Remodelling whole blood processing through automation and pathogen reduction technology at the Luxembourg Red Cross.

In 2014-2015, the Luxembourg Red Cross (LRC) implemented a fully automated system (FAS) able to process 4 whole blood units simultaneously, and a pathogen reduction technology (PRT) based on riboflavin and ultraviolet light to improve safety of platelet concentrates (PCs). In this observational study, the impact of both technologies to enable this centralised blood transfusion centre to provide safe and timely blood components supply for the whole country was analysed. Standard quality control parameters for blood components, productivity and safety were compared from data collected with the conventional semi- automated buffy coat method and with FAS/PRT. The FAS decreased processing time when compared with the buffy coat method and facilitated the daily routine at the LRC. Red blood cell concentrates, plasma units and PCs prepared with both methods were conform to the European Directorate for the Quality of Medicines & HealthCare specifications. PCs prepared by FAS showed high yields, with decreased variability when the device-related software (T-Pool Select) was used. PRT had minimal impact on platelet yields and product quality and induced no increase in transfusion reaction notifications. The FAS and PRT transformed the daily routine of blood component manufacture by allowing increased productivity and efficiency, notwithstanding resource containment and without impacting quality, yet promoting safety.

Adopting a vein assessment tool improves procedural outcomes in double dose platelet collections - A prospective study.

BACKGROUND: This study aims to determine the phlebotomy and procedural outcomes using a vein assessment tool (VAT) in Double Dose Platelet (DDP) collections by apheresis. METHODS: VAT was based on assessing vein visibility, palpation and size with maximum score of 12 and the least being 0 and the scores were graded as adequate and inadequate. A vein-viewer was used for studying cubital vein patterns (type 1-5). Phlebotomy outcome was defined based on need for re-puncture. Procedural outcomes in terms of target yield attained and RBC reinfusion completed. Chi square test and Mann- Whitney U test were used to assess the vein score and pattern against phlebotomy and procedural outcome. RESULTS: Out of 200 DDP collections, the phlebotomy was successful in 88 % with good procedural outcome in 94 % donations. The cut off in VAT scores for successful phlebotomy was ≥8 (AUC: 70 %). Median vein scores of the arm selected for phlebotomy was 9 and graded adequate in 154 (77 %) donations.Odds for successful phlebotomy was 3.7 times higher when donors had an adequate VAT grades(p = 0.003). Procedural outcomes was favourable when at least one arm had adequate VAT grade when compared to both arms being inadequate (98 % vs 82 %; p < 0.001). Phlebotomy failure was more with first time apheresis donors than repeat apheresis donors (p = 0.014). CONCLUSION: This study indicated that a VAT score with a cut off of ≥8 had better phlebotomy and procedural outcomes in DDP collections and that donor with at least one arm having the VAT score of ≥8 are preferred for DDP collections.

Blood derived products in pediatrics: New laboratory tools for optimizing potency assignment and reducing side effects.

Neonates and children can develop rare bleeding disorders due to congenital/acquired coagulation Factor deficiencies, or allo-immune/autoimmune complications, or can undergo surgeries at high haemorrhagic risk. They then need specialized transfusion of blood components/products, or purified blood extracted products or recombinant proteins. Blood-derived therapies conventionally used for management of affected infants with genetic/acquired deficiencies, bleeding problems (coagulation Factor reduced or missing) or thrombotic disorders (reduced or missing anticoagulant proteins) pose some additional risks. These remedial therapies can cause tolerance when used very early in life and, sometimes needed, repeatedly. The introduction of recombinant proteins has allowed manufacturers to produce large amounts of the proteins usually present at very low concentration in blood. This has also changed the risk pattern of plasma-extracted products, especially in terms of continual reduction of viral transmission. Many efforts have been made over these past decades to reduce the risks associated with the use of all these products in terms of viral and bacterial safety, as well as immune disorders but they are not the objective of this article. Other associated side effects are the presence of undesired activities in blood products, which can produce thrombotic events or adverse reactions. The progressive introduction of blood derived products has greatly improved the prognosis and quality of life of affected patients. This concerns whole blood, but also blood cell concentrates, mainly platelets and red blood cells, plasma, while the blood extracted products are increasingly replaced by recombinant proteins. All these therapeutic products, i.e. blood extracted drugs, improve health and quality of life for hemophiliac's A or B, or patients with auto/allo-immune thrombocytopenias or with rare bleeding disorders, and those with thrombotic events occurring in childhood, which are mainly due to Protein C or Protein S deficiencies (congenital or acquired). Progress in analytical methods and biotechnology allow better control of the manufacturing processes for all blood derived or plasma extracted products and recombinant proteins, and contribute to improved manufacturing processes to minimize the occurrence of side effects. These adverse events can be due to the aging of the blood cell concentrate with release of their granule content, and generation of EVs, which can produce anaphylactic reactions and risk of thrombosis, but also to the presence of activated coagulation Factors in purified products, such as Factor Xia as recently identified in immunoglobulin concentrates. Characterization and measurement of contaminant products is of special usefulness during product preparation and for optimization of manufacturing processes for purified extracted products, but also for recombinant proteins. The pharmaceutical industry introduces these new methods for validating manufacturing processes, or for quality control assessments. The objective is first to warrant the full quality and safety of the lots produced, and assure the highest efficacy with the lowest risks when used in patients. For cell concentrates and fresh blood, storage conditions are critical and measurement of analytes such as EVs or Annexin V allows evaluation of quality of each individual transfused pouch. In addition to all the rules around viral and bacterial transmission risk, and immune tolerance, our available laboratory methods contribute to reducing the side effects of blood cell concentrates and derived plasma products, as well as those of the therapeutic recombinant proteins.

Indicaciones, eficacia y complicaciones en el uso de productos sanguíneos, Hospital General San felipe, Honduras / Indications, efficacy and complications of blood products, Hospital General San Felipe, Honduras

Los hemoderivados son productos valiosos cuya utilización puede salvar vidas, pero pueden dañar aquien los recibe. El país no dispone de información publicada sobre la utilización de productossanguíneos a nivel hospitalario, sus indicaciones, eficacia y complicaciones. Objetivo: Determinar las indicaciones, eficacia y complicaciones en el usode productos sanguíneos en el Hospital General San Felipe. Material y Métodos: se realizó un estudio descriptivo de tipo transversal en 166 pacientes mayores de 18 años, hospitalizados, que precisaban productos sanguíneos en el periodo comprendido entre el 18 de marzo 2013 al 4 de marzo 2014. Parala recolección de datos se utilizó un cuestionario con preguntas abierta y cerradas; la información para el análisis se extrajo de las boletas de requisiciónde productos sanguíneos recibidas en el Banco de Sangre, del expediente clínico y del instrumento de trabajo. Los pacientes fueron evaluados antes,durante y después de la transfusión. Resultados: 166 pacientes fueron transfundidos, 107(64.5%) mujeres y 59(35.5%) hombres. 138(83.1%) pacientes adolecían alguna enfermedad neoplásica. De 174 transfusionesrealizadas, los productos indicados fueron 154(88.5%) glóbulos rojos empacados, 8(4.8%) plaquetas y 6(3.4%) plasma. 104(62.6%) de los 166 pacientes transfundidos refirieron mejoría subjetiva, 26(15.7%)mejoraron su rendimiento físico, medido por la escala del Eastern Collaborative Oncology Group. Se encontró diversas complicaciones clínicas en 87(57.6%) de pacientes transfundidos con glóbulosrojos empacados. Conclusión: Más del 60% de los pacientes transfundidos experimentaron una sensación de bienestar, sin embargo la frecuencia decomplicaciones es considerable...(AU)

Segments from red blood cell units should not be used for quality testing.

BACKGROUND: Nondestructive testing of blood components could permit in-process quality control and reduce discards. Tubing segments, generated during red blood cell (RBC) component production, were tested to determine their suitability as a sample source for quality testing. STUDY DESIGN AND METHODS: Leukoreduced RBC components were produced from whole blood (WB) by two different methods: WB filtration and buffy coat (BC). Components and their corresponding segments were tested on Days 5 and 42 of hypothermic storage (HS) for spun hematocrit (Hct), hemoglobin (Hb) content, percentage hemolysis, hematologic indices, and adenosine triphosphate concentration to determine whether segment quality represents unit quality. RESULTS: Segment samples overestimated hemolysis on Days 5 and 42 of HS in both BC- and WB filtration-produced RBCs (p < 0.001 for all). Hct and Hb levels in the segments were also significantly different from the units at both time points for both production methods (p < 0.001 for all). Indeed, for all variables tested different results were obtained from segment and unit samples, and these differences were not consistent across production methods. CONCLUSION: The quality of samples from tubing segments is not representative of the quality of the corresponding RBC unit. Segments are not suitable surrogates with which to assess RBC quality.

Ensuring that blood transfusion sets administer an effective dose of functional blood components.

BACKGROUND: Proposed changes to ISO 1135-4 will require that blood transfusion administration sets are demonstrated by the manufacturers to be suitable for the range of cellular and plasma blood components for which they are designated. AIMS: To design a test protocol to asses the depletion of the blood components by transfusion sets and damage and activation of blood components during their passage through the set. METHODS: Transfusion giving sets (CareFusion Ref no. 60895 180311 and Fresenius Ref no. 2900032) were assessed by comparing samples of the blood component taken prior to and after passage through the transfusion set in strict accordance with the manufacturer's instructions. As well as depletion of red cells, platelets and FVIIIc, the following markers of damage/activation were assessed: red cells-supernatant haemolysis and potassium; FFP-prothrombin fragments 1 and 2 and fibrinopeptide A and platelets-pH, CD62P, CD63 and sP-selectin. RESULTS: The CareFusion and the Fresenius transfusion sets gave less than 5% depletion of blood components and caused negligible and clinically insignificant effects on red cells, platelet concentrates and FFP. CONCLUSION: A practical test protocol has been established to assess the depletion, damage to and activation of the key constituents of commonly requested blood components. This protocol would provide a valuable addition to ISO 1135-4 in assuring the suitability of transfusion sets.

The donor line break cannula: effect on the donation process, blood component quality and transfusion microbiology testing of an important new blood bag safety feature.

BACKGROUND: The use of blood packs with an integral sampling system can result in anti-coagulant from the main bag reaching the sample pouch via the donor line, causing delayed coagulation of blood samples. In NHS Blood and Transplant, this has prevented the use of serum, the preferred matrix for transfusion microbiology (TM) testing, which has led to an increased false positive rate with ethylenediaminetetraacetic acid (EDTA) plasma. There is also a remote possibility of false negative results owing to sample dilution. Manufacturers have responded by offering packs with a donor line break cannula (DLBC) to prevent these adverse effects. OBJECTIVES: The aims of this study were to assess the impact of DLBC packs on donation, blood component quality and of the potential return to serum for TM testing. METHODS: DLBC packs from three manufacturers were assessed against control packs of the same dimensions and configuration. Donation duration, flow rate, platelet factor 4, prothrombin fragment 1+2, haemolysis and collection and processing incidents were compared. RESULTS: Results indicated no clinically significant adverse effect from the DLBC on the activation state of platelets, the coagulation cascade or increased haemolysis. Donation duration and blood collection and processing incident rates for DLBC packs were not significantly different to controls. CONCLUSIONS: The use of DLBC packs would reduce the complexity of manipulations during blood collection and therefore the likelihood of microbially contaminated donations (incorrect skin core diversion) and false negative TM tests. DLBC packs would enable the use of serum for TM testing with a significant reduction in false positive tests compared to EDTA plasma.

Linear accelerator: a reproducible, efficacious and cost effective alternative for blood irradiation.

BACKGROUND: The dedicated devices for blood irradiation are available only at a few centers in developing countries thus the irradiation remains a service with limited availability due to prohibitive cost. OBJECTIVE: To implement a blood irradiation program at our center using linear accelerator. MATERIALS AND METHODS: The study is performed detailing the specific operational and quality assurance measures employed in providing a blood component-irradiation service at tertiary care hospital. X-rays generated from linear accelerator were used to irradiate the blood components. To facilitate and standardize the blood component irradiation, a blood irradiator box was designed and fabricated in acrylic. Using Elekta Precise Linear Accelerator, a dose of 25 Gy was delivered at the centre of the irradiation box. Standardization was done using five units of blood obtained from healthy voluntary blood donors. Each unit was divided to two parts. One aliquot was subjected to irradiation. Biochemical and hematological parameters were analyzed on various days of storage. Cost incurred was analyzed. RESULTS: Progressive increase in plasma hemoglobin, potassium and lactate dehydrogenase was noted in the irradiated units but all the parameters were within the acceptable range indicating the suitability of the product for transfusion. The irradiation process was completed in less than 30 min. Validation of the radiation dose done using TLD showed less than ± 3% variation. CONCLUSION: This study shows that that the blood component irradiation is within the scope of most of the hospitals in developing countries even in the absence of dedicated blood irradiators at affordable cost.

An evaluation of statistical process control techniques applied to blood component quality monitoring with particular reference to CUSUM.

BACKGROUND: Statistical process control (SPC) is used to monitor the performance of blood component collection and production processes in the UK and elsewhere. The sensitivity of the applied technique(s) needs to be matched to the clinical importance of the parameter being monitored such that significant deviations in the process mean and/or variability of critical parameters (e.g. the leucocyte content of leucodepleted components) are detected and investigated immediately. AIMS: This study assessed the sensitivity and specificity of a range of techniques for variable and attribute (proportion non-conforming) data. MATERIALS AND METHODS: Comparison was based on a range of simulated and 'live' blood component quality monitoring data including X/R, cumulative sum (CUSUM) procedures, the scan statistic and np charts. RESULTS: X/R and CUSUM could detect shifts of two standard deviations in the process mean within 5 days. Current leucocyte count data (substantially skewed even after log transformation) was found to be better suited to attribute analysis. CUSUM alone was able to detect shifts on the same day when based on 20 or more samples and achieved acceptable specificity. CONCLUSIONS: CUSUM procedures for proportion non-conforming can usefully augment existing X/R techniques for leucodepletion monitoring, provide valid control limits and the required sensitivity. The scan statistic and 'np' charts offered no obvious advantages.

Eurobloodpack: a common European design for blood bag systems with integral leucodepletion filters.

Three EBA specified blood bag configurations ('Eurobloodpack') are described which are capable of meeting >80% of its member's requirements. These include a 'top-and-top' and two 'bottom-and-top' packs enabling aseptic, pre-donation collection of up to 40 ml of samples, 427.5-522.5 ml of whole blood and the preparation of an extensive range of blood components. Features currently beyond the scope of ISO standardisation have been controlled including: anticoagulant and additive volumes; collection needle and sampling system; transfer tubing; cross-match line; base label; leucodepletion filter performance; compatibility of access ports and transfusion sets. Eurobloodpack has significant advantages for blood services and blood bag manufacturers.

Evaluating the 'next generation' of cell salvage--will it make a difference?

INTRODUCTION: Donor blood supplies are diminishing, becoming more costly and these transfusions lead to higher mortality in cardiac patients. The transfusion risks and the literature highlight the need for an alternative similar to cell salvage to be routinely considered. The Xtra is the first cell saver to be launched since 2001 and will undoubtedly initiate evolution towards the 'next generation' of cell savers. It is also the first to be launched in a new era where the demand for electronic perfusion data management (EPDM) has grown. RESULTS: The user interface (UI) was easy to use. The increased data entry options improved the quality of the recordable data. The integrated data management system (DMS) was comprehensive. Data was easy to manage and enabled central data compilation, which reduces repeated data, the risk of inconsistent data inventory and provides the potential for research and analyses. The haematocrit of the processed blood is a key quality indicator for cell salvage. The comparison of the manufacturer's integrated protocol, Popt, to our team's own protocol showed that Popt delivered a higher haematocrit on its '1st bowl' (59.1% compared to 57.3%) and its 'total process' end product haematocrit was 0.68% higher. The Popt cycle took an average of 330s, whereas our own settings completed in just over 300s. CONCLUSION: The Xtra is a device which will lead the evolution of 'next generation' cell saver technology. The user interface and data management system provide export options and the ability to record the level of data required for good EPDM. This is essential to 'future proof' cell salvage technology. The manufacturer's integrated protocol achieved a higher end product haematocrit than our perfusion team's best practice. The design of the Xtra is contemporary, but the DMS equips this cell saver for the new era that faces both Perfusion and Cardiac Surgery.

Toxicity testing of a novel riboflavin-based technology for pathogen reduction and white blood cell inactivation.

The Mirasol PRT System (Gambro BCT, Lakewood, CO) for platelets and plasma uses riboflavin and UV light to reduce pathogens and inactivate white blood cells in donated blood products. An extensive toxicology program, developed in accordance with International Organisation for Standardisation (ISO) 10993 guidelines, was performed for the Mirasol PRT system. Test and control articles for most of the reported studies were treated (test) or untreated (control) blood products. For some studies, pure lumichrome (the major photoproduct of riboflavin) or photolyzed riboflavin solution was used. Systemic toxicity was evaluated with in vivo animal studies in the acute and subchronic settings. Developmental toxicity was evaluated with an in vivo animal study. Genotoxicity and neoantigenicity were evaluated with in vitro and in vivo tests. Hemocompatibility and cytotoxicity were assessed with standard, in vitro assays. The pharmacokinteics, excretion, and tissue distribution of (14)C-riboflavin and its photoproducts was evaluated with an in vivo animal study. The possible presence of leachable or extractable compounds (from the disposable set) was evaluated with novel assays for measuring these compounds in blood. No treatment-related toxicity was observed in any of the studies.

Use of a (proposed) standard protocol to validate Terumo TSCD-II connections between dissimilar blood bag tubing.

BACKGROUND AND OBJECTIVES: ISO standards for blood bags do not adequately define and control the dimensions of blood bag transfer tubing. This lack of standardization presents potential difficulties when making sterile connections between the wide range of tubing that has evolved in the absence of such standards. We aim to validate the suitability of the TSCD-II and provide a minimum standard for assessing the suitability of sterile connections (welds) between dissimilar tubing. MATERIALS AND METHODS: The Terumo TSCD-II was used in this study to connect by hermetic welding seven tubing types with a wide range of dimensions from five suppliers. Thirty sterile connections were made between each combination split between dry/dry, wet/wet and dry/wet connections. Welds were assessed for visual defects, by tensile stress test (TST) and pressure tests. RESULTS: All welds passed visual inspection and pressure tests. All welds had a minimum tensile strength of greater than 40 N and mean of greater than 45 N. CONCLUSION: Successful connections have been made between dissimilar tube types and this work does not support the requirement for 'tight' tubing dimensional specifications. We have recommended to the ISO Technical Committee 76 Work Group 1 that ISO 3826-1 be revised and should include a minimum standard validation protocol for joining dissimilar tubing.

The use of a World Health Organization Transfusion Basic Information Sheet to evaluate transfusion practice in Croatia.

BACKGROUND AND OBJECTIVES: To assess the feasibility of using the World Health Organization (WHO) Transfusion Basic Information Sheet as a bedside tool for data collection and assessing transfusion practice. MATERIALS AND METHODS: A prospective 6-month audit of all transfusion episodes using the tool. RESULTS: Eight hundred and twenty-two forms were completed, capturing data on 59.7% of transfusion episodes. Completion of data fields was > 80%, except for the clinician's transfusion targets that were documented in only 58.5% of cases. Twenty per cent of patients received single red cell unit transfusions. CONCLUSIONS: The Basic Information Sheet can be incorporated into bedside clinical practice. We have identified the need to encourage clinicians to determine and document their transfusion targets before prescribing blood components.

Contamination control in nursing with filtration: part 2: emerging rationale for bedside (final) filtration of prestorage leukocyte-reduced blood products.

The first part of this 2-part series focused on the manufacture of filters and the application of filtration technology to intravenous fluids and point-of-care hospital water. This second part describes an apparent emerging potential for final filtration defined as bedside filtration of blood and component blood products leukocyte-reduced at the blood center prior to storage. Final filtration serves to further reduce the leukocyte burden in a previously leukocyte-reduced blood product. Another target for final filtration includes putative soluble mediators of morbidity.Selected patients may be at greater risk for alloimmunization and refractory to the benefits afforded by transfusion of blood leukocyte reduced to the current established standards. Multiparous patients who subsequently find themselves in need of a transplanted organ are alloimmunized by exposure to fetal proteins and may be further alloimmunized by transfusion. Such effects can put them at risk for increased latency for donor organ availability and organ rejection. Kidney transplant patients find themselves the recipients of transfused blood products particularly during end-stage renal disease and recent data suggest such patients are not benefited by the levels of leukoreduction prescribed by current standards and may need more dramatic leukocyte removal. The process of blood production is described and affords a greater appreciation for the levels of white cells found in component blood products. The development of alloimmunization is reviewed and fosters greater appreciation for a discussion of the potential for therapeutic value of more dramatic leukocyte reduction and blood conditioning accomplished through the removal of soluble mediators of morbidity.

Protein composition and activation markers in plasma collected by three apheresis procedures.

BACKGROUND: Scientific and technical advances made in transfusion medicine sustain the need for more comprehensive understanding of the impact of collection procedures on the quality of plasma for fractionation and for transfusion. This prospective work evaluated protein composition and markers of activation in plasma donations collected with three different automatic collection procedures (performed on Haemonetics machines), including a new procedure using a high-separation core-molded bowl. STUDY DESIGN AND METHODS: A total of 90 collection procedures have been performed from a population of 37 donors, under comprehensively standardized conditions. Plasma aliquots were taken from the plasma units within 30 minutes of the end of the collection procedures and immediately frozen at -70 degrees C. Content in an extended range of proteins and of markers of activation of the coagulation and fibrinolytic systems has been measured using standard in vitro testing methods. RESULTS: Plasma donations had normal mean total protein, IgG, IgM, and fibrinogen content. The mean levels in coagulation FV, FVII, FVIII, and FXI and in antithrombin were above the standard international requirements. There was no sign of activation of the hemostasis system, as assessed by activated FVII, thrombin antithrombin complex, Prothrombin fragment 1+2, and D-dimers. Activated complement component C3 and C5 were low. CONCLUSION: Data indicates the good and consistent protein composition of plasma obtained by those automatic apheresis procedures. In particular, the new high-separation core procedure yields a high-quality plasma meeting requirements for transfusion and fractionation.