Transfusion Medicine has Emerged: Redefining the Role of the Transfusion Specialists in the Changing Scenario Shivaram Chandrashekar Global Journal of Transfusion Medicine 2019 4(2):129-131

Risk mitigation in blood transfusion services – A practical approach at the blood center level Shivaram Chandrashekar, Ambuja Kantharaj Global Journal of Transfusion Medicine 2019 4(2):132-139 Hemovigilance is a set of surveillance procedures starting from the donor vein and ending with the patient vein, aimed at reducing the risks associated with transfusion which could be donor related, recipient related, or process related. Donor-related risks include local and systemic complications which need a variety of interventions to ensure safe blood donation and are mainly aimed at preventing local trauma and fall or injury after a blood donation resulting from a vasovagal reaction. Recipient-related risks are hemolytic and nonhemolytic in nature and may present with fever, rash, or dyspnea besides other features. Appropriate mitigation measures are needed for each of them, especially the more ominous ones like transfusion-related acute lung injury/transfusion-associated circulatory overload. Process-related risks are the leading cause of risks associated with transfusion. Human errors can be mitigated by the use of technology such as barcoding, radio-frequency identification, digital transporter boxes, and having effective protocols and checklists in place.

Platelet refractoriness B Sunil Rajadhyaksha, D Priti Desai, A Anisha Navkudkar Global Journal of Transfusion Medicine 2019 4(2):140-147 Platelet transfusion support is extensively required for hemato-oncology patients who are multiply transfused. Platelet refractoriness can represent a significant clinical condition that complicates the platelet transfusion support in such patients. It remains a challenge associated with an increased bleeding risk, longer hospital stays, and increased morbidity and mortality. Causes for refractoriness are broadly divided into nonimmune and immune causes. Approximately two-thirds of refractory episodes are due to nonimmune factors while one-third are due to immune factors. Common formulae to assess platelet refractoriness include corrected count increment (CCI), posttransfusion platelet increment, and percentage platelet recovery. Measurement of CCI is one of the best parameters to differentiate between immune and nonimmune causes. In nonimmune factors which are associated with increased platelet consumption, treating the underlying cause and increasing the frequency of transfusion should be considered. However, in immune factors which are due to increased destruction of platelets owing to alloimmunization, other strategies such as ABO-identical/ABO-compatible fresh platelets, human leukocyte antigen-matched platelets, and crossmatched platelet transfusions should be considered. The newer approach includes epitope-matched platelet transfusion which is still in amateur stage. The strategies in the prevention of alloimmunization include leukoreduction of blood components, reducing donor exposure by providing single-donor platelets, and providing ABO-compatible platelets from the beginning of the treatment. This review will address the causes of platelet refractoriness and practical approach to the diagnosis, management, and its prevention.

Platelet compatibility and platelet antibodies detection: A step towards resolving dilemma in management of platelet refractoriness in oncology patients Sadhana Mangwana, Atin Kacker, Nikhil Simon Global Journal of Transfusion Medicine 2019 4(2):148-153 Background: Platelet refractoriness complicates the provision of platelet transfusions- a critical and essential part in management of thrombocytopenia in Oncology patients. Platelet refractoriness poses challenge due to alloimmunization to HLA (Class I) and human platelet antigens (HPAs) and is associated with adverse clinical outcomes and increases health care costs. Aim: A prospective, observational study was planned in medical oncology patients having thrombocytopenia to analyse result of platelet compatibility with post-transfusion platelet count increment and to ascertain presence of platelet antibodies as causative factor in platelet refractory patients. Methods: Eighty oncology patients having thrombocytopenia in a tertiary care centre; both solid organ and hematological malignancies, requiring platelet transfusion were included in this study. ABO-compatible, leucoreduced, random donor platelets with less than 72 hours storage and platelet cross matched were transfused. In case of platelet refractoriness and presence of platelet incompatibility, platelet antibody screening test was performed using SPRCA technique. A P-value < 0.05 was considered statistically significant. Results: Study population was 18-85 years with maximum number of cases (31.3 %) in 60-70 years age group with equal number of both genders. 80% cases showed platelet cross-match compatibility, while 20% were platelet cross-match incompatible. Amongst incompatible platelet cross matches, 87.5% cases showed presence of platelet alloantibodies and all cases except one showed platelet refractoriness. Platelet yield in compatible platelet cross match was higher than in patients with incompatible platelet cross match (P-value < 0.001). Previous exposure in the form of Pregnancy (61% cases) and history of transfusion (54% cases) played a vital role in platelet refractoriness and development of platelet alloantibodies. Patients treated with chemotherapy (78.8%) had significant risk of platelet refractoriness and platelet alloimmunization. Conclusion: Platelet cross matching along with testing for anti-platelet antibodies using SPRCA method is an effective, useful tool and rapid, first-line approach for selecting compatible platelets from the local inventory as compared to HLA-matched platelets in the treatment of thrombocytopenic cancer patients. Blood services must be aware of the measures to prevent alloimmunization and correct identification of refractoriness to provide adequate transfusion support for oncology patients reducing hospital length of stay and minimizing health care cost.

The least incompatible crossmatch red blood cell transfusion by biological compatibility test Senem Maral, Sule Mine Bakanay, Sema Akıncı, Aysun Senturk Yıkılmaz, Pinar Comert, Imdat Dilek Global Journal of Transfusion Medicine 2019 4(2):154-157 Introduction: Pretransfusion testing is an essential serological test to protect the recipient from hemolysis and provide compatible blood product. The final step is the crossmatching test which is done by the transfusion center. Although all products are crossmatched in same cases, compatible products may not be available. Aims and Objectives: This study aimed to determine the safety and efficacy of the least incompatible crossmatched erythrocyte transfusion, through the use of biological in vivo crossmatch testing. Materials and Methods: The study included twenty patients who required transfusion and for whom appropriate red blood cell (RBC) could not be found. Totally, 69 units of least incompatible RBC transfusion from crossmatch incompatible products was administered by applying the “in vivo compatibility” test. Patients were observed during the transfusion with respect to acute hemolytic reactions that could develop. The biochemical hemolysis parameters were examined before and at 24 h after transfusion. Results: All transfusions were completed successfully with no complications or symptoms observed in any case. A statistically significant increase in hematocrit (Hct) and hemoglobin was seen post transfusion (P < 0.001). As parameters of hemolysis, lactate dehydrogenase and bilirubin levels were found to be statistically normal (not increased) (P = 0.453 and 0.946, respectively). Conclusions: Biological in vivo compatibility testing seems to be a safe, predictive, and bedside feasible test, which could be lifesaving for many patients.

NATSpert ID TripleH: A novel individual donor multiplex nucleic acid amplification test to reduce risk of transfusion-transmitted infections: Two-year experience of a blood bank in central India Sheela M Mundhada, Gautam R Wankhede, Shefali Desai, Dakhave Minal Global Journal of Transfusion Medicine 2019 4(2):158-162 Background: In India serological screening is mandatory for all donated blood for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) while Nucleic Acid Amplification Testing (NAT) is not a mandatory screening test. There is a risk of transfusion-transmitted infections (TTI) during window period using serology. Aims and Objectives: The aim of this study was to analyse NAT screening using an indigenously developed, Indian manufactured Individual Donor NAT (ID-NAT) and compare it with serology. Materials and Methods: All blood donations between June 2017-March 2019 were screened serologically for HBV, HCV and HIV at an Indian blood bank. Blood donations also underwent ID-NAT screening using the NATSpert ID TripleH detection assay based on real time PCR. The results were analysed to identify yield cases. Results: In the study, 30,772 blood donor samples were screened serologically out of which 214 were reactive. 30,558 serologically non-reactive blood donations and 77 randomly selected, serologically reactive blood donations were screened using NATSpert. Out of 30,635, 85 donor samples were reactive on the NATSpert which included 77 serology positive and 8 NAT yield cases. The NAT yield found was 2 each for HBV/HIV and 4 of HCV. Conclusion: The NATSpert ID TripleH offers a statistically significant advantage over EIA in ability to detect TTI in blood donors (P < 0.05, Fishers Exact Test). The NAT yield of 1:3829 was in line with other Indian studies. NATSpert assay will provide a significant improvement in blood safety and offer a cost benefit compared to the imported products.

Adverse effects of intermittent flow therapeutic plasmapheresis in neurology patients in a resource constrained setting Sukanya Baruah, Sundar Periyavan Global Journal of Transfusion Medicine 2019 4(2):163-167 Introduction: Therapeutic plasma exchange (TPE) aims at removing harmful substances from patient's plasma. It has become a treatment option in a variety of neurological disorders with good outcome. In the last decade, there has been an increase in the number and spectrum of indications for therapeutic apheresis. Aims and Objectives: To analyse the complications of plasmapheresis patients with varied neurological disorders in a tertiary care neurocentre to evaluate the safety of the procedure. Materials and Methods: A retrospective analysis of complications in all patients who underwent TPE for various neurological disorders in the Transfusion Medicine Department from April 2013 to May 2014 was carried out. Patient record files and TPE protocol forms were analysed to collect the data about various complications during the procedure. Results: A total of 1912 procedures were carried out on 399 patients. Guillain Barre Syndrome was the most common indication. A total of 145( 36.3%) patients had adverse reactions. Mild reactions like rash (40%), chill and rigor (21%), cramps (6.8%) were found in 98 cases (68%). Moderate reactions included hypotension (17.9%), access site pain and hematoma (7.5%), vasovagal attack (3.44%), seizure (1.37%) etc. Severe life threatning reactions were not seen in any of the cases. Conclusion: Our results advocate TPE as a safe and effective procedure in neurological disorders. Most complications are mild and can be managed effectively. Complications can be further reduced by careful patient monitoring, use of prophylactic calcium and use of albumin as replacement fluid.

“Prevalence of Inhibitors in Hemophilia Patients and its Clinical Implications”: A Study of 276 Patients in Western India Sangita Darshan Shah, Tarak R Patel, Nidhi M Bhatnagar, Maitrey D Gajjar, Mamta Chintan Shah, Sujata Tripathi Global Journal of Transfusion Medicine 2019 4(2):168-174 Introduction: Hemophilia is an X-linked congenital bleeding disorder caused by a deficiency of coagulation factor VIII (FVIII) in hemophilia A (HA) or factor IX (FIX) in hemophilia B (HB). Accurate diagnosis of hemophilia by factor assay to demonstrate deficiency of FVIII or FIX is essential for appropriate management. Inhibitor development results in partial or complete lack of the efficacy of replacement therapy, and it makes the management of patients more difficult with an increased risk of morbidity, serious bleeding, and disability, resulting in a substantial impact on patient's quality of life and health-care costs, compared to patients without inhibitors. Aims and Objectives: To assess the incidence of inhibitor development in HA and HB patients along with its consequences. Materials and Methods: The present study was carried out at a tertiary care teaching hospital in Western India. A total of 276 patients of hemophilia were included in the study. FVIII, FIX, and inhibitor screening were carried out in all patients sample as routine testing. Patients who were found positive in inhibitor screening were further evaluated for quantitative assay (Bethesda assay). Results: Out of total 276 patients, 243 patients of HA and 33 patients of HB were observed. The incidence of inhibitor development is 20.57% in HA and 6.06% in HB. The maximum number of patients and maximum number of inhibitors was between the age group of 11 and 30 years. There was more number of patients with severe disease as compared to mild and moderate forms. The concentration of inhibitor >5 BU was seen in 76% of HA patients and 100% of HB patients with inhibitor. Sixty-one patients came for follow-up. In three patients, inhibitor disappeared. The incidence of complications was more in patients who had developed inhibitor which increases the cost of treatment and increases the social suffering of the patients. Conclusion: Inhibitor development affect the severity and treatment of the disease significantly and there by increases the suffering and cost to the patient.

Critical audit of fresh frozen plasma transfusion practices in obstetric and gynecology departments in a tertiary care hospital – Where and what needs to be improved? Vandana Puri, Ipsita Dhal, Kalpana Singh, Geetika Sharma, Preeti Rai, Sunita Sharma Global Journal of Transfusion Medicine 2019 4(2):175-179 Introduction: Fresh frozen plasma (FFP) prepared from whole blood contains plasma proteins and all the coagulation factors including factor V and factor VIII. Many FFP transfusion guidelines have been published till now. However, the administration is inappropriate without any scientific basis or clinical indication in many hospital settings. Aims and Objectives: A retrospective study was carried out between February 2016 and August 2016 in the regional blood transfusion center of our institution to assess the appropriate usage of FFP in obstetrics and Gynecology. It was done using the FFP transfusion guidelines based on the British Committee for Standards in Hematology and College of American Pathologists. Materials and Methods: Blood bank requisition forms received from patients of obstetrics and gynecology department during this period were screened. Indications for transfusion requests were studied and further divided into appropriate and inappropriate requests. Results: A total of 901 units of FFP were issued to 250 patients during this period. Appropriate usage of FFP was found in 67% and inappropriate usage in 33% of the 250 patients evaluated. Bleeding related to surgery with deranged coagulation profile constituted the most common appropriate indication for FFP infusion, and severe anemia was the most inappropriate indication for FFP use. Conclusion: The usage of FFP requires a proper understanding and knowledge about the appropriate and inappropriate usages. It also involves training and supervising the medical staff at regular intervals. Computerized audit programs are required to do a prospective monitoring of the FFP issue and usage in any clinical setting. Further studies are required on the usage of FFP specifically in obstetric and gynecology patients to improve the utilization of this precious blood product.

Allogenic blood transfusion requirements and effects of storage age of blood units on postoperative period in cardiac surgeries: An analytical study Basudev Pokhrel, Abhishekh Basavarajegowda, Sai Chandran, Debdatta Basu, Tanveer Rehman Global Journal of Transfusion Medicine 2019 4(2):180-185 Introduction: The clinical use of blood with regard to cardiac surgeries should be justifiable as it is associated with significant transfusion requirements, and tends to put a great burden on the blood inventory. Storage of red blood cell (RBC) induces various biochemical, biomechanical, and immunological changes that affect red cell viability, deformability, oxygen-carrying capacity, microcirculatory flow, and hence cause various adverse outcomes related to transfusion. Aim of Study: We made an effort to investigate the patterns of usage of allogenic blood products and the effect of volume and storage age of transfused RBCs with morbidity and mortality after cardiac surgery. Methodology: This was a cross-sectional analytical study conducted from January 2016 to June 2017, including all patients undergoing elective open-heart cardiac surgery at a tertiary care hospital. Records were reviewed for the details of blood components issued such as date of collection, date of transfusion, date of expiry and number of units of blood components transfused, details of the surgery, demographic details, postoperative length of stay (PLOS), and complications. Results: A total of 75 patients were included in this study. The majority of the surgeries (60%) were done for rheumatic heart disease. The difference in the transfusion patterns of various blood products with respect to the types of surgery, age or gender was statistically not significant. There was an association between increased PLOS (considered to be >11 days which is the mean) and mean unit age of the transfused packed RBCs (pRBCs) and the difference was statistically significant using the Chi-square test. Conclusion: There is a wide variation in transfusion practices in patients undergoing cardiac surgery. There is no significant association between the number of pRBCs transfusions and postoperative neurological, pulmonary, and other complications when number of pRBCs units ≤4.