Neil Blumberg

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

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

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

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.

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.

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.

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.

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.

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.

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.

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.

Obviously worth repeating. Sample mixup, technical error are other possibilities.

Should add that individuals with sickle trait have % S that is usually less than 50%. At those levels, even patients with SS disease usually are asymptomatic. Sickle trait individuals do not have symptoms under anything less than extreme physiologic stress, although some believe that occasional individuals have had complications when severely hypoxic or stressed. These case reports tend to neglect the fact that individuals who do not have S hemoglobin can have similar symptoms under extreme physiologic or hypoxic stress, so it's not clear these individuals with sickle trait are truly at gre

Sounds like a good plan. Reducing needless work is a great idea. I find it absurd to require busy practitioners to attest to the urgency of a clinical request by installing bureaucratic obstacles. It may be required by regulators and accreditation agencies, but it is bureaucratic nincompoopery (sic) to my mind, serving no real purpose. A discussion of the pros and cons of giving out red cells without an antibody screen should occur with every such request when time allows. Almost no one does a physical crossmatch these days anyway, to my knowledge, except if alloantibodies are present

Patients with sickle trait do not have sickle crises at all, except in very rare cases when they become seriously hypoxic. There are rare cases reported in military personnel and athletes. It's not clear whether they are sickle crises in some cases or just similar symptoms seen in non-sickle cell patients. These are truly rare cases, and usually at higher stress than an altitude of 8,000 feet, which really isn't terribly high. No personal experience. In extreme circumstances, patients heterozygous for S may be slightly more susceptible to symptoms like mountain sickness, just like everyon