Effects of the COVID-19 pandemic on supply and use of blood for transfusion

Chemotherapy plus therapeutic plasmapheresis with 4% human albumin solution in multiple myeloma patients with acute kidney injury: a prospective, open-label, proof-of-concept study

As no unified treatment protocol or evidence yet exists for plasmapheresis without plasma, this study explored the outcomes of using 4% human albumin (ALB) solution as a replacement solution in patients undergoing plasma exchange for multiple myeloma (MM) patients with acute kidney injury (AKI). This study was prospectively registered (ChiCTR2000030640 and NCT05251896). Bortezomib-based chemotherapy plus therapeutic plasmapheresis (TPP) with 4% human ALB solution was assessed for three years in patients with MM aged >18 years, with AKI according to the Kidney Disease Improving Global Outcomes criteria, and without previous renal impairment from other causes. The primary endpoints were changes in renal function over 18 weeks and survival outcomes at 36 months. The secondary endpoints were the incidence of adverse reactions and symptom improvement. Among the 119 patients included in the analysis, 108 experienced renal reactions. The M protein (absolute changes: median -12.12%, interquartile ranges (IQRs) -18.62 to -5.626) and creatine (median -46.91 μmol/L, IQR -64.70 to -29.12) levels decreased, whereas the estimated glomerular filtration rate (eGFR) increased (median 20.66 mL/(min·1.73 m2), IQR 16.03-25.29). Regarding patient survival, 68.1% and 35.3% of patients survived for >12 and >36 months, respectively. The three symptoms with the greatest relief were urine foam, poor appetite, and blurred vision. All 11 patients (7.6%) who experienced mild adverse reactions achieved remission. In conclusion, in MM patients with AKI, plasma-free plasmapheresis with 4% human ALB solution and bortezomib-based chemotherapy effectively alleviated light chain damage to kidney function while improving patient quality of life.

Opportunities to improve feedback to reduce blood component wastage: Results of a national scheme evaluation

BACKGROUND

Blood components are costly and scarce. The Blood Stocks Management Scheme (BSMS) was established in the United Kingdom (UK) to support hospital transfusion services and national blood services through collection, analysis, and monthly feedback of data on blood component inventory and wastage management. There is a growing evidence base on how best to deliver feedback for quality improvement. We assessed the quality and utility of the monthly BSMS component reports.

METHODS

We assessed the content of BSMS reports issued in March 2023 against established criteria for effective feedback. Two researchers independently rated whether criteria spanning the five domains of goal setting, data collection, feedback content, feedback display and feedback delivery were fully, partially or not met. Disagreements were resolved through discussion. We conducted an online questionnaire survey of recipients of BSMS reports during March 2023 to assess their use of reports and seek suggestions for improvement.

RESULTS

Five out of 20 criteria for effective feedback were fully met. Areas for improvement included placing more emphasis in the feedback on positive change, linking data and summary messages, and including specific suggestions for action. Respondents highlighted the value of benchmarked comparisons with other hospital transfusion services.

CONCLUSION

There is scope for enhancing the effectiveness and utility of BSMS feedback reports and hence reducing wastage of blood components. This methodology for evaluation of feedback could be utilized to improve other areas of transfusion practice.

Dried Plasma for Major Trauma: Past, Present, and Future

Uncontrollable bleeding is recognized as the leading cause of preventable death among trauma patients. Early transfusion of blood products, especially plasma replacing crystalloid and colloid solutions, has been shown to increase survival of severely injured patients. However, the requirements for cold storage and thawing processes prior to transfusion present significant logistical challenges in prehospital and remote areas, resulting in a considerable delay in receiving thawed or liquid plasma, even in hospitals. In contrast, freeze- or spray-dried plasma, which can be massively produced, stockpiled, and stored at room temperature, is easily carried and can be reconstituted for transfusion in minutes, provides a promising alternative. Drawn from history, this paper provides a review of different forms of dried plasma with a focus on in vitro characterization of hemostatic properties, to assess the effects of the drying process, storage conditions in dry form and after reconstitution, their distinct safety and/or efficacy profiles currently in different phases of development, and to discuss the current expectations of these products in the context of recent preclinical and clinical trials. Future research directions are presented as well.

Predictors of Blood Transfusion in Patients Undergoing Cytoreductive Surgeries for Ovarian Malignancy

OBJECTIVES

The aims of this study were to describe the baseline estimated blood loss (EBL) in surgery and transfusion rate in patients undergoing cytoreductive surgeries for ovarian malignancy, and identify perioperative variables associated with blood loss and transfusion.

METHODS

A retrospective cohort study at a single institution was performed that included patients with known or suspected ovarian malignancy undergoing cytoreductive surgery between 2016 and 2021. t tests, χ2 tests, and multiple logistic regression analyses were used.

RESULTS

Among 44 patients meeting inclusion criteria, 61% received perioperative blood transfusion. There were significant differences in EBL and preoperative hemoglobin levels between patients who did and did not receive transfusion (EBL 442.6 vs 236.8 mL, P = 0.0008; preoperative hemoglobin 10.2 vs 11.2 g/dL, P = 0.049). After adjusting for preoperative hemoglobin, the risk of transfusion increased for each additional 200 mL of EBL (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.5-9.5). Stratified by race, the association between EBL and transfusion risk remained statistically significant only for non-Latinx White patients (OR 6.1, 95% CI 1.7-21.9), who made up 77% of the study population, but not for patients of other races and ethnicities (OR 1.0, 95% CI 0.16-6.42).

CONCLUSIONS

Perioperative blood transfusion is common in patients undergoing cytoreductive surgery. In this study, EBL and preoperative hemoglobin levels were significantly associated with transfusion receipt. Clinicians should optimize hemoglobin levels and intraoperative blood conservation strategies to reduce the need for transfusion. The results also highlight the importance of considering racial and ethnic differences when developing strategies to reduce transfusion risk.

Mitigating the impact of blood shortages in England

The supply of blood components and products in sufficient quantities is key to any effective health care system. This report describes the challenges faced by the English blood service, NHS Blood and Transplant (NHSBT), towards the end of the COVID-19 pandemic, which in October 2022 led to an Amber Alert being declared to hospitals indicating an impending blood shortage. The impact on the hospital transfusion services and clinical users is explained. The actions taken by NHSBT to mitigate the blood supply challenges and ensure equity of transfusion support for hospitals in England including revisions to the national blood shortage plans are described. This report focuses on the collaboration and communication between NHSBT, NHS England (NHSE), Department of Health and Social Care (DHSC), National Blood Transfusion Committee (NBTC), National Transfusion Laboratory Managers Advisory Group for NBTC (NTLM), National Transfusion Practitioners Network, the medical Royal Colleges and clinical colleagues across the NHS.

Forecasting demands of blood components based on prediction models

BACKGROUND

An adequate blood supply is an important guarantee for saving lives and protecting health. In order to manage the blood supply more effectively when the condition of demand and supply are uncertainty, it is very important to forecast the demands of blood resources.

MATERIALS AND METHODS

SARIMAX model and LSTM model were integrated into the prediction system of blood station. The collection and supply data of blood components was directly imported into the forecasting models to achieve automatic data update and model update. The forecasting daily demands of apheresis platelets, washing red blood cells (RBCs), suspended RBCs and plasma were recorded from January to June 2023 and compared with real data.

RESULTS

The prediction models had good forecasting performances. In the goodness of fit results of apheresis platelet model, the maximum value of coefficient of determination (R2) could reach 87.6%, and the minimum value of the mean absolute percentage error (MAPE) was only 0.0037. The predicted data of washing RBCs could be basically fitted, and the MAPE was 0.0121. For the prediction of suspended RBCs, the R2 was greater than 66%, and the MAPE could be 0.0372. The plasma model generated very high goodness of fit results, with R2 of over 90% and the lowest MAPE of 0.0394.

CONCLUSION

The forecasting models, which predicts future demands of different blood components based on historical data, can help managers to overcome the challenges of blood stock control more effectively, thereby reducing blood waste and blood shortages.

Demand forecasting for platelet usage: From univariate time series to multivariable models

Platelet products are both expensive and have very short shelf lives. As usage rates for platelets are highly variable, the effective management of platelet demand and supply is very important yet challenging. The primary goal of this paper is to present an efficient forecasting model for platelet demand at Canadian Blood Services (CBS). To accomplish this goal, five different demand forecasting methods, ARIMA (Auto Regressive Integrated Moving Average), Prophet, lasso regression (least absolute shrinkage and selection operator), random forest, and LSTM (Long Short-Term Memory) networks are utilized and evaluated via a rolling window method. We use a large clinical dataset for a centralized blood distribution centre for four hospitals in Hamilton, Ontario, spanning from 2010 to 2018 and consisting of daily platelet transfusions along with information such as the product specifications, the recipients' characteristics, and the recipients' laboratory test results. This study is the first to utilize different methods from statistical time series models to data-driven regression and machine learning techniques for platelet transfusion using clinical predictors and with different amounts of data. We find that the multivariable approaches have the highest accuracy in general, however, if sufficient data are available, a simpler time series approach appears to be sufficient. We also comment on the approach to choose predictors for the multivariable models.

Has the knowledge economy a role to play in transfusion medicine?

The history of blood transfusion has been dominated by the search for compatibility for species specificity, the search for how to transfer blood from one individual into another or infuse. Safety has become a major issue since it became clear that blood was not only able to allow mystical miracles to take place but could transmit infectious diseases. The science behind these ideas reflects observation, a thinking and exchange of knowledge and skills, originally documented in reports or case studies of what has happened and was observed, and peer presented - knowledge economy.

Resuscitative Thoracotomy for Traumatic Cardiac Arrest: Potential Impact of Resource Constraint on Outcomes and Blood Product Utilization

INTRODUCTION

Resuscitative thoracotomy (RT) in the setting of traumatic arrest serves as a vital but resource-intensive intervention. The COVID-19 pandemic has created critical shortages, sharpening the focus on efficient resource utilization. This study aims to compare RT performance and blood product utilization before and after the onset of the COVID-19 pandemic for patients in traumatic cardiac arrest.

METHODS

All patients undergoing RT for traumatic cardiac arrest in the emergency department at our American College of Surgeons-verified Level 1 trauma center (August 01, 2017-July 31, 2022) were included in this retrospective observational study. Study groups were dichotomized into pre-COVID (before October 03, 2020) versus COVID (from October 03, 2020 on) based on patient arrival date demographics, clinical/injury data, and outcomes were collected. The primary outcome was blood product transfusion <4 h after presentation.

RESULTS

445 RTs (2% of 23,488 trauma encounters) were performed over the study period: Pre-COVID, n = 209 (2%) versus COVID, n = 236 (2%) (P = 0.697). Survival to discharge was equivalent Pre-COVID versus COVID (n = 22, 11% versus n = 21, 9%, P = 0.562). RT patients during COVID consumed a median of 1 unit less packed red blood cells at the 4 h measurement (3.0 [1.8-7.0] versus 3.9 [2.0-10.0] units, P = 0.012) and 1 unit less of platelets at the 4 h measurement (4.3 [2.6-10.0] versus 5.7 [2.9-14.4] units, P = 0.012) compared to Pre-COVID. These findings were persistent after performing multivariable negative binomial regression.

CONCLUSIONS

Rates of RT and survival after RT remained consistent during the pandemic. Despite comparable RT frequency, packed red blood cells and platelet transfusions were reduced, likely reflecting resource expenditure minimization during the severe blood shortages that occurred during the pandemic. RT performance for patients in traumatic arrest may, therefore, be feasible during global pandemics at prepandemic frequencies as long as particular attention is paid to resource expenditure.

Routine use of cell salvage during cesarean section: A practice evaluation

INTRODUCTION

Intraoperative cell salvage is a well-documented alternative to donor blood transfusion given the scarcity of donor blood pools and the incumbent risk of allogenic blood transfusion. Its use in obstetrics has been limited by concern over fetal alloimmunization due to the risk of fetomaternal hemorrhage. However, there are a paucity of studies reporting on outcome. The aim of this study was to report on a four-year experience of routine use of intraoperative cell salvage and the impact on subsequent pregnancy outcomes.

MATERIAL AND METHODS

This was a tertiary center retrospective service evaluation cohort study and included all women undergoing cesarean section between December 2014 and November 2018 in a tertiary obstetric unit, identifying women who had reinfusion of intraoperative cell salvage. Data regarding index pregnancy as well as subsequent pregnancies at the hospital were extracted from hospital electronic records. Subsequent pregnancy outcome and maternal antibody status in that pregnancy were collected up until November 2022.

RESULTS

During the study period, 6656 cesarean sections were performed, with 436 (6.6%) receiving reinfusion of salvaged blood. The mean volume of reinfused blood was 396 mL. A total of 49 (0.7%) women received donor blood transfusion. Of those who received reinfusion of salvaged blood, 79 (18.1%) women had subsequent pregnancies over the eight-year follow-up period. There was one case (0.23%) of fetal cell alloimmunization demonstrated by the presence of anti-D antibodies on the subsequent pregnancy booking bloods.

CONCLUSIONS

Routine intraoperative cell salvage may be used to reduce the need for blood transfusion during cesarean section. The risk of fetal cell alloimmunization in a future pregnancy following reinfusion of intraoperative cell salvage is one in 436. Given an apparent small risk of fetal cell alloimmunization, further work is required to establish the safety profile of intraoperative cell salvage in pregnancy.

Benefit of balance? Odds of survival by unit transfused: Retrospective analysis of the ACS-TQIP database

BACKGROUND

The critical blood shortage in January 2022 threatened the availability of blood. Utility of transfusion per unit was reported in a previous study, revealing patients receiving balanced transfusion are more likely to die after 16 units of packed red blood cells. We aimed to validate this study using a larger database.

METHODS

Retrospective analysis utilizing the American College of Surgeons Trauma Quality Improvement Program was performed. Trauma patients aged ≥16 receiving transfusion within 4 hours of arrival were included and excluded if they died in the emergency department, received <2 units of packed red blood cells, did not receive fresh frozen plasma, or were missing data. Primary outcome was mortality. Subgroups were balanced transfusion if receiving ≤2:1 ratio of packed red blood cells:fresh frozen plasma, and unbalanced transfusion if >2:1 ratio.

RESULTS

A total of 17,047 patients were evaluated with 28% mortality (4,822/17,408). Multivariable logistic regression identified advancing age (odds ratio 1.03 95% confidence interval 1.03-1.04), higher ISS (odds ratio 1.04, 95% confidence interval 1.03-1.04), and lower GCS (odds ratio 0.82, 95% confidence interval 0.82-0.83) as risk factors for mortality. Protective factors were balanced transfusion (odds ratio 0.81 95% confidence interval 0.71-0.93), male sex (odds ratio 0.90, 95% confidence interval 0.81-0.99), and blunt mechanism (odds ratio 0.74, 95% confidence interval 0.67-0.81). At 11 units of packed red blood cells, balanced transfusion patients were more likely to die (odds ratio 0.88, 95% confidence interval 0.80-0.98). Balanced transfusion patients survived at a higher rate for each unit of packed red blood cells, between 6 and 23 units of packed red blood cells.

CONCLUSION

Mortality increases with each unit of packed red blood cell transfused. At 11 units of packed red blood cells, mortality is the more likely outcome. Balanced transfusion improves the chance of survival through 23 units of packed red blood cells.

Exploration of the Healthy Donor Effect Among 0.6 Million Blood Donors in China: Longitudinal Study

BACKGROUND

The World Health Organization emphasizes the importance of completely voluntary blood donation to maintain safe and sustainable blood supplies. However, the benefits of blood donation for donors, such as reducing the risk of disease, remain a topic of debate due to the existence of the healthy donor effect (HDE). This effect arises because of inherent health differences between blood donors and the general population, and it is also considered a methodological issue.

OBJECTIVE

This study aims to generate a more detailed health profile of blood donors from a donor cohort study to mitigate and quantify the HDE and properly interpret the association between blood donation and disease outcomes among blood donors.

METHODS

A retrospective cohort study was conducted between January 2012 and December 2018 among donors before their first donation. One-to-one propensity score matching was conducted through a random selection of individuals without any history of blood donation, as reported from their electronic health records. We conducted a Poisson regression between blood donors and non-blood donors before the first donation to estimate the adjusted incidence rate ratio (AIRR) of selected blood donation-related diseases, as defined by 13 categories of International Classification of Diseases, Tenth Revision (ICD-10) codes.

RESULTS

Of the 0.6 million blood donors, 15,115 had an inpatient record before their first donation, whereas 17,356 non-blood donors had an inpatient record. For the comparison between blood donors and the matched non-blood donors, the HDE (the disease incidence rate ratio between non-blood donors and blood donors) was an AIRR of 1.152 (95% CI 1.127-1.178; P<.001). Among disease categories not recommended for blood donation in China, the strongest HDE was observed in the ICD-10 D50-D89 codes, which pertain to diseases of the blood and blood-forming organs as well as certain disorders involving the immune mechanism (AIRR 3.225, 95% CI 2.402-4.330; P<.001). After age stratification, we found that people who had their first blood donation between 46-55 years old had the strongest HDE (AIRR 1.816, 95% CI 1.707-1.932; P<.001). Both male and female donors had significant HDE (AIRR 1.082, 95% CI 1.05-1.116; P=.003; and AIRR 1.236, 95% CI 1.196-1.277; P<.001, respectively) compared with matched non-blood donors.

CONCLUSIONS

: Our research findings suggest that the HDE is present among blood donors, particularly among female donors and those who first donated blood between the ages of 46 and 55 years.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200055983; https://www.chictr.org.cn/showproj.html?proj=51760.

Telemedicine pre-screening for blood donor

INTRODUCTION

The COVID-19 pandemic had an important impact on blood bank services. The onset of the pandemic led to a decrease in the number of blood donors. A remote interview would avoid deferred donors from having to travel to the blood bank. We evaluate the feasibility of using telemedicine as an alternative to a face-to-face interview as a first blood donor screening.

METHODS

Our retrospective study included 404 whole blood and platelets donors, who underwent the clinical interview remotely via telemedicine. The deferred donor would not need to go to the blood bank and eligible candidates were required to donate within 7 days. On the day of donation, a mini-interview was held to ensure donor and blood safety.

RESULTS

The appointments were made from June 2020 to June 2022, including 263 candidates for whole blood (WB) and 141 for platelets (PLTs). At the end of the telemedicine interview, 285 (70.6 %) candidates were considered eligible. Telemedicine was not performed for 60 (14.8 %) candidates due to technical problems (with audio or video) or absences. The deferral rate among candidates who underwent telemedicine pre-screening was 14.6 % and, among eligible donors after telemedicine, only 7 (2.9 %) were unable to donate blood.

CONCLUSION

Telemedicine is a viable alternative and a welcome convenience for potential donors to avoid unnecessary travel.

Blood donations and donors' profile in Lithuania: Trends for coming back after the COVID-19 outbreak

The coronavirus disease (COVID-19) pandemic has significantly affected blood donors worldwide. It is important for the blood service to return to its pre-pandemic level as soon as possible and to perform its functions fully. This study compared the donation and demographic profiles of blood and its component donors one year before and during three pandemic years in Lithuania. All blood and blood component donations (n = 413,358) and demographic characteristics of all donors from April 1, 2019, to March 31, 2023, were analyzed. All data were obtained from annual publications, and statistics were obtained from the Blood Donor Register. Data were analyzed using descriptive statistics. Following a 9.41 percent decrease in the first year of the pandemic, the quantity of blood and blood component donations increased by 3.49 percent in the third year compared to the pre-pandemic year. Throughout the three years of the pandemic, a statistically significant decrease in the proportion of first-time blood and blood component donations was observed. Both the number and proportion of donations by donors under 25 years old decreased during the pandemic. The proportion of pre-donation deferrals for all attempts to donate significantly decreased during the pandemic. There was a statistically significant lower prevalence of all positive transfusion-transmitted infectious (TTI) markers among all donations compared to the pre-pandemic year for all three pandemic years. The odds for hepatitis B virus, hepatitis C virus, and all TTI markers during the second and third pandemic years were significantly lower than those in the pre-pandemic year. In conclusion, most dimensions of blood and its component donations and donor characteristics have returned to pre-pandemic levels or show positive trends. However, the major concern is the remaining decrease in donations from first-time and donors under 25 years old.

Post-Reconstitution Hemostatic Stability Profiles of Canadian and German Freeze-Dried Plasma

Despite the importance of the hemostatic properties of reconstituted freeze-dried plasma (FDP) for trauma resuscitation, few studies have been conducted to determine its post-reconstitution hemostatic stability. This study aimed to assess the short- (≤24 h) and long-term (≥168 h) hemostatic stabilities of Canadian and German freeze-dried plasma (CFDP and LyoPlas) after reconstitution and storage under different conditions. Post-reconstitution hemostatic profiles were determined using rotational thromboelastometry (ROTEM) and a Stago analyzer, as both are widely used as standard methods for assessing the quality of plasma. When compared to the initial reconstituted CFDP, there were no changes in ROTEM measurements for INTEM maximum clot firmness (MCF), EXTEM clotting time (CT) and MCF, and Stago measurements for prothrombin time (PT), partial thromboplastin time (PTT), D-dimer concentration, plasminogen, and protein C activities after storage at 4 °C for 24 h and room temperature (RT) (22-25 °C) for 4 h. However, an increase in INTEM CT and decreases in fibrinogen concentration, factors V and VIII, and protein S activities were observed after storage at 4 °C for 24 h, while an increase in factor V and decreases in antithrombin and protein S activities were seen after storage at RT for 4 h. Evaluation of the long-term stability of reconstituted LyoPlas showed decreased stability in both global and specific hemostatic profiles with increasing storage temperatures, particularly at 35 °C, where progressive changes in CT and MCF, PT, PTT, fibrinogen concentration, factor V, antithrombin, protein C, and protein S activities were seen even after storage for 4 h. We confirmed the short-term stability of CFDP in global hemostatic properties after reconstitution and storage at RT, consistent with the shelf life of reconstituted LyoPlas. The long-term stability analyses suggest that the post-reconstitution hemostatic stability of FDP products would decrease over time with increasing storage temperature, with a significant loss of hemostatic functions at 35 °C compared to 22 °C or below. Therefore, the shelf life of reconstituted FDP should be recommended according to the storage temperature.

Harnessing the potential of data-driven strategies to optimise transfusion practice

No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.

Prediction of Mid-term Platelet Transfusion in Stable Trauma Patients Using Rotational Thromboelastometry

Background

Rotational thromboelastometry (ROTEM; TEM International GmbH, Munich, Germany) is a global coagulation test that guides evidence-based platelet transfusion in trauma patients. We evaluated ROTEM parameters for predicting mid-term (five days) platelet transfusion in trauma patients.

Methods

Maximum clot firmness and clot amplitudes after 5, 10, and 15 mins (A5, A10, and A15, respectively) of fibrin-specific ROTEM (FIBTEM) and extrinsically activated ROTEM (EXTEM) were retrospectively collected from 82 hospitalized, stable, non-bleeding trauma patients after successful initial resuscitation. Platelet-specific ROTEM (PLTEM) was calculated by subtracting FIBTEM from EXTEM. Platelet transfusions were reviewed for five days after ROTEM.

Results

The areas under the curve for FIBTEM, EXTEM, and PLTEM predicting platelet concentrate transfusion of >12 U at mid-term were 0.915-0.923, 0.878-0.896, and 0.551-0.735, respectively. FIBTEM and EXTEM parameters were comparable to those of fibrinogen, fibrin/fibrinogen degradation products, D-dimer, and antithrombin III. Strong correlations (r>0.7) were noted between platelet count and EXTEM (A5, A10, and A15) or PLTEM (A5), platelet function (per platelet count) and EXTEM (A10 and A15), and fibrinogen levels and all FIBTEM parameters.

Conclusions

FIBTEM and EXTEM can reliably predict mid-term platelet transfusion in trauma patients. FIBTEM, EXTEM, and PLTEM parameters correlate with conventional coagulation tests (platelets and fibrinogen).

Barriers and enablers to and strategies for promoting domestic plasma donation throughout the world: Overarching protocol for three systematic reviews

INTRODUCTION

The growing demand for plasma protein products has caused concern in many countries who largely rely on importing plasma products produced from plasma collected in the United States and Europe. Optimizing recruitment and retention of a diversity of plasma donors is therefore important for supporting national donation systems that can reliably meet the most critical needs of health services. This series of three systematic reviews aims to synthesize the known barriers and enablers to source plasma donation from the qualitative and survey-based literature and identify which strategies that have shown to be effective in promoting increased intention to, and actual donation of, source plasma.

METHODS AND ANALYSIS

Primary studies involving source or convalescent plasma donation via plasmapheresis will be included. The search strategy will capture all potentially relevant studies to each of the three reviews, creating a database of plasma donation literature. Study designs will be subsequently identified in the screening process to facilitate analysis according to the unique inclusion criteria of each review (i.e., qualitative, survey, and experimental designs). The search will be conducted in the electronic databases SCOPUS, MEDLINE, EMBASE, PsycINFO, and CINAHL without date or language restrictions. Studies will be screened, and data will be extracted, in duplicate by two independent reviewers with disagreements resolved through consensus. Reviews 1 and 2 will draw on the Theoretical Domains Framework and Intersectionality, while Review 3 will be informed by Behaviour Change Intervention Ontologies. Directed content analysis and framework analysis (Review 1), and descriptive and inferential syntheses (Reviews 2 and 3), will be used, including meta-analyses if appropriate.

DISCUSSION

This series of related reviews will serve to provide a foundation of what is known from the published literature about barriers and enablers to, and strategies for promoting, plasma donation worldwide.

Blood-derived product therapies for SARS-CoV-2 infection and long COVID

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is capable of large-scale transmission and has caused the coronavirus disease 2019 (COVID-19) pandemic. Patients with COVID-19 may experience persistent long-term health issues, known as long COVID. Both acute SARS-CoV-2 infection and long COVID have resulted in persistent negative impacts on global public health. The effective application and development of blood-derived products are important strategies to combat the serious damage caused by COVID-19. Since the emergence of COVID-19, various blood-derived products that target or do not target SARS-CoV-2 have been investigated for therapeutic applications. SARS-CoV-2-targeting blood-derived products, including COVID-19 convalescent plasma, COVID-19 hyperimmune globulin, and recombinant anti-SARS-CoV-2 neutralizing immunoglobulin G, are virus-targeting and can provide immediate control of viral infection in the short term. Non-SARS-CoV-2-targeting blood-derived products, including intravenous immunoglobulin and human serum albumin exhibit anti-inflammatory, immunomodulatory, antioxidant, and anticoagulatory properties. Rational use of these products can be beneficial to patients with SARS-CoV-2 infection or long COVID. With evidence accumulated since the pandemic began, we here summarize the progress of blood-derived product therapies for COVID-19, discuss the effective methods and scenarios regarding these therapies, and provide guidance and suggestions for clinical treatment.

Hemoglobin S target of <50% as compared to 30% in chronic red cell exchange for secondary stroke prevention in sickle cell disease

BACKGROUND

Sickle cell disease (SCD) patients with a history of stroke are encouraged to receive chronic red blood cell exchange (RBCx) for stroke prevention. The American Society of Hematology guideline published in 2020 recommends an HbS target of <30%. However, this approach necessitates more frequent RBCx and more RBC units. UT Southwestern has devised a chronic exchange protocol that elevates the HbS target to <50% in patients with a low risk of stroke.

STUDY DESIGN

This retrospective chart review study reviewed the medical records of patients receiving chronic RBCx with a target of HbS <50% over the past 10-year period to assess the safety of maintaining higher HbS targets in SCD patients with a low risk of cerebrovascular accidents (CVA).

RESULTS

Among 49 SCD patients in the chronic RBCx program for secondary stroke prevention, 33 patients were maintained on an HbS target of <50% (average measured: 35.4%) for the duration of RBCx program enrollment (median 93.0 months, 95% CI, 83-99). Stroke or transient ischemic attack (TIA) clearly attributable to changing target HbS had not been identified among the 33 study subjects. Seven patients experienced conversion between the HbS targets of <50% and <30% HbS target. Significant reductions were observed in the frequency of RBCx and usage of blood volume in four of them.

CONCLUSION

The findings suggest that liberalizing the HbS target could confer clinical flexibility without increasing the risk of CVA in a selective population. Further studies to fully evaluate the potential benefits of this approach are indicated.

The Year in Coagulation and Transfusion: Selected Highlights from 2022

This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.

Patient Blood Management and Its Role in Supporting Blood Supply

Blood donors and voluntary blood donations are essential for ensuring the blood supply that can be maintained by good patient blood management (PBM) practices. This review article explores the role of blood donation in PBM and highlights the importance of donor screening and selection processes in different regions worldwide. The donor health questionnaires and the focused physical examination guidelines have changed in the last decade to increase donor and recipient safety. This article also discusses the status of transfusion practices, including the challenges of ensuring a safe blood supply. Significant among these are the effects of the COVID-19 pandemic on the blood supply chain and the impact of an aging donor population, especially. Promoting autologous donations and other blood conservation strategies are suggested to mitigate these issues. The role of replacement donors and the upper age limit for voluntary blood donation may be decided based on the demography and donor pool. The involvement of C-suite executives is also critical in implementing and running a successful PBM program. The review highlights how these different aspects of blood donation are integral to a successful PBM program and the safety of patients who receive blood transfusions.

Red Blood Cell Transfusion: 2023 AABB International Guidelines

Importance

Red blood cell transfusion is a common medical intervention with benefits and harms.

Objective

To provide recommendations for use of red blood cell transfusion in adults and children.

Evidence Review

Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed.

Findings

For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence).

Conclusions and Relevance

It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.

COVID-19 in a Portuguese whole blood donor population

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), leading to pneumonia and acute respiratory distress syndrome. The COVID-19 pandemic had a major impact on the stock of blood banks worldwide. This study aims to assess the prevalence of COVID-19 in a population of whole blood donors and analyze the possible association between blood group and susceptibility to the disease and the impact of adopting preventive measures against SARS-CoV-2 infection. Material and methods: This retrospective study included all whole blood donors from a Portuguese hospital between July and September 2021. A self-assessment questionnaire was used to collect data on COVID-19 infection, vaccination, and preventive measures. Statistical analysis was performed using Chi-square and Mann-Whitney U tests. Results: The prevalence of COVID-19 in the donor population was 11.96% (n = 97), with only 2 cases of serious illness requiring hospitalization. No association was found between blood group and disease susceptibility. Older men were less likely to adopt preventive measures. The vaccination rate was high, with 84.26% of donors having received at least one dose of the vaccine. Seven donors declined COVID-19 vaccination. Preventive measures did not differ based on COVID-19 infection status or vaccination. Discussion: Although there was a higher frequency of COVID-19 in group A donors, the blood group was not associated with susceptibility to infection. The donor population consisted of young individuals without comorbidities, showing a COVID-19 prevalence like the general population and few severe cases. The high vaccination rate and adoption of preventive measures likely contributed to these findings.

The reports of my death are greatly exaggerated: An evaluation of futility cut points in massive transfusion

BACKGROUND

Following COVID and the subsequent blood shortage, several investigators evaluated futility cut points in massive transfusion. We hypothesized that early aggressive use of damage-control resuscitation, including whole blood (WB), would demonstrate that these cut points of futility were significantly underestimating potential survival among patients receiving >50 U of blood in the first 4 hours.

METHODS

Adult trauma patients admitted from November 2017 to October 2021 who received emergency-release blood products in prehospital or emergency department setting were included. Deaths within 30 minutes of arrival were excluded. Total blood products were defined as total red blood cell, plasma, and WB in the field and in the first 4 hours after arrival. Patients were first divided into those receiving ≤50 or >50 U of blood in the first 4 hours. We then evaluated patients by whether they received any WB or received only component therapy. Thirty-day survival was evaluated for all included patients.

RESULTS

A total of 2,299 patients met the inclusion criteria (2,043 in ≤50 U, 256 in >50 U groups). While there were no differences in age or sex, the >50 U group was more likely to sustain penetrating injury (47% vs. 30%, p < 0.05). Patients receiving >50 U of blood had lower field and arrival blood pressure and larger prehospital and emergency department resuscitation volumes ( p < 0.05). Patients in the >50 U group had lower survival than those in the ≤50 cohort (31% vs. 79%; p < 0.05). Patients who received WB (n = 1,291) had 43% increased odds of survival compared with those who received only component therapy (n = 1,008) (1.09-1.87, p = 0.009) and higher 30-day survival at transfusion volumes >50 U.

CONCLUSION

Patient survival rates in patients receiving >50 U of blood in the first 4 hours of care are as high as 50% to 60%, with survival still at 15% to 25% after 100 U. While responsible blood stewardship is critical, futility should not be declared based on high transfusion volumes alone.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Research Progress in Oxygen Carrier Design and Application

Ischemia or hypoxia can lead to pathological changes in the metabolism and function of tissues and then lead to various diseases. Timely and effective blood resuscitation or improvement of hypoxia is very important for the treatment of diseases. However, there is a need to develop stable, nontoxic, and immunologically inert oxygen carriers due to limitations such as blood shortages, different blood types, and the risk of transmitting infections. With the development of various technologies, oxygen carriers based on hemoglobin and perfluorocarbon have been widely studied in recent years. This paper reviews the development and application of hemoglobin and perfluorocarbon oxygen carriers. The design of oxygen carriers was analyzed, and their application as blood substitutes or oxygen carriers in various hypoxic diseases was discussed. Finally, the characteristics and future research of ideal oxygen carriers were prospected to provide reference for follow-up research.

Poly(2-ethyl-2-oxazoline)-Conjugated Hemoglobins as a Red Blood Cell Substitute

Hemoglobin wrapped covalently with poly(2-ethyl-2-oxazoline)s (POx-Hb) is characterized physicochemically and physiologically as an artificial O2 carrier for use as a red blood cell (RBC) substitute. The POx-Hb is generated by linkage of porcine Hb surface-lysines to a sulfhydryl terminus of the POx derivative, with the average binding number of the polymers ascertained as 6. The POx-Hb shows moderately higher colloid osmotic activity and O2 affinity than the naked Hb. Human adult HbA conjugated with POx also possesses equivalent features and O2 binding properties. The POx-Hb solution exhibits good hemocompatibility, with no influence on the functions of platelets, granulocytes, and monocytes. Its circulation half-life in rats is 14 times longer than that of naked Hb. Hemorrhagic shock in rats is relieved sufficiently by infusion of the POx-Hb solution, as revealed by improvements of circulatory parameters. Serum biochemistry tests and histopathological observations indicate no acute toxicity or abnormality in the related organs. All results indicate that POx-Hb represents an attractive alternative for RBCs and a useful O2 therapeutic reagent in transfusion medicine.

Self-anticoagulant sponge for whole blood auto-transfusion and its mechanism of coagulation factor inactivation

Clinical use of intraoperative auto-transfusion requires the removal of platelets and plasma proteins due to pump-based suction and water-soluble anticoagulant administration, which causes dilutional coagulopathy. Herein, we develop a carboxylated and sulfonated heparin-mimetic polymer-modified sponge with spontaneous blood adsorption and instantaneous anticoagulation. We find that intrinsic coagulation factors, especially XI, are inactivated by adsorption to the sponge surface, while inactivation of thrombin in the sponge-treated plasma effectively inhibits the common coagulation pathway. We show whole blood auto-transfusion in trauma-induced hemorrhage, benefiting from the multiple inhibitory effects of the sponge on coagulation enzymes and calcium depletion. We demonstrate that the transfusion of collected blood favors faster recovery of hemostasis compared to traditional heparinized blood in a rabbit model. Our work not only develops a safe and convenient approach for whole blood auto-transfusion, but also provides the mechanism of action of self-anticoagulant heparin-mimetic polymer-modified surfaces.

Lessons learned from patient outcomes when lowering hemoglobin transfusion thresholds during COVID-19 blood shortages

OBJECTIVES

This study examines whether patient outcomes were affected when the hemoglobin (Hb) transfusion threshold was lowered by 1 g/dL during COVID-19-related blood shortages.

METHODS

Outcomes of lowered Hb thresholds (from <7 to <6 g/dL) were defined by 14-month intervals in 2 patient groups (prepandemic [January 2019-February 2020] and pandemic [April 2020-May 2021]). We evaluated patient admissions, pretransfusion (if transfused) or nadir admission (if not transfused) Hb levels between 5.0 and 8.0 g/dL, and total red blood cell (RBC) transfusions during admission (if transfused). Baseline variables and outcomes were selected from electronic health records. Primary COVID-19-related admissions were excluded. Regression analysis was conducted to determine outcomes.

RESULTS

Those in the prepandemic group (1976) and pandemic group (1547) were transfused. Fewer RBCs (2186, vs 3337) were used in the prepandemic group than in the pandemic group, respectively. Those in the prepandemic group had significantly higher rates of hypertension and diabetes as well as more smokers. Significant differences were observed when comparing the number of procedures and incidence of sepsis between the patient groups. Similar patterns were observed for the not transfused and transfused subgroups.

CONCLUSIONS

Patient outcomes were not affected after implementing lower Hb pretransfusion thresholds. Although confounding factors were mitigated, some may have been associated with procedures or sepsis. Proactive patient blood management strategies during COVID-19-related blood shortages may include adopting lower Hb thresholds.

Predictive indicators for determining red blood cell transfusion strategies in the emergency department

BACKGROUND AND IMPORTANCE

Appropriate decision-making is critical for transfusions to prevent unnecessary adverse outcomes; however, transfusion in the emergency department (ED) can only be decided based on sparse evidence in a limited time window.

OBJECTIVES

This study aimed to identify factors associated with appropriate red blood cell (RBC) transfusion in the ED by analyzing retrospective data of patients who received transfusions at a single center.

OUTCOME MEASURES AND ANALYSIS

This study analyzed associations between transfusion appropriateness and sex, age, initial vital signs, an ED triage score [the Korean Triage and Acuity Scale (KTAS)], the length of stay, and the hemoglobin (Hb) concentration.

MAIN RESULTS

Of 10 490 transfusions, 10 109 were deemed appropriate, and 381 were considered inappropriate. A younger age ( P  < 0.001) and a KTAS level of 3-5 ( P  = 0.028) were associated with inappropriate transfusions, after adjusting for O 2 saturation and the Hb level.

CONCLUSIONS

In this single-center retrospective study, younger age and higher ED triage scores were associated with the appropriateness of RBC transfusions.

Effect of COVID-19 pandemic on blood transfusion service: an experience from a regional blood transfusion center

The unforeseen and uncertain life-threatening situation of the COVID-19 pandemic dramatically affected all areas of the human daily work schedule. This study was designed to assess the impact of the COVID-19 pandemic on blood transfusion services and discuss the adopted confrontation measures for uninterrupted blood supply during the pandemic situation. The data on blood donation, blood component preparation, and issue from January 2019 to December 2022 were collected from the inventory registers of the RBTC, Delhi, India. Compared to the non-pandemic year 2019, during the year 2020, all variables decreased gradually. The observed maximum decrease in variables such as blood collection (-79.16%) in the month of October, blood issue (-71.61%) in the month of August, random donor platelets (RDP) preparation (-98.09%) in the month of October, RDP issue (-86.08%) in the month of September, fresh frozen plasma (FFP) preparation (-100%) in the month of October, and FFP issue (-96.08%) in the month of July with an annual decrease of -45.52%, -42.87%, -33.00%, -59.79%, -40.98%, and -54.48%, respectively, as compared to year 2019. Compared to year 2020, in year 2021, the annual increase in blood collection, blood issue, FFP preparation, FFP issue, RDP preparation, and RDP issue was +50.20%, +21.68%, +65.31%, +78.52%, +116.23%, and +213.30%, respectively. Our study results show that the COVID-19 pandemic has significantly affected blood transfusion services at our blood bank. The adopted coping strategies to maintain the safe and uninterrupted blood transfusion chain at our blood bank gave us lessons for future preparedness if faced with a similar situation.

Re-examine the transfusion transmitted risk of SARS-CoV-2 virus during a major COVID-19 outbreak in 2022

INTRODUCTION

Although no case of COVID-19 transmission through transfusion has been reported, blood transfusion service (BTS) continues to implement pre-donation and post-donation measures to minimise the risk. In year 2022, when local healthcare system was badly impacted by a major outbreak, it opened an opportunity to re-examine the viraemia risk in these asymptomatic donors.

MATERIALS AND METHODS

Records were retrieved from blood donors who reported COVID-19 after donation and follow-up was also made for recipients who received their blood. Blood samples at donation were tested for SARS-CoV-2 viraemia by single-tube nested real-time RT-PCR assay designed to detect most SARS-CoV-2 variants including the prevailing delta and omicron variants.

RESULTS

From 1 January to 15 August 2022, the city with 7.4 M inhabitants recorded 1 187 844 COVID-19 positive cases and 125 936 successful blood donations were received. 781 donors reported to the BTS after donation with 701 being COVID-19 related (including close contact and symptoms respiratory tract infection). 525 COVID-19 were positive at the time of call back or follow-up. Of the 701 donations, they were processed into 1480 components with 1073 discarded upon donors' call back. For remaining 407 components, no recipient was found to have adverse event or COVID-19 positive. 510 samples from the above 525 COVID-19 positive donors were available and all tested negative for SARS-CoV-2 RNA.

DISCUSSION

With the negative SARS-CoV-2 RNA in blood donation samples and follow up data in transfusion recipients, the risk of transfusion transmitted COVID-19 appears negligible. However, current measures remains important in securing blood safety with ongoing surveillance of their effectiveness.

Managing blood supplies during natural disasters, humanitarian emergencies and pandemics: lessons learned from COVID-19

INTRODUCTION

The COVID-19 pandemic has resulted in a historic public health crisis with widespread social and economic ramifications. The pandemic has also affected the blood supply resulting in unprecedented and sustained blood shortages.

AREAS COVERED

This review describes the challenges of maintaining a safe and sufficient blood supply in the wake of natural disasters, humanitarian emergencies and pandemics. The challenges, which are accentuated in low- and high- income countries, span the impact on human capacity (affecting blood donors and blood collections personnel alike), disruption to supply chains, and economic sustainability. COVID-19 imparted lessons on how to offset these challenges, which may be applied to future pandemics and public health crises.

EXPERT OPINION

Pandemic emergency preparedness plans should be implemented or revised by blood centers and hospitals to lessen the impact to the blood supply. Comprehensive planning should address the timely assessment of risk to the blood supply, rapid donor recruitment and communication of need, measures to preserve safety for donors and operational staff, careful blood management, and resource sharing.

Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011-2021

BACKGROUND

Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation.

METHODS

We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitate-pools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant.

RESULTS

Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death.

CONCLUSIONS

One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality.

Training of medical students in the use of emergency whole blood collection and transfusion in the framework of a civilian walking blood

INTRODUCTION

In this report, we describe a training program in emergency whole blood collection and transfusion for medical students at the University of Bergen. The overall aim of the program is to improve the availability of early balanced blood transfusion for the treatment of patients with life-threatening bleeding in rural health care services.

STUDY DESIGN AND METHODS

The voluntary training program provides the knowledge needed to practice emergency whole blood transfusions and understand the system for emergency whole blood collection in the framework of a civilian walking blood bank (WBB). It includes theoretical and practical sessions. In-person teaching and web-based learning resources are provided. An anonymous survey of the students attending the training course in the autumn of 2022 and spring 2023 was performed.

RESULTS

128 of 178 students participated in the practical training. 88 of 128 (69%) responded to the survey. 82 (93%) performed blood typing, 71 (81%) performed donor interviews, 61 (69%) partially performed whole blood collection (up to blood in bag) and 27 (30%) participated in complete whole blood collection and performed autologous reinfusion. No complications occurred during training. The students reported that the training course increased their understanding of how to ensure access to emergency blood transfusion by the use of a WBB.

DISCUSSION

Structured theoretical and practical training in emergency whole blood collection and emergency transfusion is feasible and of interest to medical students. A multidisciplinary approach to student training in emergency whole blood collection and transfusion should be considered.

Management of hemotherapy services in the context of the COVID-19 pandemic

This study aimed to analyze the management of hemotherapy services (HS) in the context of the COVID-19 pandemic from the perspective of municipal managers in different regions of Brazil. A qualitative approach with semi-structured interviews was applied to HS managers in the three Brazilian capitals, from different regions of Brazil, during the period between September 2021 and April 2022. The textual content of the interviews was submitted to lexicographic textual analysis using the free access software, Iramuteq. The managers' perceptions resulted from the descending hierarchical classification (DHC) analysis, which generated six classes: availability of resources for the development of work; installed capacity of services; strategies and challenges for attracting blood donors; risks and worker protection; measures for crisis management; and communication strategies for the adhesion of candidates for donation. The analysis highlighted several strategies used by the management, as well as pointed out limits and challenges for HS organization and management, exacerbated in the context of the pandemic.

Multidisciplinary paper on patient blood management in cardiothoracic surgery in the UK: perspectives on practice during COVID-19

The coronavirus (COVID-19) pandemic disrupted all surgical specialties significantly and exerted additional pressures on the overburdened United Kingdom (UK) National Health Service. Healthcare professionals in the UK have had to adapt their practice. In particular, surgeons have faced organisational and technical challenges treating patients who carried higher risks, were more urgent and could not wait for prehabilitation or optimisation before their intervention. Furthermore, there were implications for blood transfusion with uncertain patterns of demand, reductions in donations and loss of crucial staff because of sickness and public health restrictions. Previous guidelines have attempted to address the control of bleeding and its consequences after cardiothoracic surgery, but there have been no targeted recommendations in light of the recent COVID-19 challenges. In this context, and with a focus on the perioperative period, an expert multidisciplinary Task Force reviewed the impact of bleeding in cardiothoracic surgery, explored different aspects of patient blood management with a focus on the use of haemostats as adjuncts to conventional surgical techniques and proposed best practice recommendations in the UK.

Requests for Directed Blood Donations

This Ethics Rounds presents a request for directed blood donation. Two parents feel helpless in the setting of their daughter's new leukemia diagnosis and want to directly help their child by providing their own blood for a transfusion. They express hesitancy about trusting the safety of a stranger's blood. Commentators assess this case in the setting of blood as a scarce community resource during a national blood shortage. Commentators review the child's best interest, future risks, and harm-benefit considerations. Commentators recognize the professional integrity, humility, and courage of the physician to admit his own lack of knowledge on the subject and to seek help rather than claim directed donation is not possible without further investigation into options. Shared ideals such as altruism, trust, equity, volunteerism, and solidarity are recognized as values relevant to sustainment of a community blood supply. Pediatric hematologists, a blood bank director, transfusion medicine specialists, and an ethicist conclude that directed donation is only justified by lower risks to the recipient in particular circumstances.

A study on blood donor characteristics and preferred environment of South Koreans during the COVID-19 pandemic: A conjoint analysis

Objective

The COVID-19 pandemic has caused a decrease in the number of blood donors worldwide, posing a global problem. Therefore, this study investigates people who have continuously participated in blood donation during the COVID-19 pandemic and collects basic information as a reference for maintaining stable amounts of blood during future pandemics.

Methods

The participants of this study were selected from the population of South Korea through stratified sampling considering region and age distributions. Owing to the COVID-19 pandemic, the participants were recruited online through Embrain, an online research and survey company, from June 1 to June 28, 2021. Data were collected from a total of 1,043 participants and used in the study.

Results

The results of this study showed that there was a difference between the donors group and non-donors group in factors such as donation attitude (F = 73.342, p &lt; 0.001), donation knowledge (F = 6.530, p &lt; 0.01), and preventive health behavior (F = 12.352, p &lt; 0.001). Overall, blood donors showed favorable attitude toward and considerable knowledge of blood donation as well as a high level of preventive health behavior. The environment most preferred by people who participated in blood donation during the COVID-19 pandemic was “going with family to a blood donation center that gives out free gifts in a region far away with no confirmed cases,” which showed the highest utility (utility = 0.734).

Conclusion

Even during pandemics, donation attitude, donation knowledge, and preventive health behavior can serve as key factors affecting participation in blood donation. Additionally, blood donation centers that donors can visit with their families represent a favorable environment for the promotion of blood donation during pandemics.

Intraoperative cell salvage using swab wash and serial thromboelastography in elective abdominal aortic aneurysm surgery involving massive blood loss

The loss of 50% blood volume is one accepted definition of massive haemorrhage, which ordinarily would trigger the massive transfusion protocol, involving the administration of high ratios of fresh frozen plasma and platelets to allogeneic red cells. We investigated 53 patients who experienced >50% blood loss during open elective abdominal aortic aneurysm surgery to assess allogeneic blood component usage and coagulopathy. Specialist patient blood management practitioners used a tailored cell salvage technique including swab wash to maximise blood return. We assessed the proportion of patients who did not require allogeneic blood components and develop evidence of coagulopathy by thromboelastography (TEG) parameters. Blood loss was 50%-174% (mean [SD] 68% [27%]) of blood volume. The mean (SD) intraoperative decrease in haemoglobin concentration, assessed by arterial blood gas analysis, was 5 (13) g/l. No patient received allogeneic red cells intraoperatively. Four of the 53 (8%) patients received blood components in the first 24 h postoperatively at the anaesthetists' discretion. No patient had intraoperative TEG changes indicative of fibrinolysis or coagulopathy. The 30-day mortality was 2% (one of 53). Reduction of allogeneic transfusion is one aim of patient blood management techniques. We have demonstrated virtual avoidance of allogeneic blood product transfusion despite massive blood loss. These data show possible alternatives to the current massive transfusion protocols to the management of elective vascular surgical patients.

Use of blood products during the first months of COVID-19 pandemic period: A single center report

The novel coronavirus (SARS-CoV-2) outbreak exerted a serious effect on healthcare. Between 1st of January and May 31, 2020 due to the special regulations in Hungary, the number of reported COVID-19 infections were relatively low (3876 cases). The inpatient and outpatient care and the blood supply were significantly affected by the implemented regulations. The aim of this study was to evaluate the use of blood products amid the first five months of the pandemic situation. This investigation has observed a significant reduction of hospitalizations (37.35%). Analyzing individually the included units, pre-transfusion hemoglobin concentrations of transfused patients presented slight modifications, which were not statistically significant. The special regulations resulted major changes in the frequency of diagnoses at admissions in case of the Department of Surgery, while in case of the other specialities (Division of Hematology and Department of Anesthesiology and Intensive Therapy), there were no major changes compared to pre-pandemic period. Considering each department separately, transfused red blood cell concentrates (RBC) per patient, and the proportion of transfused patients did not change significantly. However, the combination of these modifications resulted in the significant decrease in RBC transfusions (p < 0.0001) compared to the pre-pandemic baseline. With regard to platelet and fresh frozen plasma (FFP), their usage was significantly reduced (44.40% platelet concentrates and 34.27% FFP). Our results indicate that the pandemic had an important effect on the blood product usage at the included departments by introducing different patient care policies and the temporary deferral of the elective surgical interventions. Despite the challenging circumstances of blood collection and blood product supply, the hospitalized patients received adequate care.

Reduced Mortality among COVID-19 ICU Patients after Treatment with HemoClear Convalescent Plasma in Suriname

Convalescent plasma is a promising therapy for coronavirus disease 2019 (COVID-19), but its efficacy in intensive care unit (ICU) patients in low- and middle-income country settings such as Suriname is unknown. Bedside plasma separation using the HemoClear device made convalescent plasma therapy accessible as a treatment option in Suriname. Two hundred patients with severe SARS-CoV-2 infection requiring intensive care were recruited. Fifty eight patients (29%) received COVID-19 convalescent plasma (CCP) treatment in addition to standard of care (SOC). The CCP treatment and SOC groups were matched by age, sex, and disease severity scores. Mortality in the CCP treatment group was significantly lower than that in the SOC group (21% versus 39%; Fisher's exact test P = 0.0133). Multivariate analysis using ICU days showed that CCP treatment reduced mortality (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.18 to 0.66; P = 0.001), while complication of acute renal failure (creatinine levels, >110 mol/L; HR, 4.45; 95% CI, 2.54 to 7.80; P < 0.0001) was independently associated with death. Decrease in chest X-ray score in the CCP treatment group (median -3 points, interquartile range [IQR] -4 to -1) was significantly greater than that in the SOC group (median -1 point, IQR -3 to 1, Mann-Whitney test P = 0.0004). Improvement in the PaO₂/FiO₂ ratio was also significantly greater in the CCP treatment group (median 83, IQR 8 to 140) than in the SOC group (median 35, IQR -3 to 92, Mann-Whitney P = 0.0234). Further research is needed for HemoClear-produced CCP as a therapy for SARS-CoV-2 infection together with adequately powered, randomized controlled trials. IMPORTANCE This study compares mortality and other endpoints between intensive care unit COVID-19 patients treated with convalescent plasma plus standard of care (CCP), and a control group of patients hospitalized in the same medical ICU facility treated with standard of care alone (SOC) in a low- and middle-income country (LMIC) setting using bedside donor whole blood separation by gravity (HemoClear) to produce the CCP. It demonstrates a significant 65% survival improvement in HemoClear-produced CCP recipients (HR, 0.35; 95% CI, 0.19 to 0.66; P = 0.001). Although this is an exploratory study, it clearly shows the benefit of using the HemoClear-produced CCP in ICU patients in the Suriname LMIC setting. Additional studies could further substantiate our findings and their applicability for both LMICs and high-income countries and the use of CCP as a prepared readiness method to combat new viral pandemics.

Blood donation during COVID-19 lockdown and its association with anger and stress: A cross-sectional study from Syria

BACKGROUND

The demand for blood donations in Syria was high as the country has suffered for 9 years from war, and this demand has substantially increased during and after the lockdown from the COVID-19 pandemic. This study aims to assess blood donations in Syria and their association with multiple factors.

METHODS

Online questionnaires were distributed to social media groups, with questions related to stress, anger, and COVID-19 distress.

RESULTS

This study included 1,423 participants, of which 899 (63.2%) were women. Only 48.5% have ever donated blood, of which 33.3% donated only once in their lifetime. Not having a good reason to donate blood was the main reason for not donating. Obtaining documents was the main reason for blood donation among people who donated blood (64.8%). Stress, anger, and fear of infection were not associated with blood donation and its patterns. Losing someone close and being endangered by war were associated with more frequent blood donations in contrast to being distressed by war.

CONCLUSION

COVID-19 distress, stress, and anger were not associated with the decrease in blood donation. Spreading awareness on volunteer blood donation is crucial to combat blood shortage during stressful times.

Recommendations for in vitro evaluation of blood components collected, prepared and stored in non-DEHP medical devices

BACKGROUND AND OBJECTIVES

DEHP, di(2-ethylhexyl) phthalate, is the most common member of the class of ortho-phthalates, which are used as plasticizers. The Medical Device Regulation has restricted the use of phthalates in medical devices. Also DEHP has been added to the Annex XIV of REACH, "Registration, Evaluation, Authorisation and Restriction of Chemicals" due to its endocrine disrupting properties to the environment. As such, the sunset date for commercialisation of DEHP-containing blood bags is May 27^th 2025. There are major concerns in meeting this deadline as these systems have not yet been fully validated and/or CE-marked. Also, since DEHP is known to affect red cell quality during storage, it is imperative to transit to non-DEHP without affecting blood product quality. Here, EBA members aim to establish common grounds on the evaluation and assessment of blood components collected, prepared and stored in non-DEHP devices.

MATERIALS AND METHODS

Based on data as well as the input of relevant stakeholders a rationale for the validation of each component was composed.

RESULTS

The red cell components will require the most extensive validation as their quality is directly affected by the absence of DEHP, as opposed to platelet and plasma components.

CONCLUSION

Studies in the scope of evaluating the quality of blood products obtained with non-DEHP devices, under the condition that they are carried out according to these recommendations, could be used by all members of the EBA to serve as scientific support in the authorization process specific to their jurisdiction or for their internal validation use.

When is enough enough? Odds of survival by unit transfused

BACKGROUND

Balanced transfusion is lifesaving for hemorrhagic shock. The American Red Cross critical blood shortage in 2022 threatened the immediate availability of blood. To eliminate waste, we reviewed the utility of transfusions per unit to define expected mortality at various levels of balanced transfusion.

METHODS

A retrospective study of 296 patients receiving massive transfusion on presentation at a level 1 trauma center was performed from January 2018 to December 2021. Units of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets received in the first 4 hours were recorded. Patients were excluded if they died in the emergency department, died on arrival, received <2 U PRBCs or FFP, or received PRBC/FFP >2:1. Primary outcomes were mortality and odds of survival to discharge. Subgroups were defined as transfused if receiving 2 to 9 U PRBCs, massive transfusion for 10 to 19 U PRBCs, and ultramassive transfusion for ≥20 U PRBCs.

RESULTS

A total of 207 patients were included (median age, 32 years; median Injury Severity Score, 25; 67% with penetrating mechanism). Mortality was 29% (61 of 207 patients). Odds of survival is equal to odds of mortality at 11 U PRBCs (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.50-1.79). Beyond 16 U PRBCs, odds of mortality exceed survival (OR, 0.36; 95% CI, 0.16-0.82). Survival approaches zero >36 U PRBCs (OR, 0.09; 95% CI, 0.00-0.56). Subgroup mortality rates increased with unit transfused (16% transfused vs. 36% massive transfusion, p = 0.003; 36% massive transfusion vs. 67% ultramassive transfusion, p = 0.006).

CONCLUSION

Mortality increases with each unit balanced transfusion. Surgeons should view efforts heroic beyond 16 U PRBCs/4 hours and near futile beyond 36 U PRBCs/4 hours. While extreme outliers can survive, consider cessation of resuscitation beyond 36 U PRBCs. This is especially true if hemostasis has not been achieved or blood supplies are limited.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Real world reduction in red cell transfusion with restrictive transfusion threshold in haematology inpatients

OBJECTIVES

The aim of this study was to assess the reduction in red cell transfusions following a change in the red cell transfusion threshold for haematology inpatients from 80 to 70 g/L.

BACKGROUND

Haematology patients are among the high users of red blood cells. We reduced the threshold for transfusion of haematology inpatients to 70 g/L. This was based on evidence provided by randomised controlled trial published in 2020 that showed restrictive transfusion is non-inferior to liberal transfusion.

METHOD

We assessed red cell transfusions for haematology inpatients at Oxford University Hospitals NHS Foundation Trust for 9 months before and 9 months after a change in red cell transfusion threshold from 80 to 70 g/L.

RESULTS

After the change in threshold to 70 g/L or less from 80 g/L, the median number of red cell transfusions per month reduced to 88 from 111. This was a 23% reduction in the total number of red cells administered per month.

CONCLUSION

These results show the real-world reductions in transfusion that can be made by putting local transfusion guidelines in line with the international recommendations. This is of particular importance at a time of national blood shortage.