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Neil Blumberg

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Neil Blumberg last won the day on July 18

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    Hematologist/Transfusion Medicine Physician

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  1. Disciplinary action over product wastage sounds like it is perhaps well intentioned but ignorant bureaucrats, not health care workers running the show. That's a big part of the problem in many institutions these days. We are fortunate in that the senior decision makers in our hospital are all physicians, nurses, etc., including the CEO, CMO, COO. Washing your hands before delivering babies turns out to be inconvenient but a better idea. Universal leukoreduction and avoiding infusion of ABO incompatible antigen and antibody are also better ideas than what we have done for decades or lon
  2. Once clinicians understand that ABO mismatched platelets not only do not provide hemostasis, but make bleeding more likely/worse, they will be less willing to accept infusion of ABO mismatched antibody/antigen. Once blood transfusion services realize that infusing ABO mismatched platelets increases utilization by two fold, they will be more interested in making the effort to give ABO identical or remove incompatible plasma by washing. Doing the right thing for patients is never the wrong answer to the question. Our current practices are convenient for us and minimize waste. We need to prior
  3. Cannot post the entire article due to copyright restrictions, but most institutions have access to NEJM through their library. If not, shoot me an email at neil_blumberg@urmc.rochester.edu and I'll send along the .pdf. If you are transfusing 40-60 platelets a day, giving ABO identical to group O and A individuals should be relatively easy. When patients are changing ABO blood group it becomes more difficult. We avoid transfusion ABO antigen and/or antibody that is incompatible with either original recipient type or donor type. Usually means washed group O red cells and platelets. That
  4. Research letter in NEJM describes our findings. https://www.nejm.org/doi/full/10.1056/NEJMc2034764?fbclid=IwAR1BQRvpaHBAMDaHxCPY07xBjPQHlIHoJCOmpjoT_pBNvQsV7pzzDVdLYaY Table 1. HLA-Matched Platelets as a Percentage of All Platelet Transfusions, According to the Initiation of Other Protocols.* Protocol and Timing of Initiation No. of Years HLA-Matched Platelets Difference from Previous Period (95% CI) median % (IQR) percentage po
  5. I've summarized the data in this letter: https://www.bmj.com/content/366/bmj.l4968 In randomized trials, the fresher blood arm is associated with a higher incidence of nosocomial infection (immunomodulation, presumably). There has never been any data examining clinical outcomes that actually favors using very fresh blood. Mostly just "expert opinion" and "it seemed like a good idea." That's not good enough now, in my view. Two key references (one only published in abstract form) are: Alexander PE, Barty R, Fei
  6. Our neonatal intensive care transfusions are all irradiated because many severe immunodeficiency states are not evident until weeks to months after birth. These are rare, and leukoreduced transfusions probably mitigate the risk of GVHD somewhat, but we are erring on the side of caution. We irradiate just before transfusion so the storage based problems with irradiated red cells are less of a concern. We define fresh as <21 days of storage, because the data suggest very fresh blood is actually more dangerous to patients than blood stored 7-21 days or so. Seat of the pants, to be sure, but
  7. All you need to do is document platelet recovery (should be at least 80%) and pH. Nothing else is required. No platelet function tests, etc. since these are not used with unwashed platelets. Would recommend washing in platelet additive solution rather than saline.Washed platelet buffy coat platelet additive manual.pdf
  8. Should mention that Terumo has a similar process that is licensed in Europe using riboflavin. Both Cerus and Terumo have licenses for whole blood platelets but for some reason these have not been introduced in the USA, so only apheresis platelets are pathogen reduced at present. Which makes little sense from a resource or cost standpoint. There are no clinical advantages to pathogen reduced apheresis platelets over whole blood platelets and apheresis platelets carry a greater risk of acute lung injury due to the five fold increase in plasma from a single "dangerous" donor.
  9. Pathogen reduced platelets are treated with a Cerus Corp. method of using light to activate a photo-activated psoralen compound that cross links DNA and RNA, thus making it impossible for cells to replicate, and, more importantly, viruses, bacteria and fungi to replicate. Thus the risks of bacterial infection after platelet transfusion become near zero. Increases the cost by about $150 from your blood supplier. Saves the occasional life threatening post-transfusion bacterial septic infection, and may reduce line infections too I'd guess.
  10. There is absolutely no scientific or clinical reason that a vaccine could not be stored with frozen blood components. That doesn't mean you won't get some overly officious inspector who will decide it's a bad idea. But currently there are no regulatory or accreditation issues that I am aware of.
  11. We used to do universal irradiation but then became aware of two things. One, irradiation of red cells causes increased hemolysis during storage. That's been known for some time. But in recent years, the toxic effects of infusing free hemoglobin or increasing hemolysis in vivo have become evident (e.g., sickle cell anemia; levels of hemolysis correlating with morbidity in surgical patients). So we stopped irradiating everything at that point. Just per protocol. Leukoreduction reduces GVH in the British data.
  12. No one knows what to do for sure. We keep such patients on irradiated for life, since these recipients are not immunologically normal in many cases. But there are no data to support or refute this practice. Seems low risk and prudent to us.
  13. I would not be performing one hour post-transfusion vital signs unless the patient has signs or symptoms that require assessment. I would not be reacting to one hour post-transfusion data unless they were consonant with a transfusion reaction. If fever was the only sign or symptom, it's probably not transfusion related in the vast majority of cases. Routine vital signs in the absence of a clinical rationale are a problem, not a solution.
  14. Agree with Malcolm. We would tend to give Rh negative blood transfusions so we can tell when the recipient's cells are largely gone. We might do this in particular if the recipient is a female of child bearing age or younger. But we would not be giving Rh immune globulin in the vast majority of settings for the reason that Malcom mentioned.
  15. IM injections hurt. IV hurt much less. Both acutely and over the next day or two. That's the likely motivation. Most physicians don't administer IV meds in their office as it requires more time and skill.
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