Transfusion-Related Acute Lung Injury In A Paediatric Intensive Care Unit Of Pakistan.

BACKGROUND: Transfusion-Related Acute Lung Injury (TRALI) is a major cause of transfusionrelated morbidity and mortality in the intensive care unit setting. There is a paucity of such data from Pakistan. The purpose of this study is to assess the incidence and outcome of TRALI in critically ill children admitted in a pediatric intensive care unit (PICU) of Pakistan. METHODS: This is a retrospective cohort study of all critically ill or injured children who developed TRALI or "possible" TRALI after blood transfusion based on Canadian Conference Consensus criteria in a closed multidisciplinary-cardiothoracic PICU from January 2012 to June 2016. The demographic, pertinent clinical data, transfusion-related variables and outcome of all cases of TRALI were recorded. RESULTS: Of total 2975 admissions in the PICU during study period, 35.8% (1066) received 5124 blood components. Eleven cases developed TRALI in our cohort. The incidence of TRALI was 1.03% per patient transfused and 0.19% (19/100,000 per blood product transfused). Median age was 8 (range 1-14) yr., 70 % (n=8) were male. Mean PRISM-III score was 16.3±6.7. Mean time interval for onset of TRALI was 2.73±1.67 hr. The postoperative cardiac surgical and hematology-oncology patients were most common categories (63.6%). Plasma and platelets were the most commomly identified trigger of TRALI. The case-specific mortality was 63.6% and the overall mortality was 10.7% (p<0.0001). CONCLUSIONS: The incidence of TRALI in critically ill children is low, but is associated with high mortality. Critically ill children with high PRISM-III score, postoperative cardiac surgical and hematology-oncology patients are often affected by TRALI.

Estimating window period blood donations for human immunodeficiency virus Type 1, hepatitis C virus, and hepatitis B virus by nucleic acid amplification testing in Southern Pakistan.

BACKGROUND: Recently, strategic planning was initiated by the National Blood Transfusion Services Pakistan to improve its blood bank facilities. Emphasis has been placed on appropriate screening of blood products. Located in the southern region, Aga Khan University Hospital is a 700-bed tertiary care academic institute with comprehensive blood banking. Screening of blood donors has been based on verbal screening and serologic testing to date. Additionally, the need of implementing nucleic acid testing (NAT) was considered in 2011 because of an upsurge in hepatitis epidemiology. The aim of this study was to analyze the efficacy of this additional donor screening program and to evaluate the impact of NAT on the yield and residual risk of transfusion-transmissible viral infections. STUDY DESIGN AND METHODS: A total of 42,830 blood donations collected between 2011 and 2012 were screened for routine serologic assays. Only serologically negative donors (n=41,304) were tested for NAT. The frequency of viral infections was evaluated through serologic techniques and NAT yield for viral agents was estimated for computing window period donors. Residual risk per million donors was computed for viral infections in seronegative blood donors. RESULTS: Serologic work-up showed 1571 abnormal screening results in 1526 blood donors with the following results: hepatitis C virus antibodies (anti-HCV; n=708), hepatitis B surface antigen (n=555), human immunodeficiency virus antibodies (anti-HIV; n=29), malaria (n=30), VDRL (n=249), and coinfection (n=45). Thirty-five NAT-reactive samples were identified: HIV-1, one; HCV, 27; and hepatitis B virus (HBV), seven. Incident rates per 10(5) donors were highest for HCV (453.3) followed by HBV (171.5) and HIV (72.2). Calculated residual risk per million donors was highest at 1 in 10,900 for HBV, intermediate at 1 in 13,900 for HCV, and least at 1 in 62,600 for HIV. CONCLUSION: Incidence rates and estimated residual risk indicate that the current risk of transfusion-transmitted viral infections attributable to blood donation is relatively high in this country. The study recommends the parallel use of both serology and NAT screening of donated blood in countries that have high seroprevalence of these viral infections.

Hyper-reactive malarial splenomegaly in the absence of raised IgM antibodies.

Hyper-reactive malarial splenomegaly (HMS) is diagnosed by the presence of massive splenomegaly, raised IgM and antimalarial antibodies and a response to antimalarial therapy. Although malaria is endemic to Pakistan, HMS is uncommon. We report on HMS in a patient with massive splenomegaly, positive Plasmodium falciparum polymerase chain reaction but normal immunoglobulin M antibody levels. The investigations were not consistent with any other diagnosis. HMS is also briefly reviewed.

Implementation of Maximum Surgical Blood Ordering Schedule and an Improvement in Transfusion Practices of Surgeons subsequent to Intervention.

Over ordering of blood is a common practice for elective surgeries in many developing countries. Over a decade back, our institution-The Aga Khan University, Pakistan noticed that surgeons were making unnecessary arrangement of red cells. This was reflected in their undesirably high cross-matched to transfusion (CT) ratios. A clinical audit conducted in 1998-2000 confirmed this. This prompted the institution for designing a maximum surgical blood ordering schedule (MSBOS) in 2000 based on the retrospective usage of blood in various elective surgeries. This study aimed at observing the impact of implementation of MSBOS on surgeons' transfusion practices by comparing pre and post intervention cross-matched to transfused ratio in selected elective surgeries. For this purpose, we conducted a clinical audit from 2009 to 2010 and data was retrieved for quantity of red cells units arranged and transfused in the peri-operative period. C:T ratio was computed and compared with those in 2000. Identification of patients and physicians were kept confidential. Baseline C:T ratios for C-section, TURP, total knee replacement, laparoscopic cholecystectomy and CABG were 32, 22, 11.42, 23 and 4.77 respectively. In 2009-2010, red cells were transfused in 86 of 1,224 C-sections (7 %), 599 of 727 CABG (82 %), 10 of 324 TURP (3 %),16 of 890 laparoscopic cholecystectomy (1.7 %) and 14 of 85 total knee replacement (16.4 %) The C:T ratio in these surgeries was between 0 and 1. Implementation of MSBOS and efforts of BUC showed a significant impact in transfusion practices of surgeons with marked reduction in the utilization of blood and the C:T ratio. We recommend that regular audits should be conducted in every institution to improve the quality of services, encourage team work and ensure high standards.