[The management of nephropathic patients during the Covid-19 pandemic: the experience of Ragusa].

The public emergency caused by Covid-19 has forced health services to reorganize in order to separate positive patients from negative ones. In nephrology, this reorganization involves several levels of assistance concerning hospitalizations, ambulatory care and haemodialysis. Within the Complex Unit of Nephrology in Ragusa, the distribution of nephro-dialytic resources has involved four different hospitals, hence ensuring haemodialysis services for asymptomatic and pauci-symptomatic Covid-19 patients as well as for patients in Covid-Unit, Sub-Intensive Therapy and Intensive Care Unit. In this complex context, we had to create a common protocol involving all the professionals who provide assistance in our Unit, across the different structures. We also report some encouraging data that seem to indicate the effectiveness of the protocols put in place.

The prevention of adverse reactions to transfusions in patients with haemoglobinopathies: a proposed algorithm.

BACKGROUND: Transfusion therapy remains the main treatment for patients with severe haemoglobinopathies, but can cause adverse reactions which may be classified as immediate or delayed. The use of targeted prevention with drugs and treatments of blood components in selected patients can contribute to reducing the development of some reactions.The aim of our study was to develop an algorithm capable of guiding behaviours to adopt in order to reduce the incidence of immediate transfusion reactions. MATERIALS AND METHODS: Immediate transfusion reactions occurring over a 7-year period in 81 patients with transfusion-dependent haemoglobinopathies were recorded. The patients received transfusions with red cell concentrates that had been filtered prestorage. Various measures were undertaken to prevent transfusion reactions: leucoreduction, washing the red blood cells, prophylactic administration of an antihistamine (loratidine 10 mg tablet) or an antipyretic (paracetamol 500 mg tablet). RESULTS: Over the study period 20,668 red cell concentrates were transfused and 64 adverse transfusion reactions were recorded in 36 patients. The mean incidence of reactions in the 7 years of observation was 3.1‰. Over the years the incidence gradually decreased from 6.8‰ in 2004 to 0.9‰ in 2010. DISCUSSION: Preventive measures are not required for patients who have an occasional reaction, because the probability that such a type of reaction recurs is very low. In contrast, the targeted use of drugs such as loratidine or paracetamol, sometimes combined with washing and/or double filtration of red blood cells, can reduce the rate of recurrent (allergic) reactions to about 0.9‰. The system for detecting adverse reactions and training staff involved in transfusion therapy are critical points for reliable collection of data and standardisation of the detection system is recommended for those wanting to monitor the incidence of all adverse reactions, including minor ones.

Blood transfusion practice: a nationwide survey in Italy.

BACKGROUND: Blood transfusion is a complex activity. Some of the components of this activity are implementation of standard procedures, evaluation of appropriateness of the blood use, methods for bedside identification of patients and the release of blood in emergencies, during out-of-routine hours and from hospitals lacking a Blood Centre. An overview about how these issues are managed in Italy could be of interest. MATERIALS AND METHODS: A survey dealing with some issues regarding blood release was performed, using a questionnaire sent to 278 Italian Blood Centres. RESULTS: Out of the 278 Centres, 179 (64%) returned the questionnaire. The geographic distribution of the Centres that responded (80 in the north, 46 in the centre and 53 in the south of Italy) offers a good picture of the Italian reality. Globally there seems to be a relatively uniform application of procedures and guidelines, of methods to identify patients, and of evaluating transfusion appropriateness. The systems used to deal with emergency blood release and blood release in non-routine conditions are more variable. The use of technological resources seems to be disappointingly low. DISCUSSION: Although many aspects of the blood transfusion process should be improved, the picture that emerged from the survey seems to show, on the whole, a fair quality of blood transfusion practice in Italian Blood Centres.

Use of an identification system based on biometric data for patients requiring transfusions guarantees transfusion safety and traceability.

BACKGROUND: One of the most serious risks of blood transfusions is an error in ABO blood group compatibility, which can cause a haemolytic transfusion reaction and, in the most severe cases, the death of the patient. The frequency and type of errors observed suggest that these are inevitable, in that mistakes are inherent to human nature, unless significant changes, including the use of computerised instruments, are made to procedures. METHODS: In order to identify patients who are candidates for the transfusion of blood components and to guarantee the traceability of the transfusion, the Securblood system (BBS srl) was introduced. This system records the various stages of the transfusion process, the health care workers involved and any immediate transfusion reactions. The patients and staff are identified by fingerprinting or a bar code. The system was implemented within Ragusa hospital in 16 operative units (ordinary wards, day hospital, operating theatres). RESULTS: In the period from August 2007 to July 2008, 7282 blood components were transfused within the hospital, of which 5606 (77%) using the Securblood system. Overall, 1777 patients were transfused. In this year of experience, no transfusion errors were recorded and each blood component was transfused to the right patient. We recorded 33 blocks of the terminals (involving 0.6% of the transfused blood components) which required the intervention of staff from the Service of Immunohaematology and Transfusion Medicine (SIMT). Most of the blocks were due to procedural errors. CONCLUSIONS: The Securblood system guarantees complete traceability of the transfusion process outside the SIMT and eliminates the possibility of mistaken identification of patients or blood components. The use of fingerprinting to identify health care staff (nurses and doctors) and patients obliges the staff to carry out the identification procedures directly in the presence of the patient and guarantees the presence of the doctor at the start of the transfusion.

Adverse reactions in blood and apheresis donors: experience from two Italian transfusion centres.

BACKGROUND: Blood and apheresis donations are widely considered to be safe with a low incidence of adverse reactions and injuries; however, data reported in the medical literature on the prevalence of adverse events in donors and studies on the predictive risk factors for donor reactions are limited and contradictory. METHODS: From January 2002 to December 2006 we recorded every adverse reaction verified during 240,596 consecutive blood and apheresis donations (183,855 homologous whole blood donations, 6,669 autologous whole blood donations, 38,647 plasmapheresis, 2,641 plateletpheresis and 8,784 multicomponent donations) at the Italian Transfusion Centres of Verona and Ragusa,. RESULTS: Using a special, pre-arranged form within the quality system, a total of 686 adverse reactions (related to 0.28% of all donations) were recorded. Vasovagal reactions, mostly of mild intensity, were the most commonly observed adverse reactions, with a frequency of 0.20% (487/ 240,596). The frequency of the vasovagal reactions varied according to the different types of donation, being 0.19% (346/183,855) for homologous whole blood donations, 0.24% (16/6,669) for autologous whole blood donations, 0.16% (63/38,647) for plasmapheresis, 0.68% (18/2,641) for plateletpheresis and 0.49 (43/8,784) for multicomponent donations. Citrate toxicity was reported in 0.38% (189/50,072) of apheresis donations. Severe adverse reactions were very rare, as they occurred in 0.004% of the donations (10/240,596). CONCLUSIONS: In conclusion, the results of our 5-year survey document that apheresis and blood donation are safe procedures for the donor with a low incidence of adverse reactions; the adverse reactions that did occur were mostly mild and resolved rapidly.

Continuous improvement of our autologous blood donation program carried out during 10 years in 1198 orthopaedic patients.

BACKGROUND: We analysed the relationship between baseline haemoglobin levels and the need for post-operative blood transfusion in our patients. The aim of this study was to evaluate and optimize the pre-operative autologous blood donation (PABD) program at our hospital through a constant audit. MATERIALS AND METHODS: Between January 1997 and December 2006 we evaluated 1198 consecutive patients who underwent elective, unilateral, primary total hip or knee arthroplasty and who met our inclusion criteria. We determined the baseline haemoglobin level to establish the relationship to the need for post-operative transfusion. RESULTS: The results of our study show that the baseline haemoglobin level is a strong predictor of blood transfusion after unilateral, primary total hip or knee arthroplasty. CONCLUSIONS: The baseline haemoglobin level is a strong predictor of blood transfusion after elective, unilateral, primary total hip or knee arthroplasty. On the basis of these findings, we do not recommend autologous predonation for patients with a baseline haemoglobin level of >14g/dl moreover we always recommend the use of a blood cell salvage system and a constant audit of pre-operative autologous blood donation (PABD) to avoid unnecessary expense and waste.

A comparison of two automated methods for the detection and identification of red blood cell alloantibodies.

BACKGROUND: The aim of this study was to compare the routine use of two automated systems (OrthoAutoVue Innova, microcolumn, and Immucor Galileo, solid phase) for the screening and identification of irregular red blood cell alloantibodies in samples, analysed in our Transfusion Service during 6 months of normal activity. The study focused particularly on an evaluation of the repeatability of the screening tests, the identification of antibody specificities and the identification of antibodies in samples showing discordant results. MATERIALS AND METHODS: Overall 2,229 samples from potential blood donors (A), multiply transfused patients with blood disorders (DH), potential transfusion recipients (TS), and external cases (E) were studied. The protocols were carried out according to the manufacturers recommendations. RESULTS: The screening tests detected 78 samples that were positive with both systems, while 18 were positive only with Immucor and 11 only with Ortho (thus, overall, Immucor detected 96 positive samples and Ortho 89 positive samples). The use of the respective identification panels enabled us to identify the antibodies in 65 samples with Immucor and in 61 samples with the Ortho system; 74 antibodies were identified with Immucor (55 with a single specificity and 19 with mixed specificities) and 68 antibodies with Ortho (51 and 17, respectively). In the remaining cases (31 samples for Immucor and 28 for Ortho), the antibody specificity was not identified. The two systems were found to be essentially similar. The Immucor system revealed a greater number of antibodies, mainly because of its greater sensitivity at detecting anti-D antibodies. CONCLUSIONS: Both systems showed a repeatability of over 85%, demonstrating that automation of immunohaematological tests is advantageous. The specificity of the antibody was identified in 68% of the samples. Furthermore, using the two systems led to the identification of ten new antibodies (6 anti-D, 2 anti-E, 1 anti Le(a), and 1 anti-Vel), which would not have been detected had only one of the two methods been used.

Chronic red blood cell exchange to prevent clinical complications in sickle cell disease.

We tracked the results of 394 manual or automatic red blood cell exchanges done with a cell separator in 20 sickle cell patients at high risk for recurrent complications. Over an average of 6 years, none of the patients developed complications related to the procedure or to the increased blood use. It was safe and effective in preventing complications of sickle cell disease, and if done automatically, reduced iron overload. Ferritin levels also decreased in patients treated with automatic red blood cell exchange. Furthermore, using Single Donor Red Blood Cell units (SDRC) we reduced the potential exposure to transfusion transmitted infectious diseases (TTI).

The selection of donors in multicomponent collection management.

The use of cell separators in multicomponent collection (MCC) makes it possible to use donors effectively by personalising the donation on the basis of their haemotological and physical profiles and thereby standardising the product. We have applied the selection parameters currently used in our collection centre to 6687 donors using a common software programme for all: 57.6% were eligible for the various forms of MCC, although our parameters are even stricter than those required by law. Between 01 September 2001 and 28 February 2002, 345 MCC (9% of all the donations made) were performed and assessed: 111 donations of double red cell units, 153 donations of red cells and plasma, 62 donations of plasma and platelets, 19 donations of double platelet units: only slight, adverse reactions were encountered in 6% of the procedures. 68 double red cell unit donors and 65 red cell and plasma donors were then reassessed 6 months after MCC: the parameters assessed (hemoglobin, serum iron, ferritin, and total protein) were the same as the pre-donation data. All the units collected complied with legal requirements. With the use of parameters based on donor hematological and physical characteristics we can move from the concept of tailored transfusions to the concept of tailored donations thereby ensuring donor safety and meeting patient needs.