surgery, and potentially other similar high-risk cases.

Platelet refractoriness

Platelet transfusion support is extensively required for hemato-oncology patients who are multiply transfused. Platelet refractoriness can represent a significant clinical condition that complicates the platelet transfusion support in such patients. It remains a challenge associated with an increased bleeding risk, longer hospital stays, and increased morbidity and mortality. Causes for refractoriness are broadly divided into nonimmune and immune causes. Approximately two-thirds of refractory episodes are due to nonimmune factors while one-third are due to immune factors. Common formulae to assess platelet refractoriness include corrected count increment (CCI), posttransfusion platelet increment, and percentage platelet recovery. Measurement of CCI is one of the best parameters to differentiate between immune and nonimmune causes. In nonimmune factors which are associated with increased platelet consumption, treating the underlying cause and increasing the frequency of transfusion should be considered. However, in immune factors which are due to increased destruction of platelets owing to alloimmunization, other strategies such as ABO-identical/ABO-compatible fresh platelets, human leukocyte antigen-matched platelets, and crossmatched platelet transfusions should be considered. The newer approach includes epitope-matched platelet transfusion which is still in amateur stage. The strategies in the prevention of alloimmunization include leukoreduction of blood components, reducing donor exposure by providing single-donor platelets, and providing ABO-compatible platelets from the beginning of the treatment. This review will address the causes of platelet refractoriness and practical approach to the diagnosis, management, and its prevention.

Minimising Transfusion Therapy and Alloimmunisation in Patients with Sickle Cell Disorder in the Era of Hydroxyurea

In the UK, 700 patients with sickle cell disease are on a transfusion programme1. Red blood cell (RBC) AI occurs in 4.4-76%2 of regularly transfused sickle patients. Contributing factors include repeated transfusions and ethnic differences between sickle cell patients and their donors. This results in higher rates of mismatch in phenotyped and genotyped blood. There is a continued lack of availability of blood products from more compatible ethnic donors.Sickle patients on transfusion programmes are transfused every 3-6 weeks, creating a large burden on healthcare services in terms of time, labour and resources such as extended red cell typing in order to reduce antibody formation. The presence of RBC antibodies in patients can cause significant delays in obtaining cross matched blood and reductions in phenotype matched blood being transfused.The aims of this project were to a) review transfusion use in relation to the use of hydroxyurea (HU) patients treated at Alder Hey (AH) and b) review rates of AI in these patients. At AH we have changed our practice to offer HU from age 9 months as a disease modifying therapy 20-35mg/kg/day.We retrospectively reviewed the use of blood products in our cohort of 60 patients, age between 0-20 years (mean 11yrs). Patients were observed over their life period treated at AH, mean 10.1 patient years, range 0-20years, total of 439 patient years. We studied retrospectively the number of RBC transfusions and the historical presence of antibodies. We then re-tested all patients to determine current antibody status.Prior to commencement of hydroxyurea, 342 units of bloods were transfused to 21 patients over 243 patient years, which is 1.41 units per patient per year.After commencement of hydroxyurea, 114.5 units were transfused to 17 patients in 187.1 patient years, 0.61 units per patient per year.Indications for transfusion included acute chest syndrome, aplastic crisis, prolonged crisis, increased acute anaemia, hydroxyurea induced anaemia, pre-operatively.3 patients in our cohort had previous antibodies. Upon repeat antibody screening, no patients had detectable RBC antibodies.All patients have an extended red cell phenotype as part of their initial workup on referral to our service. Elective, non-acute patients (transfusion programme, pre-operative, hydroxycarbamide induced anaemia) all receive fully phenotyped blood. This cannot be guaranteed in acute situations where patients receive the best matched blood available.This practice of minimising blood transfusion use in patients with sickle cell anaemia can reduce blood product usage and as a result reduce the demand for ethnic minority transfusion donors. The subsequent donor exposure would therefore also decrease transfusion related complication of AI.1 National Haemoglobinopathy Registry Annual Report 2016/172G. da Cunha Gomes, E & A. F. Machado, L & C. de Oliveira, L & F. N. Neto, J. (2018). The erythrocyte alloimmunisation in patients with sickle cell anaemia: a systematic review: Erythrocyte alloimmunisation in sickle cell anaemia. Transfusion Medicine. 10.1111/tme.12543. DisclosuresNo relevant conflicts of interest to declare.

Improving Outcomes in a Complex Health Care System: Lessons From Complex Cranial Vault Reconstruction.

Reducing blood donor exposure (BDE) is a meaningful improvement goal for many conditions and procedures that require a transfusion of blood products. Complex cranial vault reconstruction (CCVR) in children is a procedure that routinely requires a large-volume blood transfusion, with intraoperative blood loss routinely exceeding the circulating blood volume1–4 and ongoing losses often leading to postoperative transfusions. Large-volume transfusions increase the risk for coagulopathy5 and a need for additional blood products; increasing donor exposure increases the risk for infection, transfusion reactions, and alloimmunization.6 Optimizing the transfusion management for CCVR requires a high degree of care coordination because multiple providers are involved in the care of these children in the preoperative, intraoperative, and postoperative setting.1 In addition, an optimal transfusion strategy for this particular population has not been previously established. In this issue of Hospital Pediatrics , Muhly et al7 report the use of sequential interventions and the evaluation of outcomes over time to achieve an overall goal of reducing BDEs. They also achieve a secondary goal of reducing the overall blood transfusion volume in the CCVR population. Although …

Care Standardization Reduces Blood Donor Exposures and Transfusion in Complex Cranial Vault Reconstruction.

Complex cranial vault reconstruction (CCVR) often requires a large-volume transfusion of blood products. We implemented a series of improvement interventions to reduce blood donor exposures (BDE) and transfusion requirements in CCVR. We implemented interventions over 4 epochs: (E1) reconstituted blood (1:1 ratio of donor-matched red blood cells and fresh-frozen plasma) for intraoperative transfusions, (E2) reconstituted blood plus postoperative transfusion guidelines, (E3) reconstituted blood plus intraoperative antifibrinolytics and postoperative guidelines, and (E4) fresh whole blood for intraoperative transfusion, antifibrinolytics, and postoperative guidelines. Primary outcomes, BDE, and total volume of blood products transfused are presented by using statistical process control charts, with statistical comparisons between each epoch and baseline data. We included 347 patients <72 months old who underwent CCVR between 2008 and 2016 (E1: n = 50; E2: n = 41; E3: n = 87; and E4: n = 169). They were compared with a baseline sample group of 138 patients who were managed between 2001 and 2006. Compared with our baseline group, patients in each epoch had a significant reduction in BDE (P = .02-<.0001). Conversely, compared with the baseline group, we observed an increase the volume of blood products transfused in E1 (P = .004), no difference in E2 (P = .6) or E3 (P = .46), and a reduction in the volume of blood products transfused in E4 (P < .0001). The implementation of sequential clinical improvement strategies resulted in a sustained reduction in BDE whereas only the use of whole blood resulted in a significant reduction in the total volume of blood products transfused in children undergoing CCVR.

Feasibility of autologous intraoperative blood collection and retransfusion in small children with complex congenital heart defects undergoing cardiopulmonary bypass.

Allogeneic blood product transfusion is common in pediatric patients undergoing cardiopulmonary bypass although it is associated with an increased risk for adverse events. Furthermore, numerous donor exposures may affect future blood transfusion needs and human leukocyte antigen matching for patients who may ultimately require cardiac transplantation. Autologous intraoperative blood collection and retransfusion is a known method of blood preservation, but has not been extensively practiced in pediatric patients. In this study we assess the feasibility of this blood conservation technique in small children with complex congenital heart defects undergoing cardiopulmonary bypass. After Institutional Review Board approval, we retrospectively reviewed the medical records of children weighing <10kg who underwent cardiopulmonary bypass over a 2-year period. Eighteen patients underwent autologous intraoperative blood collection and retransfusion and comprised the study group. Eighteen control patients were chosen by a 1:1 matched design using preoperative hematocrit, surgical procedure, and body weight. Multiple corresponding demographic and surgical variables, transfusion data, and clinical outcomes were compared. Patient demographics, operative parameters and preoperative laboratory, and coagulation values were similar between the two groups. Despite the removal of autologous blood, study patients did not require more inotropic support prior to cardiopulmonary bypass. They also did not experience a significant increase in bleeding as measured by 24-hour postoperative chest tube output. Study patients were exposed to significantly fewer donor units intraoperatively and within the first 24hours postoperatively. The use of autologous intraoperative blood collection and retransfusion is a feasible option for small children with complex congenital heart defects undergoing cardiopulmonary bypass. Study patients received significantly fewer donor exposures without an increase in postoperative bleeding. Children who require multiple cardiac surgeries or eventually transplantation could benefit from this blood conservation technique.