Is It Time to Switch from Conventional Coombs Crossmatching to the Type and Screen Protocol?

Background: ABO grouping, Rh typing and crossmatching are routinely done as part of pre-transfusion testing. The Type and Screen (T&S) protocol has been used in developed countries to ensure the survival of transfused red cells. In this study, we compared the safety, costs and turnaround times (TATs) of the T&S protocol and the conventional pre-transfusion testing protocol for patients who had been scheduled for elective obstetrical or gynaecological procedures. Methods: This observational study was conducted in three phases at the Department of Transfusion Medicine, Jubilee Mission Medical College and Research Institute, Kerala, India and involved 1,800 patients from the Department of Obstetrics and Gynaecology, Jubilee Mission Medical College & Research Institute, Kerala, India over the course of 2 years. Phase I involved the traditional pre-transfusion testing and crossmatching of 150 patients. Phase II involved the use of the T&S protocol on 150 patients. Phase III involved the use of both the traditional and T&S protocols on 1,500 patients without considering the results of each protocol. The safety, costs and TATs of both protocols were compared. Results: In this study, the T&S protocol provided a safety 100% level when compared to the traditional protocol. The T&S protocol detected unexpected antibodies in 0.4% of cases, which would have gone unnoticed otherwise, demonstrating its usefulness. There was no significant difference in cost between the traditional crossmatching and T&S protocols. We discovered that using only the T&S protocol can save technologists 30% of their time. Conclusion: Implementing the T&S protocol as a pre-transfusion testing procedure can help improve hospital transfusion practices by supplying blood quickly and safely. Coombs crossmatching remains more of a tradition than a necessity.

Factor assay in victims of snake bite: Experience from a tertiary care institute in South India.

INTRODUCTION: Snake bites tend to cause a high mortality in those who develop coagulopathy. However, there is very limited literature on clotting factor assays in these patients, especially in the presence of clinical bleeding. The aim was to assess the coagulation profile and individual coagulation factors in patients with hematotoxic snake bites. MATERIALS AND METHODS: This was a prospective observational study of clotting factor levels in victims of snake bites with hematotoxicity admitted to a single hospital in south India for 12 months. In 43 individuals who fulfilled the criteria, we measured platelet count, prothrombin time (PT), international normalized ratio, activated partial thromboplastin time (aPTT), fibrinogen levels, coagulation factors V, VII, VIII, IX, and X, and the qualitative factor XIII assay. RESULTS: Forty-three patients fulfilled the criteria and their samples were studied. There were 36 Russell's viper (Daboia russelli), 4 Hump-nosed pit viper (Hypnale hypnale), and 3 unknown snake bite victims samples, in which factor assays were done. All the Russell viper bite victims without a recordable clotting screen had deficiency of Factor V (0.5%-49.62%, Mean - 20.27%), Factor X (0.08%-92.3%, Mean - 70.73%), and qualitative factor XIII. Pit viper patients showed normal levels of Factor I, V, VII, VIII, IX, X, and XIII despite prolonged PT and aPTT. CONCLUSIONS: Early detection and treatment of envenomation remains the cornerstone of managing snake venom-induced consumptive coagulopathy. Anti-snake venom plays a major role in the reversal of coagulopathy. Blood and blood products would be useful when coagulopathy does not revert by ASV alone. Evidence-based transfusion can be implemented and cryoprecipitate may be used as many of the patients had factor XIII and fibrinogen deficiency as part of venom-induced coagulopathy. To improve patient management and thereby the outcome of patients CMEs and training programs for the treating physicians also has to be implemented so that guidelines are formulated and followed.

Evaluation of process excellence tools in improving donor flow management in a tertiary care hospital in South India.

BACKGROUND: Process Excellence is a value based approach and focuses on standardizing work processes by eliminating the non-value added processes, identify process improving methodologies and maximize capacity and expertise of the staff. AIM AND OBJECTIVES: To Evaluate the utility of Process Excellence Tools in improving Donor Flow Management in a Tertiary care Hospital by studying the current state of donor movement within the blood bank and providing recommendations for eliminating the wait times and to improve the process and workflow. MATERIALS AND METHODS: The work was done in two phases; The First Phase comprised of on-site observations with the help of an expert trained in Process Excellence Methodology who observed and documented various aspects of donor flow, donor turn around time, total staff details and operator process flow. The Second Phase comprised of constitution of a Team to analyse the data collected. The analyzed data along with the recommendations were presented before an expert hospital committee and the management. RESULTS: Our analysis put forward our strengths and identified potential problems. Donor wait time was reduced by 50% after lean due to better donor management with reorganization of the infrastructure of the donor area. Receptionist tracking showed that 62% of the total time the staff wastes in walking and 22% in other non-value added activities. Defining Duties for each staff reduced the time spent by them in non-value added activities. Implementation of the token system, generation of unique identification code for donors and bar code labeling of the tubes and bags are among the other recommendations. CONCLUSION: Process Excellence is not a programme; it's a culture that transforms an organization and improves its Quality and Efficiency through new attitudes, elimination of wastes and reduction in costs.

Rapid dry plasma thawing system: An alternative to conventional thawing baths.

BACKGROUND: Fresh frozen plasma (FFP) should be thawed before transfusing to the patient. Prolonged or uncontrolled thawing can denature plasma proteins. The potential risk of contamination by wet thawing had always been a point of concern. AIMS: Here, we compared and evaluated the effect of thawing on clotting factor activities by two different methods (wet and dry) and other factors such as risk of bacterial contamination, throughput, turnaround time, and efficacy of thawing. SUBJECTS AND METHODS: All FFPs were prepared from Group O donors and stored at -40°C. Twenty-one FFPs were thawed in Plasmatherm II at 45°C for 15 min and another 21 were thawed in thawing bath at 37°C for 20-30 min randomly. Analysis of prothrombin time, activated partial thromboplastin time, fibrinogen, and factor VIII was done in ACL TOP 300 (IL) at the time of preparation and immediately after thawing of FFPs. Volume, duration of thawing, ease of use, accessibility, and equipment maintenance were also compared. RESULTS: There was a statistically significant difference in coagulation parameters after thawing in both methods compared to the time of preparation (P < 0.05), but all values were within normal limits. There was no significant difference in coagulation parameters between the two methods (P > 0.05). Mixed bacterial growth was observed from swabs taken from the water bath. CONCLUSION: Plasmatherm II can be a good alternative to water bath to rapidly thaw FFPs by preserving coagulation factors and eliminating the risk of bacterial contamination.

Perioperative normovolemic hemodilution in a case of leiomyomatous erythrocytosis.

A 66-year-old female patient presented with complaints of abdominal discomfort, pigmentation and numbness of both lower limbs for 3 years duration. On examination, she had erythema of the face and palms. Investigations revealed high hemoglobin (Hb), hematocrit (Hct) and erythropoietin. Ultrasonography abdomen showed large uterine fibroid. As there are increased tendencies of thromboembolic episodes in patients undergoing surgeries with such high Hb and Hct, a target to achieve a Hb of 15g/dl and Hct of 45 was set in the patient. Repeated phlebotomies were done over 10 days with oral hydration only and the Hb was brought down to 18 g/dl on the day prior to surgery. On the day of surgery, pre-operative phlebotomy was done so as to remove 2 units of 350 ml blood and was transfused intraoperatively to combat blood loss. Post-operatively Hb was 12.4 g %. Patient was discharged on the 10(th) post-operative day with further follow-up evaluations being uneventful.