Cold Antibodies in Cardiovascular Surgery: Is Preoperative Screening Necessary?

OBJECTIVES: Cold antibodies (CAs) are rarely significant for transfusion, but they can cause complications under the hypothermic conditions of cardiovascular surgery. The purpose of this study was to determine the incidence of such complications. METHODS: Patients with CAs who underwent cardiovascular surgery were identified, and their records were reviewed for intraoperative complications attributable to CAs. RESULTS: Over 14.5 years, of the 47,373 patients who underwent cardiovascular surgery, 99 had CAs before or within 30 days after surgery. Ninety-seven patients had hypothermic surgery, and intraoperative agglutination was noted in four; two of these cases were never reported to the transfusion service. CONCLUSIONS: The incidence of intraoperative complications among our patients with CAs was only 4%; therefore, the use of special testing protocols for the preoperative identification of CAs is neither necessary nor justified. Patient risk is best managed by preoperative clinical evaluation for potentially pathogenic CAs and intraoperative vigilance for agglutination.

How do we use molecular red blood cell antigen typing to supplement pretransfusion testing?

The molecular basis of many blood group antigens is known, and it provides a means for predicting the red blood cell phenotype. Molecular typing methods are useful when serologic typing cannot be performed, due to sample or reagent limitations. We discuss the implementation of a commercial molecular typing assay at our Transfusion Service, the indications for testing, and the advantages and drawbacks of the assay. We also present our algorithm for selecting candidates for testing.

Red blood cell storage: how long is too long?

Red blood cells (RBCs) undergo biochemical and structural changes during storage, commonly referred to as the "storage lesion." Evidence suggests that the longer the RBC product is stored, the less effective is the transfused blood. Many studies linking morbidity to transfusion have not considered duration of RBC storage as a variable that may modulate the effect. In addition, the effects of supply and demand and RBC inventory management strategies have been incompletely investigated. It is possible to envision a blood management system based on modern inventory management strategies that could greatly reduce storage duration.

Erythrocyte storage duration is not associated with increased mortality in noncardiac surgical patients: a retrospective analysis of 6,994 patients.

BACKGROUND: More than 5 million patients receive erythrocyte transfusions in the United States every year. Previous studies linked the storage duration of allogeneic erythrocytes to the risk of severe postoperative complications, especially after cardiac or trauma surgery. Limited data are available for noncardiac surgical patients. We therefore evaluated the association between storage duration of transfused erythrocytes and postoperative all-cause mortality among general surgery patients. METHODS: Perioperative data corresponding to 63,319 adult, general surgery patients were obtained from our registry and merged with blood product data. Patients receiving solely leukocyte-reduced, allogeneic erythrocyte transfusions were included. Multivariable Cox proportional hazards regression was used to characterize the relationship between median erythrocyte storage duration and postoperative mortality rate, adjusting for characteristics plausibly influencing the storage duration of erythrocytes. RESULTS: Of the 6,994 patients included in the final analysis, 23, 44, 11, 9, and 13% received 1, 2, 3, 4, and ≥5 erythrocyte units, respectively. The authors found no evidence that increasing median storage duration was associated with a difference in the risk of postoperative mortality (hazard ratio, 0.99 [0.94-1.04]; P = 0.64). Analyzing the mean storage duration of erythrocyte units as a function of year of transfusion, the authors demonstrate a relevant decrease in utilization of the oldest blood units, whereas young blood storage duration remains nearly unchanged. CONCLUSION: The authors' study supports the recent literature in surgical and medical patients and underlines the importance of sufficiently powered randomized trials to finally resolve the erythrocyte storage duration debate.

An evolution in blood management: past, present, and future.

Blood management is a concept that adopts a principle of improving patient outcome by integrating all available techniques to ensure safety, availability, and appropriate allocation of blood products. This constitutes a model of multidisciplinary care where the changes in culture are system directed on the basis of evidence-based medicine. There are about 14% US hospitals where any kind of blood management program exists, although the idea remains the same but the programs vary in their execution, implementation, and ultimately providing the value to patients. In this article, we have described our experience of creating a patient-centric, cost-effective, evidence-based, and multipronged program creation with scalable results. The use of data, education, process improvement, engagement, and accountability of caregivers have resulted in sustained results and helped in creating a comprehensive blood management program.

Retrospective targeted HCV lookback using centralized contracted notification service.

BACKGROUND: Mandated HCV 2.0 lookback significantly challenged the human and financial resources available to the six Los Angeles County Department of Health Services (DHS) hospital blood banks. To comply with FDA requirements, DHS developed a centralized process that utilized the services of a contract vendor for performing HCV lookback. STUDY DESIGN AND METHOD: A DHS public health nurse acted as HCV lookback coordinator and as liaison with the vendor. Cases were electronically forwarded to the vendor, who then reviewed the patient's chart to obtain information necessary for tracking the patient through commercial databases. The vendor was responsible for notifying the recipient for pretest counseling and for providing documentation of all efforts. RESULTS: In total, 411 recipients were identified, of which, 168 cases were completed by the hospitals, 243 were forwarded to the vendor, 50 percent were deceased, 21 percent were contacted, and 28 percent could not be contacted, and 1 percent could not be located on any databases. The vendor contacted 35 of 66 cases that the hospitals had unsuccessfully attempted to contact. Of the cases forwarded to the vendor, 82 percent were completed on time. Delays were attributable to the vendor in less than 2 percent of cases. The cost per case forwarded to the vendor was 322 US dollars. CONCLUSION: Utilizing a professional service to conduct HCV recipient notifications is an effective strategy for meeting FDA deadlines and for freeing transfusion service staff to perform critical functions. It remains to be seen whether such strategies offer a cost savings.