Mercy adopts new blood cell transfusion guidelines

SIOUX CITY | Mercy Medical Center -- Sioux City has stepped up efforts to conserve red blood cells.

All hospitals in the Trinity Health network have applied the new national recommendations developed by The Joint Commission and the American Medical Association -- convened Physician Consortium of Performance Improvement that advise adopting a "more restrictive" practice of red blood cell transfusion to produce better patient outcomes.

"We want to give just what is necessary, one unit at a time," said Dr. Gregg Galloway, a pathologist and vice chair of the Infectious Disease Committee at Mercy. "Give him a unit of blood. It will make him feel better -- that's the old paradigm. We don't believe it anymore."

Mercy has always had guidelines in place instructing staff when to give red blood cell transfusions, but Galloway said those rules have significantly changed and are "more restrictive" than they used to be.

"We're doing it because we do believe it is better quality patient care at all health care institutions and because of the cost of the resources," he said.

The new guidelines were released following a September 2012 national summit that convened representatives from 112 professional organizations and associations in effort to curb overuse of five medical treatments. Transfusion of red blood cells in hospitals was one of them.

A decade of studies, according to Galloway, found that when "more restrictive" red blood cell transfusion practices were used, hospitalized patients had lower mortality rates, fewer complications from infectious diseases, less breathing problems and cardiac events, as well as a reduced chance of developing acute respiratory distress syndrome -- a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood.

Galloway said hospital staff give patients red blood cell transfusions based on their hemoglobin (a protein in red blood cells that carries oxygen) and hermatocrit values (percentage of red blood cells found in whole blood). When their hemoglobin value dropped below 10 grams per deciliter (G/dL), the patients received a transfusion. The "more restrictive" guidelines, he said, don't recommend transfusion until hemoglobin values fall between 7 and 8 G/dL.

"Big difference. You're going to use less red cell and units in the hospital," he said. "We predict that overall we'll have a 15 to 20 percent drop over the next year and a half to two years in our red cells that we'll use in our hospital setting."

Once blood is collected at a donation center, it's processed, placed in a refrigerator and stored. Chemical changes, he said, occur in the hemoglobin, and red blood cells lose their malleability.

"Those red blood cells start to change," he said. "They are no longer like the normal red blood cells you and I have floating around in our body. Banked blood is a tissue transplant. Those are somebody else's red cells."

In addition to the new guidelines, Galloway said, improvements in surgical techniques that reduce the need for red blood cell transfusions in the operating room are also contributing to the downward trend.

Surgeons are encouraged to salvage patients' blood in the operating room, a practice that was once reserved for open heart surgery. Now it's being used in trauma, abdominal aneurism and orthopedic surgeries.

"We're trying to save the patient's own blood. We re-process it in the OR and we give it back to them," Galloway said. "We also have new hemostatic medications that we can give patients that keep them from bleeding as much in OR."

Large hospitals, he said, now have blood management programs that staff nurses who review a patient's clinical situation alongside the guidelines. Some patients seeking elective surgery, he said, may have to wait longer to get into the operating room if they lack enough healthy red blood cells.

EMMC program to reduce blood transfusions draws international interest

BANGOR, Maine — Eastern Maine Medical Center is hosting physicians and researchers from abroad this month who are interested in the hospital’s work to reduce unnecessary blood transfusions.

On Monday, a team from western Australia visited Bangor for a hands-on introduction to EMMC’s “patient blood management program,” which began in 2007 as an effort to cut down on avoidable blood transfusions. On Sept. 24, a team from Switzerland will visit the hospital to learn about the program.

EMMC has reduced the number of blood transfusions it performs by 60 percent since 2006, according to Dr. Irwin Gross, medical director of transfusion services at the hospital.

In some cases, transfusions can save lives, such as by replenishing the blood lost by severely injured trauma patients, he said. But transfusions aren’t always necessary for some conditions and can lead to complications.

The risks associated with blood transfusions have traditionally centered on patients’ exposure to diseases, such as hepatitis and HIV, Gross said. In recent years, however, with the blood supply widely considered safe, the concerns have shifted to research indicating that transfusions are associated with longer hospital stays and greater risk of hospital-acquired infections and other complications, he said.

EMMC has cut down on unneeded transfusions by screening patients for anemia before they arrive for procedures such as hip and knee replacements, Gross said. By treating the condition — a lack of healthy red blood cells in the body — ahead of time, surgeons often can avoid the need for a transfusion.

“Once [patients] are here, we use medications and surgical techniques to try to minimize the amount of blood that’s lost,” he said.

While orthopedic procedures such as joint replacements often involve blood transfusions, the procedure is actually more common in nonsurgical hospital admissions, particularly among cancer patients, Gross said.

The hospital also has integrated the blood management strategies into its electronic medical records system, which helps doctors to make better decisions about when transfusions are necessary while reviewing patients’ histories, Gross said.

The team from western Australia, which is visiting EMMC through Wednesday, is interested in developing a blood management program across a number of hospitals in their region, he said. The group from the University Hospital Zurich, visiting next Monday, plans to do the same within their hospital, Gross said.

New Study Reveals Wide Variation In Blood Transfusion Practices During Surgery

 According to a new study in the July 2012 print edition of Anesthesiology, blood transfusion, the most common procedure performed in U.S. hospitals¹, has wide variation in frequency by surgical procedure and physician as well as wide variation in the hemoglobin trigger used to help decide whether to transfuse.² The study also showed a significant number of transfusion decisions are made without laboratory hemoglobin measurements. The research adds to the growing clinical evidence highlighting the need for improved blood-management strategies. It also underscores the opportunity for noninvasive and continuous total hemoglobin (SpHb^®) monitoring from Masimo (NASDAQ:MASI) to facilitate optimal transfusion decision making to improve patient safety and reduce costs.

In the study, conducted at Johns Hopkins Hospital in Baltimore, Maryland, researchers collected data on 48,086 surgical patients over 18 months and evaluated blood transfusion frequency and hemoglobin triggers by surgical procedure and physician. A total of 2,981 patients (6.2%) received an intra-operative red blood cell transfusion, with two-thirds of those patients receiving two or more units. Transfusion rates varied up to threefold between different physicians performing the same procedure (p<0.05). The average transfusion hemoglobin trigger used to determine need for blood transfusion varied widely with both surgeons (7.2 g/dL to 9.8 g/dL, p=0.001 and anesthesiologists (7.2 g/dL to 9.6 g/dL, p=0.001). The ending hemoglobin values after the last recorded transfusion also varied widely for both surgeons (8.8 g/dL to 11.8 g/dL, p=0.001) and anesthesiologists (9.0 g/dL to 11.7 g/dL, p=0.0004). A recent laboratory hemoglobin measurement was not available when 31% of transfusion decisions were made.

Blood transfusions carry risks. In a previous meta-analysis of 45 studies evaluating the risks of blood transfusion, 42 studies showed a significant link to mortality, infection, or adult respiratory distress syndrome.³ In contrast to the historical belief that withholding transfusions harms patients, multiple randomized controlled trials have now proven that restrictive transfusion practice is safe.^4,5,6 This has led recent transfusion guidelines to focus transfusion decisions on the overall patient condition and to suggest hemoglobin transfusion triggers of 6-7 g/dL for most patients and above 7 g/dL only in select, high-risk patients.^7,8,9

Blood transfusions are also one of the largest cost centers in hospitals. While the material cost of blood ranges from $200 to $300 per unit, the additional costs from storage, labor, and waste result in an actual cost per unit between $522 and $1,183.¹⁰ In addition to the cost of blood itself, each unit of blood transfused increases the cost of care, with even higher costs incurred when patients are transfused at higher hemoglobin levels.¹¹

A recent systematic evaluation of 494 studies concluded that 59% of transfusions were “inappropriate” based on their impact on patient outcomes.¹² The risks and costs of blood transfusion paired with unnecessary transfusions led the Joint Commission in 2011 to introduce new patient blood management measures that hospitals are being encouraged to adopt as a quality indicator.¹³ The new measures include recording the clinical indication for transfusion along with the hemoglobin value of the patient prior to each unit transfused. With the need to stem rising health care expenditures, the Joint Commission and the American Medical Association have targeted blood transfusion procedures as one of the top procedures to reduce in a “National Summit on Overuse” scheduled for September 2012.¹⁴

There is no doubt that clinicians desire the best care for their patients without unnecessary costs, but they are also limited in their precise ability to determine need for transfusion with existing tools. Estimates of blood loss in the operating room can be inaccurate. Researchers at Duke University recently reported estimated surgical blood loss exceeded measured blood loss by more than 40% (860mL vs. 611 mL, p< 0.0001).¹⁵ The likely reason for this discrepancy is the inability to accurately estimate blood loss based on visual inspection of blood and fluid in suction canisters and surgical sponges. While estimating blood loss is challenging and laboratory hemoglobin results are only availably intermittently and are often delayed, transfusion decisions are made in real time. Acknowledging these challenges, the Duke Researchers stated: “Use of bedside hemoglobin concentration devices and continuous, noninvasive hemoglobin monitors may improve transfusion decisions.”

Masimo’s breakthrough SpHb measurement allows clinicians to noninvasively and continuously monitor hemoglobin. Results of an earlier randomized controlled trial conducted by researchers at Massachusetts General Hospital and Harvard Medical School showed that SpHb helped anesthesiologists reduce the frequency of blood transfusion by 87% (from 4.5% to 0.6%, p=0.03) and quantity of blood by 90% (from 0.1 to 0.01 units per patient, p<0 .0001=".0001" 327="327" in="in" orthopedic="orthopedic" patients="patients" sup="sup" surgery.="surgery." undergoing="undergoing">16

Dr. Aryeh Shander, Executive Medical Director at the Institute for Patient Blood Management & Bloodless Medicine Surgery and Chief of Anesthesiology and Critical Care Medicine at Englewood Hospital & Medical Center in New Jersey, stated: “The ability of Masimo’s noninvasive hemoglobin technology to continuously monitor hemoglobin during surgeries can offer earlier, real-time information that can result in diagnosis leading to interventions other than transfusion. And fewer unnecessary transfusions can mean improved patient outcomes.”

This year Masimo launched the Blood Transfusion Related Cost Reduction guarantee program (BTR-CR, “Better Care”) to help hospitals improve patient care and reduce costs. BTR-CR guarantees that a hospital’s blood transfusion-related cost reductions will be greater than the cost of SpHb monitoring. 

1 AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 1997 and 2007.

2 Steven M. Frank, M.D., Will J. Savage, M.D., Jim A. Rothschild, M.D., Richard J. Rivers, M.D., Paul M. Ness, M.D., Sharon L. Paul, B.S., M.S., John  A. Ulatowski, M.D., Ph.D., M.B.A. “Variability in Blood and Blood Component Utilization as Assessed by an Aesthesia Information Management System.” Anesthesiology, July 2012 – Volume 117 – Issue 1 – p 99–106 doi: 10.1097/ALN.0b013e318255e550

3 Marik, P. E. and H. L. Corwin (2008). “Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature.” Crit Care Med 36(9): 2667-74.

4 Carson, J. L., M. L. Terrin, et al. (2011). “Liberal or restrictive transfusion in high-risk patients after hip surgery.” N Engl J Med 365(26): 2453-62.

5 Hebert, P. C., G. Wells, et al. (1999). “A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.” N Engl J Med 340(6): 409-17.

6 Hajjar, L. A., J.-L. Vincent, et al. (2010). “Transfusion Requirements After Cardiac Surgery: The TRACS Randomized Controlled Trial.” JAMA 304(14): 1559-1567.

7 American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies: Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies: An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 2006; 105:198 –208

8 Napolitano LM, Kurek S, Luchette FA, Corwin HL, Barie PS, Tisherman SA, Hebert PC, Anderson GL, Bard MR, Bromberg W, Chiu WC, Cipolle MD, Clancy KD, Diebel L, Hoff WS, Hughes KM, Munshi I, Nayduch D, Sandhu R, Yelon JA, American College of Critical Care Medicine of the Society of Critical Care Medicine, Eastern Association for the Surgery of Trauma Practice Management Workgroup: Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009; 37:3124 –57

9 Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, International Consortium for Evidence Based Perfusion, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG: 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944 – 82

10 Shander, A.,A. Hofmann, et al. “Activity-based costs of blood transfusions in surgical patients at four hospitals.” Transfusion 50(4): 753-65.

11 Murphy, G. J., B. C. Reeves, et al. (2007). “Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.” Circulation 116(22): 2544-52.

12 Shander, A., A. Fink, et al. (2011). “Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes.”Transfus Med Rev 25(3): 232-246 e53.

13 Gammon HM, Waters JH, Watt A, Loeb JM, Donini-Lenhoff A: Developing performance measures for patient blood management.  Transfusion 2011; 51:2500 –9.

14 Joint Commission Perspectives.  The Joint Commission Continues to Study Overuse Issues.  Volume 32, Number 5, 2012 : 4-8(5).

15 Hill, S., Broomer, B Stover, J,  White, W. (2011). Accuracy of estimated blood loss in spine surgery. American Society of Anesthesiologists Annual Conference, San Diego, CA

16 Ehrenfeld JM, Henneman JP, Sandberg WS. “Impact of Continuous and Noninvasive Hemoglobin Monitoring on Intraoperative Blood Transfusions.” American Society Anesthesiologists. 2010;LB05

The incredible value of blood saving....

Click to enlarge.... Bloodless surgery in US Jehovah's Witnesses results in Heart benefits.

TRALI - further evidence to minimize transfusion

TRALI 

Transfusion-Related Acute Lung Injury (TRALI) is a syndrome characterized by acute respiratory distress following transfusion. All plasma-containing blood products have been implicated including rare reports of IVIG and cryoprecipitate. It is a rare complication of allogeneic blood transfusion but the incidence has not been well established due to difficulty in defining the syndrome and to variable reporting mechanisms worldwide. Various studies have estimated the overall frequency of TRALI to be between 1/1,120 and 1/57,810 units transfused. However, there is wide discrepancy in the literature with the reported frequency is as low as 1/557,000 RBC units and as high as 1/432 platelet units.

TRALI is associated with a high morbidity with the majority of patients requiring ventilatory support. However, the lung injury is generally transient with PO2 levels returning to pretransfusion levels within 48 -96 hours and CXR returning to normal within 96 hours. TRALI is associated with a significant mortality rate, often approximated at 5 to 10%. Given the gains in safety made within the blood component production industry, particularly with respect to transmission of infectious diseases, TRALI is now among the three leading causes of transfusion related fatalities along with ABO incompatibility and bacterial contamination.

Transfusion-related acute lung injury and pulmonary edema in critically ill patients: a retrospective study.

Rana R, Fernández-Pérez ER, Khan SA, Rana S, Winters JL, Lesnick TG, Moore SB, Gajic O.

Source

Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.

Abstract

BACKGROUND:

Using the recent Consensus Panel recommendations, we sought to describe the incidence of transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) in critically ill patients.

STUDY DESIGN AND METHODS:

Consecutive patients at four intensive care units (ICUs) who did not require respiratory support at the time of transfusion were identified with custom electronic surveillance system that prospectively tracks the time of transfusion and onset of respiratory support. Respiratory failure was defined as the onset of noninvasive or invasive ventilator support within 6 hours of transfusion. Experts blinded to specific transfusion factors categorized the cases of pulmonary edema as permeability edema (suspected or possible TRALI) or hydrostatic edema (TACO) according to predefined algorithm. In a nested case-control design, transfusion variables and lung injury risk factors were compared between the TRALI cases and controls matched by age, sex, and admission diagnosis.

RESULTS:

There were 8902 units transfused in 1351 patients of whom 94 required new respiratory support within 6 hours of transfusion. Among 49 patients with confirmed acute pulmonary edema, experts identified 7 cases with suspected TRALI, 17 patients with possible TRALI, and 25 cases with TACO. The incidence of suspected TRALI was 1 in 1271 units transfused; possible TRALI, 1 in 534 per unit transfused; and TACO, 1 in 356 per unit transfused. When adjusted for sepsis and fluid balance in a stepwise conditional logistic regression analysis, patients who developed acute lung injury (suspected or possible TRALI) received larger amount of plasma (odds ratio 3.4, 95% confidence interval 1.2-10.2, for each liter infused; p = 0.023).

CONCLUSION:

In the ICU, pulmonary edema frequently occurs after blood transfusion. The association between infusion of plasma and the development of suspected or possible TRALI may have important implications with regards to etiology and prevention of this syndrome.

Link: http://www.ncbi.nlm.nih.gov/pubmed/16965572

Study: Kids Given Plasma Despite No Clear Benefit

Many kids get plasma transfusions when there's little evidence they do much good, according to a new study.
Transfusions of so-called fresh frozen plasma are sometimes given to both kids and adults whose blood has problems clotting, or if they have lost a lot of blood from surgery or an accident.
But only a couple of studies in kids have shown that plasma transfusions are a good option for one specific heart surgery procedure. The rest of the time, researchers have found they don't work, or that their benefit is uncertain.
In the current study, pediatricians reported that almost three percent of kids admitted to children's hospitals in the U.S. had a transfusion. More than half of the transfusion recipients were under a year old, a third had heart disease and 70 percent were critically ill.
"For all we know, it may be used entirely appropriately," said Dr. John Puetz, from Saint Louis University, who worked on the study.
"The problem is, we don't have the evidence base... to demonstrate what's inappropriate use and what's not inappropriate use."
"The concern," he told Reuters Health, "is a fair number of children are being exposed to (fresh frozen plasma) without published data showing what it's effective for."
The problem with that, researchers said, is that the transfusions always come with a risk of side effects and complications, which range from allergic reactions to heart failure, if doctors give kids more plasma than their hearts can handle.
Puetz's team consulted a database of about 3.2 million admissions to 40 different children's hospitals in the last decade. According to hospital records, just under three percent of those kids got a plasma transfusion, most in the intensive care unit.
The researchers couldn't tell why the plasma was used in each case, or how much of it kids got. But only about one-third of the kids' records also showed they had a heart procedure known as a cardiopulmonary bypass -- when a pump does the job of the heart and lungs during surgery, and a plasma transfusion (along with red blood cells) is indicated.
There were 24 recorded cases of acute lung injuries related to the transfusions, but the authors write in the Journal of Pediatrics that it's hard to tell how many kids had other complications.
"The biggest reason not to give any transfusion... is the risk of the complications that you can have," said Dr. Lorne Holland, of the Nashville-based pathology services company PathGroup, Inc., who has researched the use of fresh frozen plasma. That would include lung injuries and congestive heart failure, as well as more minor itchy allergic reactions.
Still, Puetz added, "No one's really looked to see what all the possible side effects may be."
A typical plasma transfusion would cost a few hundred dollars, Holland said.
He thinks that too many kids are still getting the transfusions, despite the general lack of evidence that they work -- or are better than other alternatives such as whole-blood transfusions in certain cases.
"I think the numbers in that study and ones in adults are too high," Holland, who was not involved in the study, told Reuters Health. "A lot of physicians are convinced by evidence of, 'That one patient, that one time, seemed to do better when I gave it to them.'"
Puetz said it's still not clear whether plasma transfusions are being done too often, based on the lack of data. He called for more critical studies to see if fresh frozen plasma transfusions really do work in all of the cases where they're commonly used in kids.

Scientists Use Stem Cells for Blood 'Self-Transfusion'

Researchers report that they used stem cells to create cultured red blood cells and then successfully injected the blood cells back into the human donor who provided the stem cells in the first place.
The findings raise the possibility of creating individualized blood supplies without making people donate their own blood for storage before they need a transfusion, a potentially dicey situation if someone is ill.
The researchers said that the cultured red blood cells created with the help of stem cells from the donor -- and then inserted back into the donor -- lived about as long as regular blood cells normally do.
The study, the first to show that red blood cells created from stem cells can survive in the human body, is "a major breakthrough for the transplant community," Dr. Luc Douay, senior study author and a professor of hematology at Universite Pierre et Marie Curie in Paris, said in a news release from the American Society of Hematology.
"There is a dire need for an alternative source of transfusable blood products, especially with the risk of infection from emergent new viruses that comes with traditional transfusion," Douay explained. "Producing red blood cells in culture is promising since other efforts to create alternative sources have not yet been as successful as once hoped."
However, one expert said the research isn't quite as exciting as it may sound.
Creating red blood cells from your own stem cells is "going to be an extremely complex process, extremely expensive, not very convenient and uncommonly used," explained Dr. Paul Holland, a blood banking specialist and a clinical professor of medicine and pathology at the University of California, Davis Medical Center.
"Most people who need a transfusion need it now, and they use blood from donors that's already there," he said. One exception might be if someone has a condition that makes it difficult to match his or her blood to other donors and it's dangerous to draw and save their own blood, he said.
The findings appear in the Sept. 1 issue of the journal Blood.

EDQM Launches New Web Page On Blood Transfusion Projects

The European Directorate for the Quality of Medicines & HealthCare (EDQM) has launched a new web page highlighting its various projects in the area of blood transfusion. The page covers the growing number of important activities in this field.
The web page is designed to be a centralised forum to share information about ongoing projects. It includes details of the progress of each project, press releases, news updates on new or planned projects, relevant resolutions, the terms of reference of the different project groups, as well as links to other organisations working in this area. In addition, it lists the European Committee on Blood Transfusion (CD-P-TS) members.
Importantly, the new web page also serves as an information portal for 'Project TS057: Risk Behaviours having an impact on Blood Donor Management and Transfusion Safety'. Exclusion criteria for blood donors, especially with regard to sexual behaviours, are much debated. The present situation, involving the permanent exclusion of individuals whose behaviour places them at higher risks of acquiring severe infectious diseases that are transmissible by blood transfusion, is being questioned by citizens and by the press in terms of whether this kind of donor deferral is legal, right, appropriate, efficient and required.
Despite the testing of blood donations with highly sensitive test systems, there remains a residual risk of transfusion-transmitted infection due to donations given in the 'window' period, i.e. the time period between initial infection and its detection. This is not always recognised by the public.
As a consequence, the CD-P-TS of the EDQM, Council of Europe has appointed a working group (TS057) to monitor current practices, evaluate the scientific data and define a harmonised approach to establishing rules for donor deferral, linked to the risks attributable to sexual behaviour. The group started its work in February 2010 and will finish during autumn 2011.

http://www.edqm.eu/en/Whats-new-525.html

Wake Forest Researchers Discover Stored Blood Can Lead To Complications

Winston-Salem, NC -- People give the gift of life everyday and that blood is then stored properly and safely. And you may have even asked yourself or someone else, what happens to that stored blood used during transfusions?
Well, some researchers at Wake Forest University and the University of Pittsburgh School of Medicine looked into that issue.
Information released from the study states that depending on the amount and age of the stored blood used, there is evidence that transfusion can lead to complications including infection, organ failure and death.  They also found that these complications are likely due to red blood cell breakdown during storage, implying that transfused blood may need to be stored in a different way.
Their discovery could lead to changes in the way blood is stored. They believe that donated blood may need to be stored in a different manner.
Doctors have noted recently that blood stored for a long time may be associated with complications such as increased infection risk, kidney, lung, or multi-organ failure and death, particularly among medically vulnerable patients, according to study researchers Dr. Mark Gladwin of the University of Pittsburgh and Dr. Daniel Kim-Shapiro of Wake Forest.
According to Dr. Gladwyn, "When blood sits for a while, some of the cells break down and release their contents, which include molecules of hemoglobin and red blood cell microparticles."
Dr. Gladwyn further explains that these molecules accumulate in the bags the blood is stored in and are then transfused into the patient receiving the blood. This is called a storage lesion.
After they enter the bloodstream, the hemoglobin and microparticles bind to and destroy NO, a very important molecule that is used to ensure normal blood flow. This can then prevent tissues and organs from getting adequate oxygen, according to researchers.
They are working on other research projects to find approaches to correct the problem, and to assess the safety of blood, for transfusion that has been stored for longer than 14 days.
Currently, federal guidelines allow transfusion of blood that has been stored for up to 42 days.
Wake Forest University

Irish Budget cuts mean no CJD screening of donated blood

Ireland - THE MINISTER FOR Health has been advised not to introduce a new technology to screen donated blood for Creutzfeldt-Jakob disease because it would not be cost effective to do so.
Variant Creutzfeldt-Jakob disease (vCJD) is one of a group of rare, progressive fatal non-inflammatory degenerative diseases of the brain affecting humans and animals.
Also known as prion diseases, they are thought to be caused by an abnormal form of a naturally occurring protein in the brain (the prion protein) that has been acquired through infection.
Following a detailed health technology assessment (HTA) carried out by the Health Information and Quality Authority (HIQA), Dr Patricia Harrington, head of assessment with the Authority’s Health Technology Assessment Directorate, said: “The Authority’s HTA found that to filter red cell concentrates as proposed by the blood service would initially cost €11 million per year. It was estimated that such a measure would, over a 10-year period, potentially prevent two deaths from vCJD.”
The origin of vCJD is linked to the outbreak of a bovine form of the disease, bovine spongiform encephalitis (BSE), which occurred in the UK in the 1980s and 1990s.
The incidence of BSE and vCJD peaked in the Britain in 1992-1993 and 2000, respectively, and has been declining since.
However, there is an ongoing risk of vCJD transmission from transfusion of blood or blood products due to donations from carriers of the disease.
Worldwide, there have been five documented cases of transfusion- related vCJD infection, resulting in three deaths from clinical vCJD.
Emphasising HIQA’s increasingly important role as health budgets dwindle, the report states: “Given the likely number of clinical cases and, in the context of a finite healthcare budget, consideration must be given to the existing technologies and services that may need to be displaced should a decision be made to introduce prion filtration, at a cost of up to €11 million per annum.”

Blood Stored Too Long May Threaten Patient Safety

THURSDAY, July 21 (HealthDay News) -- New research links medical problems caused by blood transfusion to the breakdown of red blood cells during blood storage. The findings suggest that a better way to store blood is needed.
When transfused, older blood or high amounts of blood can lead to complications, including infection, kidney and lung failure and death, said study co-author Dr. Mark T. Gladwin in a news release from Wake Forest University, which led the study.
The study examines the interaction between nitric oxide (NO) and the byproducts created as red blood cells break down over time. The researchers found that the interaction in older blood can reduce blood flow and perhaps damage tissues in the body.
"When blood sits for a while, some of the cells break down and release their contents, which include molecules of hemoglobin and red blood cell microparticles," said Gladwin, chief of the division of pulmonary, allergy and critical care medicine at the University of Pittsburgh School of Medicine. "These accumulate in the stored bag of blood and are transfused into the patient with the blood. In the bloodstream, the hemoglobin and microparticles bind to and destroy [nitric oxide], a very important molecule that is used by the body to keep blood vessels dilated for normal blood flow."
"Transfusion of stored blood is one of the most common medical therapies," said study senior author Daniel B. Kim-Shapiro, professor of physics and director of the Translational Science Center at Wake Forest University, in the news release. "For example, perhaps we can restore nitric oxide activity that is lost upon transfusion, use preservation solutions that better limit the degradation of blood cells, or develop agents that scavenge free hemoglobin."
Future studies will examine the safety of blood stored more than 14 days. Under current federal guidelines, blood can be stored for up to 42 days.
Each year in the United States more than 5 million people receive blood transfusions, according to the study.
The study is published in the journal Circulation.

Heart Surgery Transfusions - at best a waste of resources

DURHAM, NC – Transfusion rates for blood products used in a common heart surgery range from no patients to nearly all patients, and vary by hospital, according to findings from a group of researchers from Duke University Medical Center. The study, which looked at data from 102,470 patients in 798 hospitals, examined the variation in transfusion rates for red blood cells (RBCs), plasma and platelets, but the team didn't reach conclusions about how well patients fared if they did or didn't get a transfusion.
"We don't know whether the variability is potentially harming patients," said lead author Elliott Bennett-Guerrero, M.D., director of Perioperative Clinical Research at Duke Clinical Research Institute and Professor of Anesthesiology/Critical Care. "Even if more liberal transfusion is not harmful to patients, it may represent a significant waste of scarce resources and money."
The researchers didn't find any link between patient mortality rates after surgery and whether the hospital was a high-transfusion site or a low-transfusion site, Bennett-Guerrero said.
The work was published in the Journal of the American Medical Association (JAMA) online on Oct. 12.
"To our knowledge there has never been a published large randomized trial in surgical patients looking at the impact of blood transfusion to determine whether we should be more restrictive or liberal with these transfusions," Bennett-Guerrero said. "Despite the fact that we spend billions of dollars on health care and research, we spend comparatively little on clinical effectiveness trials, which are gaining recognition as an informed way to change clinical practice."
Even when centers performing fewer operations were excluded, the researchers found that transfusion rates among the patients at hospitals ranged from 7.8 percent to 92.8 percent for red blood cells, 0 percent to 97.5 percent for fresh-frozen plasma, and 0.4 percent to 90.4 percent for platelets. The average cost of a unit of RBCs including direct and indirect costs was $761 in a 2010 study published in Transfusion journal.
The team, which included researchers from other institutions, found variation in RBC use based on geographic region, as well as higher RBC usage at academic hospitals and hospitals that performed the fewest number of coronary artery bypass graft (CABG) operations. Taken together, however, these three characteristics only accounted for 11.1 percent of variation in red-blood cell use.
The research team assessed data from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database kept by the Duke Clinical Research Institute, which captures clinical information from the majority of U.S. cardiac surgical procedures (up to 80 percent of all surgical data available).
The patients included in the study all had the same operation, a first-time, isolated coronary artery bypass graft (CABG), and all were on a heart-lung pump during surgery.
Differences in surgical techniques may help explain some of the variability. "There is a reasonable chance that some patients are getting transfused more because they are bleeding more during surgery, which could be linked to differences in surgical technique among the doctors," Bennett-Guerrero said.
Another likely difference is simply the transfusion culture at an institution. This may also have to do with early medical education and training, as some institutions pass along a pro-transfusion culture to those in training, he said.
argely circumstantial evidence suggests excessive blood transfusion for a patient may be harmful, Bennett Guerrero says. Everyone agrees that transfusion is needed when an injured person has lost most of their blood or has severe anemia. "It is difficult to get agreement, however, in situations where the patient has moderate blood loss or anemia," he said. "No one has yet proven that more liberal transfusion is harmful, and in the absence of results from high-quality randomized clinical studies, it is not surprising that there is variation in transfusion rates."
This work was supported by the Society of Thoracic Surgeons through the National Adult Cardiac Surgery Database and the Duke Clinical Research Institute.
Other authors include Yue Zhao and Sean M. O'Brien of the biostatistics division and Eric D. Peterson in the cardiology division of the Duke Clinical Research Institute; T.B. Ferguson of the Department of Cardiovascular Sciences, at the East Carolina Heart Institute, in Greenville, N.C.; James S. Gammie of the Division of Cardiac Surgery at the University of Maryland Medical Center in Baltimore; and senior author Howard K. Song of the Division of Cardiothoracic Surgery, Oregon Health and Science University in Portland.

Transfusion may do more harm than good..........

Watch the full episode. See more Need To Know.

Uni of Alabama at Birmingham Hospital reduced blood use by at least 25%...and slashed blood-related costs by $3.5 million annually

The results from such centres as the Englewood Medical Centre in the USA show that bloodless cardiac surgery is not only as good, but the results are actually better for those who avoid blood transfusion than those who are transfused. Murphy and colleagues in 2007 concluded that “Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.” (Murphy GJ Reeves BC Rogers CA et al Increased Mortality, Postoperative Morbidity, and Cost After Red Blood Cell Transfusion in Patients Having Cardiac Surgery.Circulation. 2007;116:2544-2552.)
More recently, Patient Blood Management programs have been introduced in many US hospitals and the Australian National Blood Service has set up a Patient Blood Management Steering Company. Commenting in their 19th August 2010 Daily Briefing, the Advisory Board Company also noted the cost savings available through Patient Blood Management: “About 110 hospitals currently have blood management programs, up from about 70 facilities in 2002 ... One program at the University of Alabama at Birmingham Hospital reduced blood use by at least 25% since 2003 and slashed blood-related costs by $3.5 million annually.”
The next generation of medical practitioners will no longer consider transfusion a free, helpful expedient. Instead they will seek ways to ensure that all uncomplicated elective surgery is achieved without any blood being transfused. That will save the precious gift of blood donors for those who really need it.

Increased Mortality, Postoperative Morbidity, and Cost After Red Blood Cell Transfusion in Patients Having Cardiac Surgery - Click Thumbnail to enlarge

"There was...crap in that stuff. This stuff was manky, it was filthy, it was dirty ... but they still stuck it in the arms of children"

Patients have called for the inquiry into how people were given infected blood by the Scottish NHS to have a wider remit, as hundreds of pages of evidence were published.
Campaigners hailed the release yesterday of the preliminary report by Lord Penrose, who is chairing the probe, as a milestone.
It included a list of issues that he will investigate during the next year, among them the use of commercial blood products after it was realised internationally that they carried a risk of Aids and the acceptance of blood donations from prisoners.
Hundreds of people in Scotland were given contaminated blood in the 1970s and 1980s either as treatment for blood clotting disorders or through blood transfusions.
The plight of those who caught HIV or hepatitis C as a result is acknowledged in the opening of the preliminary report.
It says: “It would have been impossible for any person involved in this inquiry to have been unaware of and to have remained untouched by the physical, mental and emotional suffering of the individuals and families affected by these serious and potentially fatal diseases.”
Campaign groups including Haemophilia Scotland said that after years of frustration they were pleased to have such a substantial document.
However, they expressed concern that many of the victims and their families who want to be core participants with legal representation when the inquiry progresses to oral hearings will be disappointed.
About 70 patients and their relatives applied to Lord Penrose to be core participants, but so far it is understood about 14 have been accepted.
In addition, Bruce Norval, who has hepatitis C after receiving contaminated blood, complained the inquiry would not explore other infections – in addition to hepatitis C and HIV – to which haemophiliacs given clotting agents may have been exposed.
He said: “One thing that needs to be highlighted is that haemophiliacs are due a public, truthful account of the full toxic potential of the clotting agents we were treated with from childhood. At the moment, the remit would not fully allow for that.
“What we are trying to get is an understanding why this small group of people, which was 500 strong, are now down to half that number, with more dying on a monthly basis.
“There was all kinds of crap in that stuff. This stuff was manky, it was filthy, it was dirty and they knew it, but they still stuck it in the arms of children.”
The inquiry will examine how patients affected were tested for infections and informed about the results. According to the report, almost two-thirds of patient witnesses said they did not know they were being tested for hepatitis C or HIV and a number describe finding out they had hepatitis C years after tests were carried out.
Lord Penrose has been given accounts of doctors dismissing the illness as “nothing to worry about”, while one witness with HIV said the doctor who told his family was “quite blase”.
The report was released after the inquiry team analysed more than 80,000 documents and took more than 100 statements from patients and relatives.
Solicitor Advocate Patrick McGuire, of Thompsons solicitors, the recognised legal representative of families and sufferers, welcomed the report.
He said: “The document … is clearly very well reasoned and therefore a clear measure of the amount of work that has been put in by Lord Penrose and his team and for that I would personally like to thank him.”
He added that it was subject to consultation and he would be discussing some issues with Lord Penrose.
Lord Penrose said: “It is important to emphasise that I have not reached any conclusions on matters of fact or provided any recommendations at this stage and the list of topics that I have included for further investigation at the public hearings is not definitive.
“I am now inviting comments on these topics from interested individuals and organisations by the end of October.”

Facts about blood needs in the U.S.

• Every two seconds someone in the U.S. needs blood.
• More than 38,000 blood donations are needed every day.
• A total of 30 million blood components are transfused each year in the U.S. (2006).
• The average red blood cell transfusion is approximately 3 pints.h
• The blood type most often requested by hospitals is Type O.
• The blood used in an emergency is already on the shelves before the event occurs.
• Sickle cell disease affects more than 80,000 people in the U.S., 98 percent of whom are African American. Sickle cell patients can require frequent blood transfusions throughout their lives.
• More than 1 million new people are diagnosed with cancer each year. Many of them will need blood, sometimes daily, during their chemotherapy treatment.
• A single car accident victim can require as many as 100 pints of blood.
• One donation can save the lives of up to three people.

Go to www.redcrossblood.org to find out more about blood donation and to see if you are eligible.

Cutting back on blood use could halt infections, illness — and even death

SEATTLE — As a doctor and a patient, Dale Reisner knows the value of donated blood. But when the Seattle obstetrician had to have heart surgery four years ago, she did everything possible not to get a single drop.
“I don’t have any religious problems with it. If I was near death, I definitely would have taken blood, no question,” said Reisner, who is fine now at age 62. “But if I could avoid a transfusion by better pre-op preparation, then I was interested.”
Dr. Dale Reisner actively avoided a blood transfusion during surgery to repair a mitral valve in her heart.
Long dominated by Jehovah’s Witnesses — whose faith forbids blood transfusions — bloodless surgeries and blood conservation programs are now attracting mainstream patients worried about what some experts say are clear risks, including more infections, longer recuperation, increased illness and even death.
"The best blood is in your own veins,” said Dr. Lori Heller, medical director of the blood management program at Swedish Medical Center in Seattle, where Reisner had her surgery — without any transfusion. “We want to think before we transfuse.”
Decades of experience with Jehovah’s Witness patients, including 1.5 million members in the United States, has helped propel the new emphasis on blood management, said Sherri Ozawa, clinical director of the Institute for Patient Blood Management at Englewood Hospital and Medical Center in New Jersey.
“In the early days, it was, ‘We have Witness patients, what in the world do we do with them?’” she recalled. “Now we believe it should be the standard of care.”
More doctors, from cardiac surgeons to orthopedists, are offering patients ways to conserve their own blood and avoid transfusions. From drugs that boost blood levels before surgery to cell salvage and blood diversion techniques during operations and lower thresholds for giving blood at all, the techniques are a sea change in the attitude that more blood is always better.

Egypt - Nearly 7 out of every 1,000 Egyptians acquire HCV infections every year, suggesting intense ongoing transmission

The Arab Republic of Egypt has the highest rates of new hepatitis C virus (HCV) infection in the world, according to a new study published today in the prestigious Proceedings of the National Academy of Sciences. The study also estimates more than 500,000 new HCV infections occur in Egypt every year, likely signaling an epidemic in a country of more than 77 million people. This high rate of HCV transmission may be due to the lack of sufficient standard safety precautions in medical and dental facilities, the authors suggest. “Nearly 7 out of every 1,000 Egyptians acquire HCV infections every year, suggesting intense ongoing transmission. This is the highest level of HCV transmission ever recorded at a national level for a blood borne infectious disease transmitted parenterally, that is, by use of non-sterile medical instruments,” said Dr. F. DeWolfe Miller, lead author of this study and professor of epidemiology at the Department of Tropical Medicine and Medical Microbiology and Pharmacology at the University of Hawaii.Although the high prevalence of hepatitis C in Egypt has been well established for many years, and linked in part to limited safety measures during anti-bilharzia campaigns, published estimates of prevalence from different Egyptian communities failed to provide a nationwide picture of the magnitude of ongoing HCV infection transmission.

To estimate the rate of new HCV cases of infection in Egypt, the authors of the study performed epidemiologic modeling of data from a range of studies, including a 2008 national HCV survey with a representative sample and well-documented study design.“The study opened our eyes to a disease burden similar in scale and challenge to the HIV problem in sub-Saharan Africa: Millions of cases of an infection for which there is no vaccine, no effective treatment, and where case management is so expensive that it is beyond the reach of most patients,” said Dr. Laith J. Abu-Raddad, co-author of the study and assistant professor of public health at the Infectious Disease Epidemiology Group at the Weill Cornell Medical College–Qatar.

The study necessitates not only further analysis of HCV transmission in Egypt but also justifies the immediate increase of resources to strengthen public health measures aimed at reducing the transmission of HCV in clinical and non-clinical settings, according to the authors. Failure to address this problem will result in a massive disease burden in the nation in terms of HCV infection complications, including active liver disease, liver failure, or liver cancer.
“There is only one way to deal with the HCV challenge in this country: HCV prevention,” warned Dr. Miller. “Effective and stronger HCV prevention programs are urgently needed in Egypt. Failure to act could swamp the public health system over the coming decades with millions of cases of HCV disease complications with an economic and social cost that this nation does not have the means to confront.”
Key scientific findings of the study
• Nearly 7 out of each 1,000 Egyptians acquire HCV infection every year for a total of 537,000 new HCV infections every year. This is by far the largest ever recorded rate of occurrence of HCV at a national level of all countries in the world.
• One in every 10 Egyptians is a carrier of the HCV infection, which means that there are at least 4,459,000 persons infected with HCV who are infectious to others. This is the largest reservoir of HCV infection in the world.
• Contrary to the widely-held perception that this rate of occurrence reflects merely the limited safety measures during anti-bilharzia campaigns, HCV incidence likely continues at alarming levels due to limitations in the implementation and enforcement of stringent standard precautions in public and private medical and dental facilities.

Tests aim to settle if fresher blood works better

WASHINGTON — Facing surgery? You could receive blood that's been stored for a week, or three weeks, or nearly six — and there's growing concern that people who get the older blood might not fare as well.
It's a question with big implications for the nation's already tight blood supply.
Blood is rotated almost like milk on the grocery shelf: The Food and Drug Administration allows red blood cells to be stored for 42 days, and hospitals almost always use the oldest in their refrigerators first to ensure none expires. How old the blood you receive is depends on how much the hospital has of your type that day. The average age of transfused blood is just over 16 days.
This summer, hospitals around the country are launching major new research to try to settle if fresher blood really is better for at least some patients. And if so, they're hunting ways to turn back the clock for older blood — like the University of Miami's work to wash away some cellular debris — and offset any deterioration.
Donated blood "saves lives every day. We certainly do not want to run out of it," says Dr. Simone Glynn of the National Institutes of Health, which is spearheading the multimillion-dollar studies.
But if shelf life is proven to make a difference, then "how can we have the safest product possible?" asks Glynn, transfusion medicine chief at NIH's National Heart, Lung and Blood Institute.
Those attempts range from trying to improve the oxygen-carrying capacity of stored blood to ridding it of so-called microparticles, cell fragments that gradually build up in storage.
"It's very challenging to find out what's causing this," Miami's Dr. Wenche Jy, who's leading the microparticle work, says of the age-of-blood debate.
About one in every seven hospitalized patients requires a transfusion, a staggering 15 million bags administered in the U.S. each year — with few donations to spare. Every year, parts of the country experience spot shortages.
Scientists have long known that blood breaks down the longer it's stored, but not whether those changes were enough to trigger side effects.
Several years ago, a number of small studies began suggesting that blood well under the FDA's 42-day storage limit may increase the risk of complications like blood clots, infections, or organ dysfunction.
Then the Cleveland Clinic examined records of 6,000 of its past heart surgery patients — and found those who received blood that was more than two weeks old were slightly more likely to die, required a ventilator longer and had higher rates of infection and kidney failure than those who got fresher blood.
Earlier this year, Connecticut researchers reported similar findings in a study of 200 trauma patients.
But that's far from proof. Maybe the sickest patients just got the oldest blood, a flaw these kinds of look-backs can't overcome. Complicating the controversy, other similarly performed studies concluded age of blood doesn't matter, finding no differences between patients who got older or fresher transfusions.
Enter the more stringent research to find out:
_In the largest NIH-backed study, 15 hospitals will recruit 1,800 patients about to have heart surgery who agree to be randomly assigned to get blood more than 20 days old or less than 11 days old, and then track how they fare. (Patients who don't participate would get older blood anyway, per standard hospital policy.)
_In Canada, researchers are enrolling 2,500 patients in critical-care units into a similar study that defines "fresh" as no older than a week. Separately, they're also studying the question in several hundred premature infants who need blood.
_The Cleveland Clinic has enrolled about 1,000 heart-surgery patients and counting into another comparison, this one defining fresh as no older than two weeks.
At the same time, the NIH is funding eight additional projects to tease apart just what happens to stored blood that might trigger side effects. One leading theory is that stored blood gradually loses its ability to get oxygen to tissues, largely through loss of a blood vessel dilator called nitric oxide.
And Jy's team has found those microparticles play a role in blood clotting and inflammation, and that they start accumulating inside blood bags around day 10. Next up is a study of 500 heart surgery patients to test if washing two- or three-week-old blood in special machines that filter out the microparticles can make a difference.
However the debate turns out, it already may be spurring hospitals to be more conservative with blood.
"We actively seek to avoid transfusions whenever possible," says the Cleveland Clinic's Dr. Colleen Koch, through such steps as using devices that capture and recycle a patient's own blood during surgery.

Use Your Own Blood In Transfusions During Emergency Operations

A new report in the July issue of Archives of Surgery, now provide information that a person using their own blood during transfusions is possibly now cost effective.
Trauma injuries is the leading cause of death in persons between the ages of one and forty four, a major player in this cause is major blood loss this is obtained from the background facts in the report. This seems to hold especially accurate in deaths which happen in the operating room or twenty four hours after the trauma had occurred. Patients that go into shock due to hemorrhaging need a transfusion, usually with packed red blood cells and plasma. Any transfusion of blood from another person (allogeneic) is linked to an array of problems which include having a reaction to the transfusion, infectious diseases being transmitted and being susceptible to antigens according to researchers. Additionally, transfusions of allogeneic blood products in trauma patients have solely been linked to heightened morbidity and mortality, specifically when using blood that has been stored awhile.
Dr. Carlos V. R. Brown, of the University Medical Center Brackenridge, Austin, Texas, and associates had examined forty seven adult trauma patients that had undergone an emergency operation and had been given intraoperative cell salvage, a method in which shed blood is gathered and prepared in order for red blood cells to be transfused back into the patient in 2006 or 2007. In everyone of these patients the researchers had chosen a corresponding patient who was the same age, sex, same system and identical severity of injury and had the same operation but did not have savage cells.
Patients that were in the savage cell group displayed an average intraoperative blood loss of 1,795 milliliters, and averaged a return of 819 milliliters of their own blood. They also had been given less intraoperative and total units of allogeneic packed red blood cells the associated group (two vs four units in surgery and four vs 8 in total units) and also had received less total units of plasma.
The amount from blood product transfusion which includes the complete cost of cell salvage, was lower in the group who had receive this particular procedure ($1,1616 vs. $2,584). The groups had alike of duration of stay in the intensive care unit (eight days for both) and in the hospital (18 for salvage group and 20 in comparison group), there was no dissimilarity in death ratios (6 in the salvage group and 10 in comparison group).
In closing, this current cohort study adjoins with the already present literature in reference concerning the benefit of outcomes in intraoperative cell salvage andautolgous transfusion in patients of trauma who undergo emergency surgical mediation according to the researchers writings in this study. They furthermore state that further studies are warranted to positively substantiate the safety of transfusing contaminated blood to per-operative determined patients that would get the greater advantages from autologous transfusion and also to maximize cost effectiveness. Meanwhile the centers that have avenues to a cell salvage program should frequently use autologous transfusion as a role in their intraoperative resuscitation. Most critically, centers that do not use intraoperative cell salvage and autotransfusion should establish and take away blockades to putting in use this life saving technique.