Immunohematological testing and transfusion management of the prenatal patient.

The primary indication for immunohematological testing in the prenatal patient is to detect and identify maternal red cell antibodies. If there are antibodies that are expected to hemolyze the fetus' red cells, their strength of reactivity must be tested, and the fetus' antigen status determined. After delivery, testing is performed to assess the extent of fetomaternal hemorrhage, as a large hemorrhage may require other therapeutic interventions. Another major role for immunohematological testing is to select blood components appropriately when intrauterine transfusion is required for fetal anemia resulting from maternal alloimmunization or some other cause. Supplementation with molecular methods has transformed the practice of immunohematology, particularly as it applies to typing for the D antigen of the Rh blood group system. Notwithstanding the advances in testing, close coordination and communication between the transfusion service and the obstetrics service are the foundation for ensuring the finest care for prenatal patients, and for new mothers and their infants. This review describes testing and transfusion practices for prenatal patients, using case presentations to highlight the management of selected immunohematological findings. It also includes a discussion of key patient management topics that are currently unresolved.

Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit.

BACKGROUND: Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. OBJECTIVES: In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. METHODS: We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. RESULTS: In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (ß1 .8.26, 95% CI 4.09-12.43; p < 0.01). CONCLUSION: A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

Implementation of a Standardized Prenatal Testing Protocol in an Integrated, Multihospital Health System.

OBJECTIVES: When our institution grew into an integrated multihospital health system, we were faced with the need to standardize laboratory processes, including blood bank processes, across all locations. The purpose of this article is to describe our experience of standardizing the protocols for prenatal testing. METHODS: For each hospital in the system, we established service tiers to define tests offered on site or referred to another location. For each prenatal test, we examined the related processes for ways to improve uniformity, efficiency, and reliability. Throughout this process of standardization, we collaborated with the clinical services to gain concurrence on the interpretation and reporting of results. RESULTS: We created and implemented a uniform protocol for testing prenatal patients. The protocol standardized the definition of critical titer, instituted criteria to identify passively acquired anti-D, and established a process for the follow-up of women with inconsistent serologic results on Rh(D) typing. CONCLUSIONS: Close collaboration with the clinical services ensured that our testing protocol is aligned with the needs of the integrated obstetrics service in the health system. The approach described in this article may provide a plan outline for pathologists facing similar challenges at other integrated health systems.

Blood management during the COVID-19 pandemic.

The worldwide COVID-19 pandemic has required healthcare systems to implement strategies for effective healthcare delivery while managing blood supply chain disruptions and shortages created by infection-limiting practices that have reduced blood donations. At Cleveland Clinic, we have made multiple synchronous efforts: a call for increased blood collection, alignment of efforts among transfusion medicine departments (blood banks), enhanced monitoring and triage of blood product use, and increased education on patient blood management practices regarding blood utilization and anemia management. In addition, we created an algorithm to assess anemia risks in patients whose elective surgery was cancelled to optimize preoperative hemoglobin levels.

Convalescent plasma for COVID-19: Promising, not proven.

While promising, convalescent plasma remains experimental and is not proven effective for COVID-19. In addition, many questions remain regarding the accuracy and predictive value of antibody testing of donors and patients, optimal donor selection, optimal timing, and selection of patients most likely to benefit. Until these questions are answered, convalescent plasma should ideally be used in the context of well-designed clinical trials.

Heat elution: a modification of the Landsteiner-Miller method.

CONCLUSIONS: Elution removes antibodies coating red blood cells and allows for serologic testing of the recovered antibodies. Heat elution may be used in the investigation of ABO hemolytic disease of the fetus and newborn, in the detection of weak A and B antigens in combination with adsorption-elution using polyclonal antibodies, and for the resolution of interfering IgM agglutinating antibodies.

Clotting during autologous hematopoietic progenitor cells collection.

Autologous hematopoietic progenitor cell (HPC) transplant through peripheral blood mobilization and leukapheresis is a standard treatment for many patients with hematopoietic malignancies. Although leukapheresis is usually completed with no complications, we present a case in which the hematopoietic progenitor cells clotted during collection. The patient had no history of hypercoagulopathy. It was identified that the anticoagulant infusion line was partially constricted by a blood warmer clamp. The machine did not alarm. Most of the multiple Food and Drug Administration reports of clotting occurring during apheresis procedures were due to the patients' preexisting hypercoagulopathy or insufficient anticoagulant solution being used. The machine alarmed in most of these cases. Our case demonstrates that inadequate anticoagulation can occur during an HPC collection procedure without activation of an alarm.

Cocaine-induced microangiopathic hemolytic anemia mimicking idiopathic thrombotic thrombocytopenic purpura: a case report and review of the literature.

Our understanding of the pathogenesis of idiopathic thrombotic thrombocytopenic purpura (TTP) has increased, but remains incomplete, particularly with respect to cases of suspected TTP that are either unresponsive to therapeutic plasma exchange (TPE) or have normal ADAMTS13 (a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13) activity. A 53-year-old woman presented with severe anemia (hemoglobin 1.8 g/dL) and clinical and laboratory findings consistent with TTP in conjunction with acute cocaine use. The patient was treated with TPE until the pre-treatment ADAMTS13 activity was reported as normal without evidence of an inhibitor. TPE was stopped and the patient continued to improve without treatment. This patient's microangiopathic hemolytic anemia (MAHA) appeared to be secondary to cocaine use. The proposed pathogenesis is likely a combination of cocaine-induced vasoconstriction, vascular damage, platelet activation, and procoagulation. This is the fifth published report of cocaine-induced MAHA and to our knowledge the first with ADAMTS13 testing.