Irradiation eradication and pathogen reduction. Ceasing cesium irradiation of blood products.

The irradiation of cellular blood components to prevent transfusion-associated (TA)-GVHD is an established practice in the developed world. Susceptible patients include those who are immunosuppressed, fetuses, very premature neonates and patients who have an increased likelihood of possessing one HLA haplotype for which the blood component donor is homozygous. Problems and challenges associated with blood component irradiation include transfusion delay, cost, failure to irradiate when indicated, increased potassium accumulation in and decreased shelf life of RBC units, reduced RBC recovery and, in the United States, substantial and onerous security requirements for cesium-137 source irradiators and their operators. Microbial contamination of blood components can pose life-threatening risks for transfusion recipients. Donor history screening and infectious disease testing are a reactive response and expensive, as well as an imperfect and incomplete means for preventing these infectious risks. In response to these threats, pathogen reduction technologies have been developed. Two such innovations (INTERCEPT, Cerus Corporation, Concord, CA, USA; and Mirasol, CaridianBCT Biotechnologies, Lakewood, CO, USA) are approved for clinical use in many countries, though not in the United States. These processes have been shown to effectively prevent proliferation of nucleic acid-containing microbes, thereby providing broad protection against transfusion-transmitted infection. These technologies have also been shown to prevent the replication of WBC. In this report, we review the substantial in vitro, clinical trial and clinical practice observational evidence that non-irradiated INTERCEPT- and Mirasol-treated cellular blood components do not cause TA-GVHD. Implementation of these processes precludes the necessity for irradiating cellular blood components to prevent TA-GVHD.

Monitoring for underutilization of RBC components and platelets.

BACKGROUND: Monitoring blood transfusion for overutilization is standard practice at most institutions. STUDY DESIGN AND METHODS: This study monitored for underutilization of blood transfusion over a 14-month period, by evaluating patients who had Hb levels that were reported to be <5 g per dL or platelet counts <10 x 10(9) per L and who did not receive an RBC or platelet transfusion within 24 hours of the reported results. RESULTS: During the study period, 24,004 units of RBCs and 3,967 units of apheresis platelets were transfused. There were 148 patients who had a Hb level that was reported to be <5 g per dL or a platelet count reported to be <10 x 10(9) per L and who did not receive a transfusion during the 24 hours after the reporting of these results. In 5 cases, the patients died before the reporting of the low Hb or platelet counts, which precluded the low Hb or low platelet count reports from triggering transfusion therapy. In 8 cases, an underutilization review investigation could not be done, because of the unavailability of patient charts. Of the remaining 135 cases, investigation revealed justifiable reasons for withholding transfusion in 133. In 2 cases, the withholding of transfusion was deemed by peer review to be inappropriate, as the patients should have received a transfusion. Overall, there was one documented underutilization of RBC transfusion therapy during a period when 24,004 units were transfused and one underutilization of platelet transfusion therapy during a period when 3,967 units of apheresis platelets were transfused. CONCLUSION: Monitoring for underutilization of transfusion therapy fulfills the requirements of the Joint Commission on the Accreditation of Healthcare Organizations: While the underutilization of transfusion therapy did not appear to be a significant problem at this medical center, determining the reasons for withholding transfusions shed light on important patient care-related issues, including preexisting causes of falsely low platelet counts and Hb levels, delays in investigating critical laboratory values, and the need for policies for the treatment of patients who refuse transfusion for personal or religious reasons.