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Neil Blumberg

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Neil Blumberg last won the day on September 12

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    Hematologist/Transfusion Medicine Physician

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  1. Neil Blumberg

    group O RBCs for non O neonates

    Because of the rare risk of a fatal hemolytic reaction, we only use washed group O red cells for our premature newborns. For other newborns and readmits we use ABO identical unless there is detectable maternal anti-A and/or anti-B, in which case we again use washed group O's. There is about 20-40 ml of residual plasma in almost all red cell units, more than enough to cause severe hemolysis in rare instances. We should not ignore that risk for our own convenience/inventory management/etc. in my view. We only transfuse unwashed group O red cells to patients of unknown ABO type in emergencies. There is additional evidence that ABO non-identical transfusions of incompatible antibody or soluble antigen causes harm to patients, in addition to the rare risk of life-threatening hemolysis. We have published a summary of this evidence. Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions? Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N. Anesth Analg. 2018 Jun;126(6):2135-2138. doi: 10.1213/ANE.0000000000002600.
  2. Neil Blumberg

    Group O platelets titer

    Sorry about the incomplete references. Here are the full references for the two missing :). ABO identical and washed blood transfusions as candidate strategies to reduce early mortality in acute promyelocytic leukemia. Sahai T, Henrichs K, Refaai M, Heal JM, Kirkley SA, Schmidt AE, Mendler JH, Masel D, Liesveld J, Aquina C, Blumberg N. Leuk Res. 2017 Nov;62:1-3. doi: 10.1016/j.leukres.2017.09.011. ABO-immune complex formation and impact on platelet function, red cell structural integrity and haemostasis: an in vitro model of ABO non-identical transfusion. Zaffuto BJ, Conley GW, Connolly GC, Henrichs KF, Francis CW, Heal JM, Blumberg N, Refaai MA. Vox Sang. 2016 Apr;110(3):219-26. doi: 10.1111/vox.12354.
  3. Neil Blumberg

    Group O platelets titer

    Transfusion of ABO-mismatched platelets leads to early platelet refractoriness. Carr R, Hutton JL, Jenkins JA, Lucas GF, Amphlett NW. Br J Haematol. 1990 Jul;75(3):408-13. The role of ABO matching in platelet transfusion. Heal JM, Rowe JM, McMican A, Masel D, Finke C, Blumberg N. Eur J Haematol. 1993 Feb;50(2):110-7. ABO and platelet transfusion revisited. Heal JM, Rowe JM, Blumberg N. Ann Hematol. 1993 Jun;66(6):309-14. Association of ABO-mismatched platelet transfusions with morbidity and mortality in cardiac surgery. Blumberg N, Heal JM, Hicks GL Jr, Risher WH. Transfusion. 2001 Jun;41(6):790-3. ABO identical and washed blood transfusions as candidate strategies to reduce early mortality in acute promyelocytic leukemia. Sahai T, Henrichs K, Refaai M, Heal JM, Kirkley SA, Schmidt AE, Mendler JH, Masel D, Liesveld J, Aquina C, Blumberg N. ABO-immune complex formation and impact on platelet function, red cell structural integrity and haemostasis: an in vitro model of ABO non-identical transfusion. Zaffuto BJ, Conley GW, Connolly GC, Henrichs KF, Francis CW, Heal JM, Blumberg N, Refaai MA. An association of ABO non-identical platelet and cryoprecipitate transfusions with altered red cell transfusion needs in surgical patients. Refaai MA, Fialkow LB, Heal JM, Henrichs KF, Spinelli SL, Phipps RP, Masel E, Smith BH, Corsetti JP, Francis CW, Bankey PE, Blumberg N. Vox Sang. 2011 Jul;101(1):55-60. doi: 10.1111/j.1423-0410.2010.01464.x. Providing ABO-identical platelets and cryoprecipitate to (almost) all patients: approach, logistics, and associated decreases in transfusion reaction and red blood cell alloimmunization incidence. Henrichs KF, Howk N, Masel DS, Thayer M, Refaai MA, Kirkley SA, Heal JM, Blumberg N. Transfusion. 2012 Mar;52(3):635-40. Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions? Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N. Anesth Analg. 2018 Jun;126(6):2135-2138.
  4. Both Plasma-Lyte A and Normosol are FDA approved in addition to saline. They are almost certainly better for the patient. The circular of information and AABB guidances need to be changed to reflect this old information (FDA label approval) and new information (normal saline is more toxic than other crystalloids--see the early March 2018 issue of NEJM for example; first authors Semler and Self, respectively).
  5. Neil Blumberg

    Physician Signature for Emergency Released Blood

    I agree that discussing the risks with the ordering provider is essential. Most physicians have zero formal training about transfusion risk. Medical school students today receive at most one lecture on transfusion, the most commonly coded procedure for inpatients in the USA. The medical curriculum is a political muddle where there is almost no relationship between what needs to be learned and what is taught. That said, every uncrossmatched blood order (with no ABO typing, no antibody screen) should be questioned, if possible. But signing a form isn't the key step :). A brief, to the point discussion of the risks of the giving ABO non-identical blood components, and in the absence of an antibody screen should be had if time permits. Clinicians, whether physicians, nurses, NPs, PAs, etc. often have no idea that these emergency transfusions are substantially less safe than waiting 20-30 minutes for ABO type specific, antibody screen vetted red cells.
  6. Neil Blumberg

    Group O platelets titer

    If anyone wants references to read supporting the above rant, I'm happy to post them. Or just go PubMed and search on Blumberg ABO platelets. I'm afraid on this issue, the academic medical community is pretty much doing the ostrich thing :). They are waiting for definitive proof when the evidence is already more than enough to change practices. The cavalier practice of using group O red cells as universal donor, equivalent to ABO identical, and AB plasma, in routine (as opposed to emergency) use should be stopped.
  7. Neil Blumberg

    Group O platelets titer

    There are multiple problems here that have not been adequately addressed by either the bedside practitioners and by the blood bankers/transfusion medicine community. The problems relate to assumptions that have turned out to be false. The first assumption is that platelet transfusion is very effective at treating or preventing bleeding. It turns out that's not really true, at least as currently practiced. Randomized trials show that, for example, in autologous stem cell transplant patients, prophylactic transfusion provides minimal benefit. In acute myeloid leukemia induction therapy (really sick patients with active disease), prophylactic transfusion provides some benefit. But at great cost to the patient. The more platelet transfusions you receive, the less likely you are to have your disease cured in our cohort study. So more conservative transfusion practice is actually a good idea. There is also no big rush. Waiting a few hours to receive a prophylactic transfusion of platelets is of no real concern in my view. Unless there is active bleeding, or a history of bleeding at certain counts, waiting for an ABO identical platelet makes great sense. It turns out that ABO mismatched platelets may not actually work to prevent bleeding and we have evidence they may actually make bleeding worse. In addition, platelet transfusion predispose to nosocomial infection, thrombosis and multi-organ failure in observational studies. And mortality. Clinicians should think six times before giving a platelet transfusion in many settings. The risks are vastly worse than we knew. As for us. We've vastly misread the efficacy and safety of platelet transfusions that are ABO mismatched. In our surgical cohorts, the more ABO mismatched transfusions you receive, the higher the mortality rate, as well as increased bleeding. The problem with titers is that antibody quantity is only one of the factors that influence biologic activity and clinical outcomes. Ability to fix complement, avidity, etc. are probably as important. There is absolutely no evidence for the common sense and likely partially true assumption that lower titer is safer. But what titer? Some places use 1:200 and some 1:50. No evidence. I'd obviously go with 1:50 before 1:200. But the real answer is ABO identical, even if waiting a few hours is necessary, or platelets stored without plasma (then group O would be best) or supernatant removal by washing. I'm sure Terumo or Haemonetics could come with a simple, fast, automated washing system (it probably won't be free ) if they thought people would buy them. They should and we should. Our current practices are probably doing minimal good, great harm and are not consistent with what we now know about ABO mismatched platelet transfusions. Hope this helps explain my passion on the subjects.
  8. Neil Blumberg

    Group O platelets titer

    To my knowledge there is not a shred of evidence that titers (or titres:)) have any clinical benefit in this situation. We are treating ourselves, not the patient. I understand the need to "do something." In our case, our something is always giving ABO identical platelets, or, when this is not possible, we wash group O platelets. Titer/titre then becomes a moot point. I also get that blood bankers hate to wash anything, especially platelets, but we have randomized trial data this improves survival in younger patients with leukemia. Also avoids positive DATs, hemolysis and refractoriness to transfusion. A culture change is needed in which we accept what we've know for decades. Transfusing a group O red cell (or platelet) to a non-O patient can very rarely result in fatal hemolysis. Why we keep doing this despite the ability to avoid this rare fatal complication is a mystery to me, except for inertia and inconvenience. Of course a long standing practice that we assumed completely safe without a shred of data is hard to change. But the evidence is quite clear that group O platelets and rbc are not universal donor unless you accept a small but real risk of death for the patient. Not a practice to be defended in this day and age. As hard as it will be, I hope we will all start doing that which is best for recipients. Not what is best for inventory control or reducing wastage, which are important but lesser values.
  9. Neil Blumberg

    Physician Signature for Emergency Released Blood

    I agree that somewhere the responsible transfusion service physician should have signed the SOP, or if the SOP could not be followed, signed a deviation report. Where I part company from the conventional way of doing things at some centers is asking that the ordering physician also sign an additional form confirming what is hopefully in the medical record, that this was an urgent situation where standard serologic testing could not be performed. Adding more bureaucracy in this way is obstructive, time wasting and energy sapping, and serves no clinical purpose in my view.
  10. Neil Blumberg

    Physician Signature for Emergency Released Blood

    This use of a signature as a bludgeon against ordering physicians is something we should give up. We all know that in most cases of life-threatening bleeding, even 5-10 minutes delay can be fatal, so why pretend that our testing is the key element in good care? We are partners in providing the appropriate care that the clinical situation calls for. If a physician says he or she cannot wait for testing (ABO/Rh, or antibody screen, or physical crossmatch) it makes no sense to contest that claim or ask them to document it with a signature putting all the responsibility for outcomes on their shoulders. Physicians give verbal orders for all sorts of things, and documenting that verbal order for blood transfusion prior to whatever testing is missing should include the verbal order. Signatures are a waste of everyone's time and an attempt to shift responsibility for outcomes for what we have to do onto the ordering provider. Your mileage may vary, but I thought we were a team.
  11. Neil Blumberg

    Platelet transfusion ABO-nonidentical

    This is a controversial subject. Firstly, ABO identical is by the most effective and safest. ABO mismatched platelets are associated in randomized trials with a 2-5 fold increase in refractoriness to transfusion, with is in itself associated with early mortality. ABO mismatched platelets in observational studies are associated with increases in febrile transfusion reactions, allergic transfusion reactions, increased bleeding and mortality. Is a single transfusion likely to be lethal? Probably not, but the blithe use of any old ABO type for multiple transfusions is highly likely to cause morbidity and mortality. In a pinch, when the ABO is not known or ABO identical aren't available, washed or plasma reduced group O platelets are probably safest. If not available, group A is probably safest. My last choice in all instances would be plasma replete group O, because there is a tiny but real risk of a fatal ABO hemolytic reaction due to the 250 ml of incompatible plasma. Incompatible antigen is probably less risky, hence the recommendation of group A platelets. Group A plasma has anti-B, which is the least dangerous of the two isoagglutinins in every respect. Is It Time to Reconsider the Concepts of "Universal Donor" and "ABO Compatible" Transfusions? Refaai MA, Cahill C, Masel D, Schmidt AE, Heal JM, Kirkley SA, Blumberg N. Anesth Analg. 2018 Jun;126(6):2135-2138. doi: 10.1213/ANE.0000000000002600.
  12. Neil Blumberg

    Group O Whole Blood, Low Titer

    The whole blood being used in Pittsburgh is leukoreduced. They have chosen a titer of 50, which I would think is much safer than 200, but who knows? It would nice to have high quality data, or any data whatever, comparing the results with whole blood with similar patients transfused with the usual group O red cells, platelets of whatever group (usually) and AB plasma. I'd speculate that there is no difference because mixing group O red cells with AB plasma gives patients a substantial dose of iatrogenic ABO immune complexes, which we have demonstrated leads to impaired platelet function (in vitro), endothelial damage (unpublished in vitro data) and increased bleeding (observational clinical data). Thus low titer group O whole blood might well be safer than our current practices, which have only been validated not to cause acute massive hemolysis, which is only one of many disastrous clinical outcomes that can result from crossing ABO barriers. Focusing on red cells is fine, but there are other cells in the body that carry ABO antigens (endothelial cells for example) and loads of soluble antigen.
  13. Neil Blumberg

    Group O Whole Blood, Low Titer

    "Stupid question - why is group O whole blood better than group O pack cells and group A thawed plasma? " Not stupid at all. There is no clinical evidence that it is superior or inferior. In fact, no clinical evidence whatever. The main attraction is that it simplifies transfusion in the patients who require red cells, plasma and platelets. One bag instead of three. That it provides better hemostasis is a supposition that may or may not prove to be wrong. It's concerning to me that it's very hard to predict who really needs anything but red cells. One estimate from London is 25% but that includes everyone with an elevated PT/INR and PTT, which are not good tests for predicting bleeding. We examined the last half year of our ED uncrossmatched blood cooler release in our Level 1 trauma center in a medium sized American city. We do not routinely start the massive transfusion protocol with the first cooler (or even the second, unless asked to do so). Of the 230 or so patients, only 2 wound up using more than 8 red cells (0.86%). I suspect this is typical of many university hospitals and almost all smaller teaching hospitals. Hence, no whole blood, no massive transfusion protocol routinely started on arrival, unless requested. I would think that whole blood as the first product to be infused for our patients would harm more patients than help (TRALI, TACO, etc.).
  14. Neil Blumberg

    <4 hour transfusion time limit requirement

    Probably not helpful, but there is not a shred of scientific or clinical evidence for the efficacy and safety of this time limit. Totally expert opinion based upon a group of white haired males (like me) sitting around a table eating tuna fish sandwiches 60 years ago :). We document such stuff for the two regulatory agencies and two accreditation groups we are inspected by. How's that for efficiency? Four inspections.
  15. Neil Blumberg

    blood in free standing ED

    Not to my knowledge. Indeed, I don't believe free standing EDs should have blood available, unless there is no hospital within 20-30 miles and no helicopters are available for transport. I would want patients with life threatening bleeding or anemia to be taken only to a facility with on-site surgical facilities, surgeons, interventional radiology, etc. which are generally not available in free standing EDs. In other words, a fully staffed hospital. I would advocate taking such critically ill patients to the nearest level 1 or 2 trauma center, whenever one can, and bypass the free standing ED.
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