Neil Blumberg

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.

I am waiting for some conscientious, firm inspector to insist we add the blood bank director's hat size and astrological sign to each procedure. About as relevant to health care as most of the stuff the accreditation and regulatory agencies obsess about.

There are no data suggesting a particular limit. Survival is very unusual after 30-50 units of red cells, but everyone has exceptional cases like those mentioned above. We have discussed futility of care many times, and our practitioners are quite amenable and forthcoming. We have stopped resuscitation in a young man having a liver transplant go badly, when there was no surgical path to hemostasis after about 250 units, but this is unusual too. Bottom line, a case by case decision as to whether care is futile and/or the patient's needs endanger the well being of other patients needing transfusion. Those are the key issues in each case to my way of thinking.

Another bureaucratic authoritarian idiocy? Sorry, couldn't restrain myself, but there is a cadre of "quality gurus" who are constantly thinking up irrelevant, pointless make work stuff for the rest of us. This is how civilizations come to an end. Why in the world would an SOP have to have the address, name, GPS co-ordinates, topographic elevation and postal code of the facility? How does that address any patient care issue in the universe?

I can see why they make this recommendation. But it is wrong if one has the ability to be sure that the ABO type is known without doubt (the discrepancy has been resolved by drawing another sample and repeating the front typing, for example). We have become quite casual in assuming group O red cells are safe as "universal donor." While this is safest when the ABO is not known, we should never forget this is sub-optimal for non-O patients. Any therapy that has significantly greater risk than the preferred therapy (ABO type specific/identical) is sub-optimal, and we seem to have forgotten this due to the logistic convenience (and sometimes necessity) to give group O red cells to non-O patients. It can be fatal not to mention impairing the blood supply. The absence of isoagglutinins, if anything, makes transfusion safer. The use of universal group O red cells in an emergency may make clinical sense, but exposes the patient to potentially fatal (if very rare) hemolysis due to few dozen milliliters of incompatible plasma when transfused to the 55% of patients who are not group O. To my knowledge, I have never seen or read about a patient whose front typing led to an ABO hemolytic reaction because it was "wrong." The front typing is immunohematologic gold and clinically critical. Not so much the back typing which is merely confirmatory. Granted that in the absence of technical and medical expertise it may not be possible to execute my suggestions, but we should be aware that following the AABB Standards advice is inferior clinical care if implemented as an absolute, because on occasion it will cause great harm.