Neil Blumberg

We have no critical values in the Blood Bank and we have a cancer center that sees thousands of patients per month. And it is my recommendation that critical values be restricted to truly life threatening conditions that require treatment within minutes to hours (e.g., very high or low potassium). I would most definitely NOT have critical values for things like creatinine/BUN, liver function tests, MCV, white count, etc. Provides no clinically actionable information acutely, and wastes a lot of time in the lab and amongst practitioners.

I'd also add that none of the cell washers are FDA approved for washing platelets. We've been washing platelets on the 2991 for about 40 years :). I believe there may be a paper on using the ACP-215 to wash platelets but as yet we do not have any hands on experience. We have developed a manual method of platelet washing using a Sorvall centrifuge. If your volume isn't too high, you might consider a manual wash method. It takes a bit longer, but actually has higher recoveries (>90% vs. about 80-85% with the 2991). Folks will tell you that washed platelets don't work clinically and the count increment is Washed Tx Leukemia.pdfWashed Tx Leukemia.pdflower. The increment is indeed lower, but if you employ platelets that aren't ABO incompatible with the recipient and remove the supernatant, the clinical results are actually better than the clueless advice to give ABO major incompatible platelets routinely (e.g., group A to group O recipients). The PLADO study had a bleeding rate using this abominable practice of about 70%. Our bleeding rate avoiding infusion of ABO incompatible antigen or antibody is 5%, with or without washing. A fourteen fold difference. So by all means give washed platelets to patients with severe or recurrent reactions, or avoid infusion of ABO incompatible plasma, and, if you believe our randomized trial data, to improve the survival of younger patients with acute myeloid leukemia. References attached if anyone is interestedWashing AML Greener_et_al-2017-American_Journal_of_Hematology.pdf. Washing Review IJCTM-101401-the-clinical-benefit-of-washing-red-blood-cells-before-transfusion.pdf Washing AML Greener Am J Hemat AML Washing Supplementary Figures and Tables.pdf Jill's washing paper.pdf Plt Washing Vo.pdf

There is no regulatory nor clinical reason not to wash AS-3 units on the Haemonetics device. Just validate it for red cell recovery and hemolysis, comparing AS-3 with five AS-1, CPD-A1 or other units you can obtain from another blood center, if this makes you feel more secure. We wouldn't and won't bother to do so. The results will likely be identical. There is no material difference in red cell preservation issues with the various additive solutions and certainly no evidence of difference in clinical outcomes.

Hail and farewell.

This is why all transfusion services need experienced/trained physicians. It's a clinical decision weighing the risks of not transfusing urgently vs. the risks of alloimmunization. And the risks of not having Rh negative red cells for patients where such products provide important safety (girls and women <40-50; patients with anti-D). Obviously the issues in alloimmunizing a male patient, particularly an older patient, are very different from a woman or girl with the potential for future pregnancy. If not terrifically urgent, requires a discussion between the practitioner responsible for the patient and the transfusion service physician. I've certainly made decisions independently and only informed the patient's physician after the fact, when the maintenance of Rh negative red cell supply has been a priority. Hard to write a procedure that covers all possibilities, so one would have to be broadly written, and probably kept it short on details, since these are so variable.

I would like to see studies as to why transfusion services continue to provide ABO non-identical transfusions when they have ABO identical components in stock. ABO mismatched red cells (so-called universal donor group O red cells), platelets and plasma (so-called universal donor AB plasma) have all been associated in randomized trials (platelets) and observational studies (red cells and plasma) with increased mortality, bleeding and other dire complications. Why has an entire specialty failed to take notice of data that contradict long standing dogma? What can be done to improve this performance and reduce suffering, morbidity and mortality amongst our patients? This is particularly important because ABO non-identical platelets may actually make hemostasis worse, and thus no transfusion is likely better than an ABO non-identical platelet transfusion, as one example.

Not in a blood collection center, so no policy. But scientifically there is no rationale for donor deferment. The vaccines are not live/attenuated but rather just protein with no potentially infectious material of concern to recipients. The virus, in any case, should only infect respiratory mucosa and thus would represent minimal to no risk to recipients even if present in donor blood (similar to coronavirus and influenza).

Our Red Cross just informed us that it will discontinue providing CPDA-1 rbc. We primarily used it to provide volume reduced red cells to pediatric patients under 3 years of age. We will volume reduce AS-1 or AS-3 by centrifugation or washing (Terumo 2991) instead. Probably unnecessary for most patients, but this is a long standing practice here, and it doesn't seem worthwhile trying to adjust pediatric practice in this regard. Most patients do not need the additional volume provided by the anticoagulant-preservative in AS-1, etc., and avoiding unnecessary volume is a reasonable goal in many patients. There is no inherent virtue to CPDA-1 vs. AS-1 and similar solutions, and rbc preservation is slightly better in AS-1/AS-3 by in vitro metrics. There is absolutely no factual basis for using CPD-A1 in preference to AS-1, etc. in pediatrics. Purely expert opinion and probably unduly conservative. I've attached a nice presentation by Dr. Saifee at the University of Washington, who createdAdditive solution AS-1 in Children Univ. Washington presentation Dec 2021.pptx it to educate her colleagues about using AS-1 instead of CPDA-1. Additive solution AS-1 in Children Univ. Washington presentation Dec 2021.pptx Pediatric RBC White Paper - November 2021.pdf

Peter was always helpful, gracious and supportive of everyone in the field. He made great contributions, not least of which was his definitive book Applied Blood Group Serology, which was recently reprinted. A fabulous reference for the ages. Doubt it will ever be replaced or exceeded. Hail and farewell.

While it is infrequently referenced, universal leukoreduction is one strategy for minimizing pulmonary and cardiovascular adverse responses to transfusion (see attached). When we instituted it in 2000 our rate of TRALI decreased by 80+ % and TACO decreased by 50%. Probably mechanism is that white cells, DNA, histones and neutrophil extracellular traps (NETs) cause acute lung injury and inflammation when infused (good animal model data exist). Thus the failure to implement universal leukoreduction in the USA during the last 23-25 years was a terrible and tragic mistake, and this fatal error persists to this day. ULR TRALI TACO PMC version.pdf

Larry Petz died about a year ago. He had completed a transition to working on cellular therapies in his later old age. Here's his obituary. He had a long and very productive life. https://obituaries.neptunesociety.com/obituaries/sherman-oaks-ca/lawrence-petz-10780477

We send cards to physicians (for their patients, if they like) because it is our responsibility to patients, not because it works well. If anyone has better ideas, please share them. Obviously a national database would be best. Doing absolutely nothing is not an option from our standpoint.

Another thing to try to increase sensitivity (other than PEG or other enhancement) is to increase the serum/cell ratio in the screen/indirect antiglobulin test. If there is no reactivity with enhancement, enzyme treated rbc (agree with Malcolm's caveat that some antigens will be destroyed) and increased serum/cell, one can be more confident there is nothing detectable pre-transfusion. Some consolation at least ...

One additional approach would be to increase the sensitivity of the antibody screen by your preferred method (e.g., PEG, ± using enzyme treated red cells). Obviously increases the possibility of detecting pan-reactivity/false positive tests.

Not a sensible approach in my opinion. No real chance of mistyping due to fetal bleed. At very least, you'd see a mixed field if there were a fetal bleed with a different type. So get rid of this requirement in my view.

Our policy is to not transfuse to patients with the corresponding antigen (obviously ) and to wash the unit with Plasmalyte (our standard washing solution). I realize most places do not have the capability for washing or even centrifugation to remove most plasma. In that case, I would simply not use it for a patient. If you don't wash it, you then have to make sure the patient isn't transfused with an antigen positive unit later in their course, or at some other hospital. Too much opportunity for misadventure to my way of thinking.

Just to be clear, these regulations are almost totally arbitrary and can be overridden by a physician's judgement. There are no data to support this 30 minutes nonsense nor the 1-10 degree storage requirement. Just so we all understand there is almost no scientific or clinical basis for our regulatory rigidity and we are usually discarding perfectly safe units of blood. Rant off :).

Could you define what you mean by deactivating, please? Not familiar with the meaning of this term.

I'd go up the food chain ladder and consult with this inspector's supervisor. Clearly if the lab receives five samples, giving them all to one technologist does not in any way mirror clinical practice, and thus violates the regulations. Thus my initial take on this is that is another extremely bad idea from an inspector who has no idea what they are doing. Sort of the old joke about some physicians: "Occasionally wrong, but never in doubt."

Transfusion Medicine in our institution includes the Blood Bank/Transfusion Service, Donor Service and Stem Cell Processing Laboratory. Outside each facility we have the relevant signage. Some places it includes Therapeutic Apheresis, which in our institution is both physically separate (so is our Donor Room) and located in the Dept. of Medicine (Cancer Center). As long as the facilities are well defined, I'm not sure the overall name matters much, except on stationery, which no one uses much anyway :).

No AABB standard requires a crash cart. Donors do not develop anaphylactic reactions, but this type of reaction is why offices or facilities that administer transfusions or IVIgG (and similar products) need to be able to administer epinephrine emergently. Most of the rest of the stuff in a crash cart would never be needed and certainly not for blood donors. So no crash cart unless you are administering human blood products or drugs that can cause anaphylaxis.

"Just curious, can one give a group A1 kidney to a group B patient who has a very low isoagglutinin titer ?" It's been done. Depends on the ability to suppress the anti-A titer low enough through immunosuppressive drugs and plasma exchange, the usual preparative regimen. Obviously ABO identical is best, but this is an alternative at some centers with experience doing these transplants.

"The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk. " I would call this some combination of cowardice and insanity, speaking purely personally. Taking responsibility for difficult decisions is why physicians get paid well, and avoiding decision making is irresponsible.

We are inspected by FDA, NY State, AABB, CAP and FACT. Lots of opportunities for self-important, obsessive folks to make useless work for the people trying to take care of patients. The stories I could tell. We've also had many rational, balanced, thoughtful inspectors who clearly are only focused on the important stuff, to be fair. But a significant portion of our profession(s)' people do not realize that getting staff to focus on minutiae that will not affect patient outcomes distracts staff from doing the important things well. A well known psychologic/cognitive fact. Keep it simple and avoid worrying about unimportant stuff. The notion that documentation is more important than anything else is the most pernicious piece of rubbish in medicine, and driven by the administrative/legal model (and billing of course). And people proudly spout this nonsense as if it actually helped anyone but those in accounts receivable. I'd personally like the technologist doing my pre-transfusion testing to get the ABO and antibody screen correct as a trillion fold more important relative to them documenting what time, date or temperature all of that was done. Not to mention what that person had for lunch or dinner before the crossmatch (coming soon to an inspection near you). For the record I'm a Gemini, which I assiduously and loyally document in every interpretation and progress note I write.

Just the person you want operating on your brain or reading your prostate biopsy, no doubt. Makes one proud to be a part of the same profession. Not. Pettifogging fool. Perhaps he is nice to his dog and children.