Faculty Bibliography

INTRODUCTION: An organized, evidence-based multidisciplinary approach to transforming blood transfusion practices may help limit usage of blood bank resources. A Patient Blood Management (PBM) program was initiated in 2013 and fully implemented in 2014 at our urban, 350-bed acute care center: broad-based educational modules for licensed practitioners, laboratory conversions to low-volume samples, changes in hemoglobin (Hgb) critical-level reporting and adjustment of divisional transfusion protocols and guidelines (e.g. universally decreasing transfusion triggers to Hgb 6g/dL standard in non-critical patients, with 7g/dL in the setting of known cardiac disease; and changing initial number of packed red blood cell [PRBC] transfusions to 1 unit instead of 2 units). The goal of this study is to analyze the effectiveness of this PBM program.
METHOD(S): We retrospectively analyzed transfusion data from January 1, 2012-December 31, 2018. Continuous variables were analyzed for Hgb on transfusion orders, number of PRBC units transfused, PRBC wastage and potential cost-savings. T-tests were used to analyze the data of this 7 years' study.
RESULT(S): Significant improvement in PRBC transfusion practices and usage occurred after implementation of the PBM program. Mean Hgb for PRBC transfusion orders decreased year-over-year after PBM program implementation compared to nadir 6.73 g/dL in 2018 vs 7.35 g/dL in 2012 (p<0.0001). Similarly, the absolute number and percentage of transfused PRBC units of the Hgb trigger >= 8g/dL significantly decreased year-over-year reaching a nadir in 2018 compared to 2012 (101 units vs 462 units, and 7.9% vs 24.7%, p<0.001). During the same period, wastage also profoundly reduced (3 units vs. 28 units). Potential cost-savings peaked at $216,048 in 2018 with total potential cost-savings of $950,915 during the 6-year PBM program implementation. Impressively the progress of this PBM program has been made on a $0 budget. DISCUSSION: An organized, evidence-based multidisciplinary PBM program may improve the culture of institutional PRBC transfusion practices and translate to more optimal patient care and resource utilization as well as pronounced cost-savings, as demonstrated in this study. Continual implementation of a PBM program may have cumulative effect. Continued education and further work needs to be done to maintain the current trends and expand the program into platelet and plasma therapy

Background: An ABO blood group subtype is called a subgroup and/or variant. Subgroups of ABO are often distinguished by decreased amounts of A, B or O (H) antigens on red blood cells. Blood type A appears to have the most variation in subgroups. In general, serologic distinction between A1 and other subgroups of A is based on the ability of anti- A1 lectin (an extract of Dolichos biflorus seeds) to agglutinate A1 red blood cells (RBC) but not cells of other A subgroups. As A2 is most common A subtype and is frequently detected at regular hospital transfusion services. Definitive identification of ABO subgroups is usually performed at a reference laboratory using molecular techniques and special immunohematology methods. Here we report an interesting case where a subgroup B was detected by an astute technologist using manual immunohematology tests and conventional reagents at our hospital transfusion service. Our hospital transfusion service received a blood specimen requesting a type and screen from a pregnant woman with no known medical problems. Testing the specimen showed a front type of O and a back type of B, with a negative antibody screening.
Aim(s): To resolve the typing discrepancy and to correctly Identify the ABO blood type of the pregnant patient.
Method(s): In an attempt to enhance the typing reactions with the patient's RBCs and plasma, mixtures of the front typing and back typing were incubated separately for 15 minutes at room temperature. This however did not result in any change in reactivity. The technologist became suspicious of a possible B subgroup as this was a healthy young woman and it would be rare for such a young patient to exhibit missing antibodies in the reverse type. He then performed a DAT on the specimen to assure that nothing was coating the patient's RBCs which might interfere with further testing. The DAT was negative for IgG and C3d. He subsequently performed an absorption on vigorously washed patient RBC) with anti-B reagent from Ortho. The reaction mixture was incubated at room temperature (RT) for 15 minutes, followed by an elution. The eluate was added to washed A cells, B cells, and screening cells (Ortho), and then incubated at room temperature for 15 minutes. The mixtures were washed with eluate washing solution. Anti-IgG Coombs reagent was added, the tubes were centrifuged, and results were recorded.
Result(s): A cells: Negative B cells: 2 + Screen cell #1: negative Screen cell #2: negative Screen cell #3: negative Summary/Conclusions: Based on the manual tests the technologist designed and performed, he was able to demonstrate the 2 + reactivity with type B reagent RBCs and concluded that the patient's blood type is a B subgroup. The patient's specimen was then sent to New York Blood Center Immunohematology Reference Laboratory for further confirmation and identification. The B group of the patient's RBCs was not detectable again by the conventional immunohematology tests. Molecular tests (PCR-RFLP) and full gene sequencing were performed. A B allele (*B1.01) and an O1 allele (*O1.09) were identified, which predicts a B weak subtype. The molecular testing confirms the conclusion made by our technologist using conventional manual immunohematology tests

BACKGROUND:Left ventricular assist device (LVAD) recipients undergoing heart transplantation have increased bleeding risk. We compared conventional warfarin reversal with fresh frozen plasma vs 4-factor prothrombin complex concentrate (PCC) and the effect on transfusion requirements, blood bank costs, and clinical outcomes. METHODS:A retrospective review identified 60 consecutive LVAD recipients undergoing heart transplantation divided into two groups: 30 (no PCC) received fresh frozen plasma and 30 (PCC) received PCC. Patient characteristics, intraoperative and postoperative transfusion requirements, short-term clinical outcomes, and blood bank costs were compared. PCC association with transfusion requirements was assessed by multivariate linear regression. RESULTS:Patients who received PCC were younger (50 ± 11 vs 57 ± 13 years, p = 0.02), fewer had ischemic cardiomyopathy (23% vs 60%, p = 0.01), had more than one prior sternotomy (7% vs 30%, p = 0.04), and had higher preoperative hemoglobin (11.8 ± 1.8 vs 10.4 ± 1.8 g/dL, p = 0.01). The PCC group had a significantly shorter bypass time (185 vs 217 minutes, p = 0.01), received less fresh frozen plasma (2 vs 5 units, p = 0.03), cryoprecipitate (0 vs 2 units, p = 0.05), and total blood products (9 vs 13.5 units, p = 0.03) intraoperatively, and was less likely to require delayed sternal closure (3% vs 23%, p = 0.05). On multivariate linear regression, PCC was significantly associated with decreased intraoperative transfusion (β = -6.09, p = 0.02). There was no difference in thromboembolic events or in-hospital death. Total blood bank costs were $4,949 for PCC and $3,677 for no PCC (p = 0.01). CONCLUSIONS:Although more costly, PCC reduced transfusion requirements and delayed sternal closure in heart transplant recipients bridged with LVAD, justifying its use over traditional warfarin reversal.