Transfusion Management Of Patients Research Articles

A national survey of current immunohematologic testing practices for the diagnosis of autoimmune hemolytic anemia in India.

Autoimmune hemolytic anemia (AIHA) is a common term for several disorders that differ from one another in terms of etiology, pathogenesis, clinical features, and treatment. Management of patients with AIHA has become increasingly evidence-based in recent years. While this development has resulted in therapeutic improvements, it also carries increased requirements for optimal diagnosis using more advanced laboratory tests. Unfortunately, limited data are available from developing countries regarding the testing and transfusion management of patients with AIHA. The main objective of this survey was to explore the current immunohematologic testing practices for the diagnosis of AIHA in India. This online survey consisted of 30 questions, covering the place of work, the number of AIHA cases encountered in the 3 preceding years, testing method(s), transfusion management, and so forth. Individuals representing 89 laboratories completed the survey; only 78 of which responded that AIHA testing was performed in their facility's laboratory. The majority of respondents agreed that the most commonly affected age-group comprised individuals of older than 20 years, with a female preponderance. Regarding transfusion management, respondents indicated that transfusion with "best-match" red blood cell units remains the most common practice. Column-agglutination technology is used by 92 percent of respondents as the primary testing method. Although a monospecific direct antiglobulin test is available at 73 percent of the sites, most of them have limited access to other resources that could diagnose cold or mixed AIHA. Merely 49 percent of responding laboratories have the resources to perform adsorption studies for the detection of alloantibodies. Furthermore, three-cell antibody screening reagents are unavailable at 32 percent of laboratories. In 72 percent of centers, clinical hematologists would prefer to consult a transfusion medicine specialist before administering treatment to AIHA patients. There is unanimous agreement regarding the need for a national registry. The survey data indicate wide variability in testing practices for patients with AIHA in India. Future studies are needed to focus on the feasibility and cost-effectiveness of different testing strategies for developing countries.

How do transfusion services manage patients taking therapies such as anti-CD38 and anti-CD47 known to interfere with red blood cell compatibility testing?

Drugs such as daratumumab (Darzalex, anti-CD38) and Hu5F9-G4 (magrolimab, anti-CD47) may interfere with red blood cell compatibility testing as CD38 and CD47 are expressed on red blood cells. A survey of AABB member transfusion services was undertaken to understand their experiences of managing patients taking therapeutic monoclonal antibodies that are known to interfere with blood grouping and compatibility testing. The survey was distributed to the contact person at US-based AABB member transfusion services. The response rate was 27%. 172 of 240 (72%) indicated they had difficulties in performing compatibility testing in patients taking daratumumab and 66 of 91 (73%) reported difficulties in performing compatibility testing in patients taking magrolimab. Actions taken to provide compatible blood for these patients included referral of all samples to a reference center, blood group pheno/genotyping the patient in advance of starting the drug, treating reagent cells with 0.2 M dithiothreitol and using K-negative red cell units for patients taking daratumumab, and Gamma-clone (Immucor) anti-IgG for indirect antiglobulin testing for patients taking magrolimab. Lack of communication from clinical services about drug treatment was identified as a concern. The results of the survey demonstrate that transfusion services are having challenges with the transfusion management of patients taking therapeutic monoclonal antibodies, and further education is needed.

Selective IgA Deficiency and Blood Component Transfusion: In Search of the Lost Evidence

Background: Selective IgA deficiency (IgA-D) has been historically considered a high-risk entity for developing allergic/anaphylactic reactions after blood transfusion (AATRs). However, it has been suggested that the IgA-D-related anaphylactic transfusion reaction is not evidence-based. Methods: We conducted three different approaches to collect evidence about epidemiology, AATRs, and transfusion management of patients with IgA-D at La Fe University Hospital. Firstly, we analysed the prevalence of IgA-D in a population of patients diagnosed with acute leukaemia, The second approach consisted of collecting transfusion data from IgA-D patients. Finally, we reviewed the IgA levels of patients recorded in the hemovigilance system suffering an AATR. Results: IgA-D prevalence was 1 in 334 patients. At least one blood component was transfused to 23 patients diagnosed with IgA-D. Plasma was transfused to eight IgA-D patients, while six patients received red blood cells, platelets, and plasma. No adverse reactions were reported in any patient. AATRs occurred in 325 men and 264 women with a median age of 52 years. Severe reactions occurred in 56 patients (1/14,520 components). Mean IgA levels were 215 mg/dL (4–5570) for mild reactions and 214 mg/dL (14–824) for severe reactions (p = ns). Washed platelets were administered to two patients who developed severe and repeated AATRs. Both had normal IgA levels. Conclusions: Since the AATRs related to IgA-D are extremely low, as reported in current hemovigilance systems, IgA-D should not be considered a high-risk entity to develop AATRs. On the contrary, our findings support standard transfusion management of IgA-D patients.

Risk of new alloimmunization in patients on anti-CD38 treatment using tube LISS-IAT method

BackgroundDaratumumab is a monoclonal antibody that targets CD38, a transmembrane protein expressed on many cells including RBCs and to a greater extent on myeloma cells. It has been used for treatment of multiple myeloma and autoimmune diseases. Transfusion management of patients on such therapy can be challenging as these drugs cross-react with RBC surface antigens and cause panreactivity. Material and methodsA retrospective study of the 68 patients treated with anti-CD38 from 2018–2023 was carried out. Data regarding transfusion history and antibody screens were analyzed. Depending whether they had immunohematological work-up before or during the treatment- DAT, antibody screen (CAT and tube), RBC pheno/genotyping and serologic cross-matches (CAT and tube) were performed for each patient. All cases with positive CAT IAT were retested in LISS-tube and cross-matches were performed with phenotypically matched units in LISS-tube. ResultsAntibody screen has shown panagglutination with all panel cells with low and variable agglutination intensity (weak to 2 +). Panagglutination remained positive for 1 − 6 months after drug cessation. Positive DAT was seen in 60,6% patients, while autocontrol was negative. Ficin treated panel-cells eliminated nonspecific reactivity. LISS-tube antibody screen and cross-matches were negative for all patients, apart from 3 patients who had preexisting antibodies. No new antibodies were detected during the course of the study. ConclusionAmong study group there were no newly identified alloantibodies, meaning that the policy of transfusing them with matched RBCs and performing IAT/cross-matches in tube is a safe and effective policy according to the findings of this study.

Red blood cell transfusions impact response rates to immunotherapy in patients with solid malignant tumors.

Red blood cell (RBC) transfusions have been shown to exert immunosuppressive effects in different diseases. In consequence, RBC transfusions might also negatively influence the response to immunotherapeutic treatment approaches. To address how RBC transfusions impact response rates of antitumor immunotherapy (IT), we conducted a retrolective clinical study of patients with different solid tumors treated with IT (atezolizumab, pembrolizumab, nivolumab and/or ipilimumab). We assessed the number of RBC concentrates received within 30 days before and 60 days after the start of IT. Primary objective was the initial therapy response at first staging, secondary objectives the number of immune related adverse events and infections. 15 of 55 included patients (27.3%) received RBC concentrates. The response rates were 77.5% in the non-transfused (n=40) versus 46.7% in the transfused patient group (n=15) and reached statistical significance (p=0.047). The correlation between therapy response and transfusion was statistically significant (p=0.026) after adjustment for the only identified confounder “line of therapy”. In contrast, transfusion in the interval 30 days before IT showed no significant difference for treatment response (p=0.705). Moreover, no correlation was detected between RBC transfusion and irAE rate (p=0.149) or infection rate (p=0.135). In conclusion, we show for the first time that the administration of RBC transfusions during, but not before initiation of IT treatment, negatively influences the response rates to IT. Our findings suggest a restrictive transfusion management in patients undergoing IT to receive optimal response rates.

Effects of rotational thromboelastometry-guided transfusion management in patients undergoing surgical intervention for postpartum hemorrhage: An observational study.

Postpartum hemorrhage (PPH) can be associated with coagulopathy, which may be difficult to rapidly assess and may exacerbate blood loss. Rotational thromboelastometry (ROTEM) at the point of care can guide clinician choice of blood products and has been shown in some settings to reduce transfusions and improve outcomes. This hospital-based observational study aims to measure effects of a ROTEM-guided transfusion protocol on transfusion practice and clinical outcomes in patients with PPH managed in the operating theater. We compared a retrospective cohort of 450 consecutive patients with PPH treated in the operating theater before the introduction of a ROTEM-guided transfusion algorithm in June 2016, with 450 patients treated after its introduction. Multivariate regression was used to evaluate the effect of ROTEM introduction on the primary outcome, patients requiring a packed red blood cell (PRBC) transfusion and adjusting for demographic and obstetric confounders. Secondary outcomes included other blood product transfusions, hysterectomy, and intensive care unit admission. A total of 90 (20%) of patients treated prior to ROTEM introduction received a PRBC transfusion, compared with 102 (22.7%) of those treated after ROTEM introduction (95% confidence interval [CI] 1.0-2.0, p= .04). There was no difference in PRBC transfusion in patients undergoing caesarean section (95% CI 0.5-1.8, p= .99). There was a trend toward increased use of cryoprecipitate and reduced use of platelets and fresh frozen plasma after ROTEM introduction. In our institution, the introduction of ROTEM-guided transfusion did not reduce PRBC transfusion in patients with PPH treated in the operating theater.

Viscoelastic coagulation test for liver transplantation.

Coagulation and transfusion management in patients undergoing liver transplantation is challenging. Proper perioperative monitoring of hemostasis is essential to predict the risk of bleeding during surgery, to detect potential causes of hemorrhage in time, and to guide hemostatic therapy. The value of conventional coagulation test is questionable in the acute perioperative setting due to their long turnaround time and the inability to adequately reflect the complex changes in hemostasis in patients with liver disease. Viscoelastic coagulation tests provide simultaneous measurement of multiple aspects of whole-blood coagulation including plasmatic coagulation and fibrinolytic factors and inhibitors that reflect most aspects of hemostasis. Coagulation initiation, mechanical clot stability, and fibrinolysis can be estimated immediately using point-of-care techniques. Therefore, viscoelastic coagulation tests including ROTEM & TEG would be useful to guide patient blood management strategy during liver transplantation.

Effects of intelligent nursing and transfusion system on transfusion management in patients with growth hormone adenoma complicated with cardiomyopathy

Objective To evaluate the effects of the intelligent nursing and transfusion system on transfusion management in patients with growth hormone adenoma complicated with cardiomyopathy. Methods The patients with growth hormone adenoma complicated with cardiomyopathy treated in the Department of Neurosurgery in a ClassⅢ Grade A hospital from January 2018 to May 2019 were selected. Totally 78 patients receiving conventional transfusion management from January to October 2018 were included into the control group, while 70 patients admitted from November 2018 to May 2019 after the intelligent nursing and transfusion system was applied were included into the experimental group. The incidence rate of adverse effects in transfusion, correct rate of transfusion speed, incidence rate of arrhythmia and patients' compliant rate in terms of transfusion were evaluated between the two groups. Results The incidence rate of adverse effects in transfusion in the experimental group was 5.7%, lower than 16.7% in the control group. The correct rate of transfusion speed was 97.0% in the experimental group, higher than 89.3% in the control group, and there was statistically significant difference between the two groups (P 0.05) . The compliant rate about transfusion was 5.7% in the experimental group, lower than 16.7% in the control group, and there was statistically significant difference between the two groups (P<0.05) . Conclusions The intelligent nursing and transfusion system can improve transfusion management in clinical practice, which not only reduce the incidence rate of adverse effects in transfusion and improve the transfusion safety in patients with growth hormone adenoma complicated with cardiomyopathy, and also reduce the compliant rate about transfusion and improve patients' satisfaction. Key words: Growth hormone adenoma; Cardiomyopathy; Venous transfusion; Intelligent nursing and transfusion system; Transfusion management; Informatization

The First Comprehensive Study of H-Deficient Phenotypes in Iran

Summary Background: The lack of correct blood grouping practices can lead to missing of the rare Bombay Oh phenotype and subjecting patients to the risk of severe hemolytic transfusion reaction. In the absence of blood donor registry, transfusion management of patients is a challenge. We performed this study in order to estimate the prevalence of the Bombay blood group (Oh) in Iran and to determine whether consanguinity plays a role in the prevalence of Oh group. Methods: This is a descriptive study in the Immunohematology Reference Laboratory of the Iranian Blood Transfusion Organization (IBTO) Tehran, Iran, over a period of 7 years. All donor blood samples showing blood group O and a strong initial reaction with blood group O RBC control cells were tested with anti-H lectin. Also blood samples from blood group O patients were tested with anti-H lectin if all cells on both antibody screening tests and antibody identification panels were reactive with negative auto control test. Specialized tests like adsorption/elution technique and inhibition assay for determination of secretor status were performed on Oh cases. Any history of consanguineous marriages were recorded. All variables were categorical variables, and percentage and proportions were calculated manually. Results: Analysis of the results of over 7 million first-time blood donors in Iran showed that the most common ABO blood group was O, with 2,520,000 (36%) subjects. 56 Oh individuals' (donors and patients) phenotypes (0.0008%) were detected. Consanguinity was observed in 50 cases (89%). Conclusions: This study shows that the prevalence of Bombay blood group in the general population of Iran is relatively high (0.0008%) and associated with consanguineous marriage. Thus, consanguinity is still an important risk factor present.

Massive Transfusion Complications Following Cutaneous Hemangioma

Aim of the work: Describe the clinical events of a patient experiencing MT complications following cutaneous hemangioma resection since there is still no clear evidence on how to approach pediatric transfusion as the existing literature is lacking. Methodology: Patient information was obtained from medical records after taking permission. Personal information that has been collected shall not be disclosed prior to consent. Patient’s clinical course was mentioned in a chronological order with literature review to show significance of such cases in medical practice. Results: A seven-month-old male who was found to have cutaneous hemangioma that required resection. Along to the clinical course, experienced several complications secondary to a massive transfusion. Conclusion: Massive transfusion management in patients with non-traumatic-related hemorrhage, or surgery-related hemorrhage, is crucial for survival and better outcomes.

Hematopoietic peripheral circulating blood stem cells as an independent marker of good transfusion management in patients with β-thalassemia: results from a preliminary study.

Beyond hemoglobin (Hb) levels and performance status, further surrogate markers of appropriate transfusion management should improve the quality of thalassemia care. We investigated the levels of peripheral circulating CD34+ stem cells as an independent marker of appropriate hematopoietic balance in patients with thalassemia. Peripheral circulating CD34+ stem cells, colony-forming unitgranulocyte, erythrocyte, macrophage, magakaryocyte (CF-GEMM), colony-forming unitgranulocyte/macrophage (CFU-GM), and erythroidburst-forming units (BFU-E) were assayed, according to standard procedures. Patients with thalassemia major (TM) and thalassemia intermedia (TI) were tested and compared to healthy controls. Demographic and clinical data were recorded. Overall, 56 patients with TM (median age, 35 years; range, 13-52 years) and 13 with TI (median age, 44 years; range, 27-67 years) were evaluated. Annual red blood cell (RBC) transfusion requirements ranged from 10 to 65 units in all patients except four nontransfused cases. A significant increase in peripheral circulating stem cells was observed in patients, in comparison with healthy controls. Nontransfused patients showed the mean highest levels of stem cells (CD34, 32.5 ± 14.8/μL; BFU-E, 41.3 ± 22.8/mL; CFU-GM, 19.6 ± 5.6/mL; CFU-GEMM, 9.0 ± 6.1/mL). CD34+ cell count was 6.9 ± 4.5/μL in TM (p = 0.014) and 11.8 ± 14.8/μL (p = 0.051) in TI. Furthermore, only in patients with TI was a significant increase in CFU-GEMM (3.0 ± 4.8 vs. 0.75 ± 2.05/mL, p = 0.0001) observed. At multivariate analysis, peripheral circulating CD34+ stem cells did not correlate with age, sex, smoking habit, number of RBCs units transfused, Hb levels, iron chelation therapy, history of splenectomy, and hypothyroidism. Circulating peripheral CD34 + stem cells are increased in β-thalassemia, in particular in nontransfused patients, compared to healthy controls.

Hematopoietic Peripheral Circulating Blood Stem Cells As an Independent Marker of Good Transfusion Management in Patients with Beta-Thalassemia

Aim Aim of the current study was to prospectively evaluate the potential role of peripheral circulating CD34+ stem cells as new independent marker of appropriate hemopoietic balance in patients with thalassemia major and intermedia.Materials and methods Peripheral blood samples from patients with thalassemia major (TM) and intermedia (TI) were drawn. Peripheral circulating CD34+ stem cells, CF-GEMM, CFU-GM and BFU-GM were assayed with monoclonal antibodies for CD34 and clonogenic tests, according to standard procedures and ISHAGE method (BD stem cell enumeration kit, Becton Dickinson; H4434, Stem Cell Technology). Demographic and clinical data were recorded from each enrolled subject. Results were compared with healthy controls.Results Overall, 56 patients with thalassemia major (median age:35 years, range:13-52 years) and 13 with thalassemia intermedia (median age:44 years, range:27-67) were evaluated. Annual red blood cells transfusion requirements ranged from 10 to 65 in all the patients except three with thalassemia intermedia, that were transfusion independent. One patient with TM did not accept transfusion for religion (Table 1). A statistically significant increase in peripheral circulating stem cells was observed in all the patients, in comparison with healthy controls. Mean peripheral circulating CD34+cells were 6.9±4.5/mmc in patients with TM and 11.8±14.8/mmc in patients with TI, significantly higher than mean CD34+ cells of healthy volunteer blood donors values (3.5±2.9/mmc, p=0.014 and p= 0.051 respectively for TM and TI). Only in patients with TI an increase in CFU-GEMM (3.0±4.8 vs 0.75±2.05, p=0.0001) was observed. Patients not treated with transfusions showed the mean highest levels of circulating stem cells (CD34: 32.5±14.8/mmc, BFU-E: 41.3±22.8, CFU-GM: 19.6±5.6, CFU-GEMM 9.0±6.1). At multivariate analysis, peripheral circulating CD34+ stem cells did not correlate with age, sex, number of red blood cells units transfused, hemoglobin levels, history of splenectomy and hypothyroidism.Conclusion Circulating peripheral CD34+stem cells are increased in patients with the highest hemopoietic stress (TI, transfusion independent), thus their determination could represent a useful independent marker of clinical response to transfusion in patients with beta thalassemia.Table 1Baseline data of patients with thalassemiaThalassemia major (n=56)Thalassemia intermedia (n=13)Males287Females286Mean Age (range)35 (13-52)42(27-67)BMI (range)21.5 (15.7-27.3)21.4 (14.7-33.5)Splenectomy3113Hypothyroidism91Smokers3231 DisclosuresNo relevant conflicts of interest to declare.

Detection of rare blood group, Bombay (Oh) phenotype patients and management by acute normovolemic hemodilution.

Background:Due to lack of correct blood grouping practices, the rare Bombay Oh phenotype may be missed, subjecting patients to the risk of severe hemolytic transfusion reaction. In the absence of blood donor registry, transfusion management of patients needing immediate surgery is a challenge. This study presents detection of rare Bombay Oh phenotype patients and their management by acute peri-operative acute normovolemic hemodilution (ANH) in a hospital from central India.Materials and Methods:Blood grouping of patients and blood donors with a standard tube method was carried out and samples identified as rare Bombay phenotype were confirmed by saliva inhibition test. Surgical management of cases needing transfusion was done by ANH, as per the British Committee for Standards in Hematology guidelines.Results:The incidence of Bombay phenotype was 0.002% or 1 in 51,924 in the study. Amongst three cases (patients) identified as Bombay phenotype, one was Bombay Oh, Rh negative. Two cases were missed in the first instance and one case actually did not require transfusion. In the absence of a blood donor registry for Bombay phenotype, the cases needing transfusion were successfully managed with ANH in the operation theatre.Conclusion:A simple test like blood grouping should be done with serious intention with incorporation of both forward and reverse grouping, so that no patient receives wrong blood leading to fatal hemolysis due to transfusion. ANH is a cost-effective transfusion option for suitable patients. Appropriate clinical decision making, use of strategies to decrease peri-operative blood losses and cost-effective country based planning could be more widely applied to improve clinical transfusion practice.

Transfusion Management and Immunohematologic Complications in Liver Transplantation: Experience of a Single Institution

Objective: Liver transplantation (LT) has traditionally been associated with major blood loss and consequently high blood transfusion requirements. Our objective was to analyze transfusion management and incidence of immunohematologic complications in patients undergoing LT at our institution. Methods: A retrospective analysis of immunohematologic events and transfusion outcomes was carried out at La Fe University Hospital in Valencia. Data from 654 patients were reviewed: 654 underwent only one LT while 36 underwent second LT. Results: Patients received a median of 3 red blood cell (RBC) concentrates, 2 platelets concentrates (PCs) and 2 fresh frozen plasma units (FFPs). Variables significantly influencing RBC transfusions were: the MELD score, hemoglobin levels, and the platelet counts before LT. 27 patients (4.1%) had a positive antibody screening before transplant. Immunohematologic events occurred in 8% of the patients, mostly in the first month after LT, and involved hemolysis in 13 cases. Mortality was significantly higher in patients developing immunohematologic disorders (42.8 vs. 18.3%; p < 0.001). In the multivariable analysis, only ABO minor incompatibility between donor and recipient significantly increased the appearance of immunohematologic incidences (OR 4.92, 95% CI 2.31-10.50; p < 0.001). Conclusion: Transfusion management of patients that underwent LT can be complicated by immunohematologic problems. Blood banks should implement the DAT test in each transfusion to detect them.

Les défaillances de la délivrance : comment s’améliorer ?

If they are not stopped before transfusion, distribution of blood components (BC) errors can have serious consequences for patients. The study of reported incidents of transfusion chain shows that the risk of failure is important, especially on the steps of patient selection in software, packing and giving the BC to transporter. The analysis of these problems most often state “human” error by misapplication of procedures. These errors are favored by systemic causes: many interfaces with numerous actors in the transfusion process, breaking between different information systems, stress of the emergency and lot of visual self-checks. Improvement may be proposed by a better the organization of the different tasks, by the ergonomic of the work, by improving distribution software and training operators to the management of the emergency. But things must be thought again by all the actors involved in the transfusion management of patients in order to reduce the risks associated with multiple interfaces.

Perioperative transfusion management in patients with sickle cell anaemia undergoing a total hip arthroplasty. Is there a role of red-cell exchange transfusion? A retrospective study in the CHU of Fort-de-France Martinique

ObjectivesWe conducted a retrospective study to examine the optimal regimen of transfusion and whether preoperative transfusion is needed in patients with Sickle cell anaemia (SCA) undergoing a Total hip arthroplasty (THA). Then, we assessed the incidence of perioperative complications rates among patients assigned to different transfusion regimens to propose finally the safety transfusion protocol. BackgroundPreoperative transfusions are usually given to reduce or prevent perioperative complications to SCA patients undergoing THA. There is no consensus however on the best regimen of transfusion. Study design and methodsDuring the period of 2000 to 2010, 14 patients with SCA (sex-ratio 0.4) with a mean age of 36 years underwent 16 THA (primary or revision). Three groups were differentiated according preoperatively protocol transfusion. Group 1: exchange transfusion (EXT), group 2: simple transfusion (ST), group 3: no transfusion (NT). ResultsOverall, preoperative transfusion was performed in 43.7% of cases and complications rate was 50%. In the group 1 (EXT) including five patients (31%), severe complications occurred in four patients (80%). in the group 2, including two patients (12.5%), no complications were observed. In the group 3, including nine patients (56%), complications occurred in four procedures (44.5%), the half of them were haemolytic complications. ConclusionOur results support the decision to transfuse, ST, preoperatively only if the patient is significantly below their steady-state haemoglobin (Hb) level. Transfusion can be used intraoperatively according Hb level and/or the blood loss volume. Exchange transfusion appeared mostly to be related to postoperative morbidity rates.

Antibodies against high frequency Gerbich 2 antigen (anti-Ge2): A real challenge in cross matching lab

Transfusion management of patients’ alloimmunized against high-prevalence erythrocyte antigens is often problematic in emergency situations. Gerbich (Ge) is very common blood group system and Gerbich–2 (Ge–2) antigen present in high frequency and outside Papua New Guinea population, Ge–2 negative population almost nil. To manage such kind of problems with real emergencies, implementation of rare donor registry program, cryopreservation of red cells of rare donors and biological cross matching to assess significance of these antibodies is warranted.

Transfusion management of patients with red blood cell antibodies

Red blood cell antibodies may cause a positive result of pre-transfusion blood compatibility testing (crossmatch test). It can be a problem to provide suitable blood units for patients with clinically significant antibodies to high-frequency antigens as well as for those with multiple alloantibody specificities. This study was aimed at identifying transfused patients in the population of South-Backa who had developed clinically significant red blood cell alloantibodies. We analyzed the records of crossmatch results and antibody screening performed at the Blood Transfusion Institute of Vojvodina during 2012. Antibodies were found in 103 patients: A) 63 patients with single antibodies: 1) 16 with antibodies of unknown specificity (3 autoantibodies, 13 alloantibodies); 2) 39 with clinically significant antibodies (23 from Rh system (2 anti-C, 2 anti-D, 12 anti-E, 7 anti-c), 4 anti-K, 3 anti-Fya, 7 anti-Jka, 2 anti-S); 3) 8 with usually not significant antibodies (6 anti-M, 1 anti-Al, 1 antiC); B) 40 patients developed multiple antibodies: 1) all patients had at least one clinically significant antibody from various blood group system (44 Rh, 13 Kell, 7 Kidd, 7 MNSs (S, s)); 2) 3 patients had usually not significant antibodies (1 Lewis, 2 Lutheran); 3) 3 patients occasionally had clinically significant antibody (3 anti-Ytd4) 3 patients had antibodies of unknown specificity (2 autoantibodies, lalloantibody). Antibodies detected in the majority of patients (65-63.1%) had a specificity of Rh and/or the Kell system. The main goal of pre-transfusion blood compatibility testing is to detect clinically significant antibodies. The provision of antigen negative blood units for those patients is a special challenge for blood establishments. Database with a sufficient number of typed blood donors can help to resolve this problem.

Thromboelastography and thromboelastometry and the management of intra-operative transfusion therapy in massively bleeding patients.

Dear Sir, I have read with interest the letter “Intra-operative transfusion management: the usefulness of point-of-care coagulation monitoring” by Feltracco et al1. Severe bleeding and coagulopathy as a result of massive transfusion are serious clinical conditions that are associated with high mortality. Since the first description in 1948, thromboelastography (TEG) and thromboelastometry (ROTEM) have been successfully used as a point-of-care tests as they are capable of providing a robust and cheap snapshot of haemostasis at the bedside. The study of visco-elastic properties of clots carried out through TEG and ROTEM is being increasingly used to guide transfusion strategies in patients with massively bleeding. TEG and ROTEM are easy to use by non-laboratory personnel as point-of-care tests in peri-operative and emergency settings. They produce rapid graphical and numerical results of the haemostatic status and are able to detect the anticoagulant effect of acidosis, hypothermia or hyperthermia, as they can be performed at temperatures between 22 °C and 42 °C. Finally, they are able to detect and quantify the underlying cause of coagulopathy, such as thrombocytopenia, clotting factor deficiency, heparin effect, hypofibrinogenaemia, and hyperfibrinolysis2. The test is carried out on a sample of whole blood and helps the clinicians to assess the cause of bleeding so that they can initiate the relevant transfusion or pharmacological therapy for coagulation problems resulting from clinical conditions such as trauma, surgery or potential disseminated intravascular coagulation. Notwithstanding their increased use to guide transfusion therapy the role of TEG and ROTEM remain controversial, and the role of the Sonoclot analyser currently seems even more limited, at least for managing transfusion therapy. A recently published Cochrane review had the objective of systematically assessing the benefits and harm of a TEG- or ROTEM-guided transfusion strategy in randomised trials involving patients with severe bleeding3. There is a lack of evidence that a TEG- or ROTEM-guided strategy improves, compared with standard treatment, morbidity or mortality in patients with severe bleeding. A statistically significant effect on the amount of bleeding was detected but the “analyses on the proportion of patients transfused with red blood cells, fresh-frozen plasma (FFP) and platelets did not show a statistically significant reduction”. However, the “analyses on the proportion of patients receiving both FFP and platelets did show a statistically beneficial reduction (RR 0.39, 95% CI 0.27 to 0.57, I2=0) when applying TEG or ROTEM. The true value of these analyses is unclear due to limited amounts of data and lack of a significant reduction in the amount of transfused FFP or platelets when examined separately”. These results call for further studies that are well designed and correctly powered to increase the level of evidence on the efficacy of these point-of-care devices in increasing the appropriate use of blood products. Furthermore, these devices can be really advantageous only when appropriately trained personnel are available, also in peri-operative and emergency settings. In fact, adequate and continuous training of non-laboratory personnel in charge of carrying out the tests and a thorough knowledge of good laboratory practice are really the essential requirements for producing reliable results, regardless of where the test is performed. In addition, an accredited external quality assessment programme and internal quality control system must be established4. For the above reasons the recently issued SIMTI guidelines did not include any recommendations on the routine use of TEG or ROTEM5. Despite the non-inclusion of TEG/ROTEM in the SIMTI guidelines, there is a more than reasonable expectation that, in the near future, the study of visco-elastic properties of clot will provide a higher level of evidence showing that TEG/TOGEM is a suitable method for guiding appropriate transfusion management of patients with massive bleeding. However, these point-of-care tests will express all their potential and be really cost-effective and efficacious in providing reliable results to guide transfusion strategy only in skilled hands and provided that validation of the technique, periodic competency assessments and good laboratory practice are ensured4, also outside the laboratory setting.

Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period.

Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period.