Faculty Bibliography

Background/Case Studies: Most United States medical school curricula devote little attention to teaching transfusion medicine (TXNM). From the early stages of their residencies, however, physicians are expected to be able to obtain informed consent for transfusion, administer transfusions, and recognize and treat transfusion reactions. Although there are many transfusion standards designed to ensure patient safety, they also can lead to a false sense of security. The overall limited knowledge of TXNM by most physicians and the reliance on this false sense of security can adversely impact patient safety. In 2010, comprehensive TXNM education was required of all incoming house staff (HS). In 2014, the blood bank staff was able to see the HS's performance question-by-question, and the staff sought to evaluate the impact of the compulsory online education and determine which topics merit additional instruction. Study Design/Methods: An online Transfusion Guidelines tutorial and competency exam, consisting of 25 true/ false questions, was administered. All HS were required to take and pass (score > 80%) the exam. The instruction course and competency exam were accessible to all HS and members of the medical school community on the institution's advanced learning exchange. The competency exams were instantly scored, and the results were reported to the test taker. Results/ Findings: Prior to starting work on July 1, 2014, all incoming HS had taken and scored >80% on the exam. From May1, 2014 to July 1,2014, a total of 977 individuals, including the incoming HS, had completed the tutorial and taken the exam. The average score on the exam was 83.2% (20.8/25). Three questions were answered correctly by <40% of the test-takers. Two questions were answered correctly by 60-69%, 4 questions were answered correctly by 70-79%, 7 questions were answered correctly by 80-89%, and 9 questions were answered correctly by 90-100%. Questions regarding effectiveness of plasma transfusion in correcting PT (39.6%), ABO type of emergency-released RBCs (13.1%), and TA-GVHD prevention (34.6%) were answered incorrectly the most frequently (see Table). Conclusion: Formalized transfusion education for all HS must continue to be conducted. Additional instruction must be developed and deployed to improve the knowledge deficits identified by the exam. (Table Presented)

BACKGROUND: The objective of this study was to characterize variations in packed red blood cell (PRBC) transfusion practices in critically ill patients and to identify which factors influence such practices. We hypothesized that significant variation in transfusion triggers exists among acute care surgeons. METHODS: A survey of PRBC transfusion practices was administered to the American Association for the Surgery of Trauma members. The scenarios examined hemoglobin thresholds for which participants would transfuse PRBCs. RESULTS: A hemoglobin threshold of less than or equal to 7 g/dL was adopted by 45% of respondents in gastrointestinal bleeding, 75% in penetrating trauma, 66% in sepsis, and 62% in blunt trauma. Acute care surgeons modified their transfusion trigger significantly in the majority of the modifications of these scenarios, often inappropriately so. CONCLUSIONS: This study documents continued evidence-practice gaps and wide variations in the PRBC transfusion practices of acute care surgeons. Numerous clinical factors altered such patterns despite a lack of supporting evidence (for or against).

Background/Case Studies: Wastage of group AB plasma is a problem for Level I trauma centers. To ensure the 1:1:1 (RBC : plasma : platelet) MTP ratio, plasmas must be kept liquid. In an attempt to reduce expiration and transfusion of group AB plasma to non-AB patients, our MTP called for only 2 units of group AB to be kept thawed. Group AB units not used within 4 d are issued to other patients requiring plasma. On January 1, 2014, our blood supplier began offering group A plasma with low-titer anti-B (<1:100) as an alternative to group AB plasma. After receiving approval from the hospital transfusion committee, we began stocking group A plasma with low-titer anti-B (low-titer A plasma) to try to reduce our wastage of group AB plasma. Study Design/Methods: The implementation process and usage of low-titer A plasma was evaluated from March 15, 2014 to April 30, 2014. The number of units thawed and used was tabulated, and the recipients' clinical information was assessed, as part of routine QA, via the EMR. Results/Findings: Although the substitution of low-titer A plasma appears easy, in practice it was challenging. HCLL Transfusion (the browser-based blood bank software system) cannot differentiate the low-titer A units from regular type A plasmas. No field exists within which to scan and capture the titer information. Our HCLL truth tables only permit AB plasma to be issued until 2 ABO types are resulted even using the emergency release function. HCLL permits a given unit of plasma to be thawed only once, and thus a unit cannot first be labeled as FP24 or FFP and then, after 24 h, be relabeled as thawed plasma. New procedures needed to be created. By using an ISBT label-duplication program, a thawed unit can first be labeled outside of HCLL as PF24 or FFP and then later labeled via HCLL as thawed plasma. The ISBT labelduplication program is also able to read the additional titer barcode label. Until a patient has 2 ABO types resulted, the low-titer A plasmas must be issued manually and then late!

Background/Case Studies: Patients on vitamin K antagonist (VKA) anticoagulants such as warfarin have reduced levels of functional coagulation factors II, VII, IX, and X. Although highly efficient at reducing the risk of thrombosis, these drugs are associated with an increased risk of bleeding. The warfarin-related bleeding can be catastrophic, but it is reversible. The factors can be slowly replenished by administering vitamin K or more rapidly replenished by plasma transfusion and/or prothrombin complex concentrates (PCCs) infusion. In 2008, we began stocking Bebulin, a three-factor PCC, as an off-label option for rapid reversal of VKA. Because of the high cost and the risk of thrombotic events, each clinical service was required to submit guidelines for appropriate use of PCCs in 2010. Once Kcentra, a four-factor PCC, received FDA approval for urgent VKA reversal in 2013, both Bebulin and Kcentra were stocked by the blood bank. We sought to evaluate the impact of adding Kcentra on our institution's use of PCCs. Study Design/Methods: Bebulin and Kcentra usage from 1/1/12 to 4/20/14 was analyzed. The specific derivative orders, indications, and clinical cases were reviewed as part of quality assurance. Bebulin was administered at a dose of 40 IU/per kg, and Kcentra was dosed as per the manufacturer's package insert. Use of Bebulin also required the transfusion of 2 units of plasma to provide factor VII The de-identified tabulated data were analyzed. Results/Findings: Forty-four patients received Bebulin, and three patients received Kcentra. The mean doses of Bebulin and Kcentra were 3288.4 IU and 1600 IU, respectively. The mean INR before infusion was 3.57 for Bebulin and 3.11 for Kcentra. The mean IRN after infusion was 1.66 for Bebulin and 1.26 for Kcentra. Bebulin was used nine times outside of the approved clinical service guidelines. Bebulin administration did not prevent the death of 12 (27.3%) patients. Only 1 patient who received Bebulin had CT evidence of a thrombotic event. The mean c!