Neil Blumberg

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.

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.

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.

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.

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.

@Neil Blumberg Exactly. We've all had the odd cases that survive when it doesn't seem they should, and I agree that it's certainly case by case and dependent on hemostasis and coagulation like @Auntie-D said above. We use TEG for coagulation eval as well. I think my trauma surgeons are looking for a prompt to make them aware of how many products they've used, so they can evaluate the futility of continuing versus stopping. Anesthesia is the group transfusing these products, and they can easily lose track as well, so we're looking for an estimate of when the blood bank staff might give them a nudge to let them know they've hit a threshold, and to evaluate the entire picture of the patient with that knowledge, rather than being tunnel visioned into fixing the damage only. I have heard 30-50 units of red cells is the sweet spot as well. We consider more than 30 units of red cells to be a super massive transfusion, so that would jive. 
 

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.

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.

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.

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?  

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.

Instead of fooling around with the back type why not consider doing an anti-globulin crossmatch, or confirming the ABO type of the unit and the patient?
There is no clinical reason to have a stronger backtype if the patient's ABO is clear on repeat samples.  If it is considered important for non-clinical reasons, perhaps do an antiglobulin backtype rather than just arbitrarily increasing the serum to cells ratio, which makes sense but is hard to validate in any convenient way.  Patients with agammaglobulinemia, whether congenital or acquired, may have no isoagglutinins to detect, and it's not worth getting obsessive about it in my view.
Here's another way of looking at this. The absence of isoagglutinins actually makes transfusion safer, as an ABO hemolytic transfusion reaction is very unlikely to occur if there are no detectable anti-A/anti-B.

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.

I could not agree more.  I believe that, if unchecked, some of the accrediting agencies will eventually regulate themselves into irrelevance. 

Neil, sorry to have touched a nerve. 
I think a lot of us "quality guru's" let one requirement bleed over into another.  It is a CMS rule that a patient report has the CLIA information as well as address of the performing lab on any patient result report.  That seems to have turned into "anything the lab publishes must have our address".
I am making some rather substantial changes to our SOP process and wanted to make sure I wasn't missing something as I do not believe this is required.
Thank you

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.

"No full blood type means you should be giving type O red cells and type AB plasma, which no one wants to do unless warranted! "
 
The AABB standards, if that's what they say, are totally wrong from a clinical perspective and shear bureaucratic rigidity.  If you know the patient's ABO type with total certainty from the front type, the correct and safest transfusions are ABO identical red cells, platelets, plasma and cryo.  We never transfuse antigen positive cells, obviously, in the face of even weak anti-A or anti-B.  But when things are clear and there is no antibody present, ABO identical is the clear clinical imperative.  I always put the patient's best interest before regulatory or accreditation bad advice, and as a physician, that is both my responsibility and authority.  Happy to defend this approach in public, court or any other venue :).

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?  

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?  

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?  

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?  

If we have a patient w no detectable ABO isoagglutinins our procedure is to perform an ahgxm in addition to the immediate spin.  When I was validating gel we had a few patients w no detectable ABO abs:  they weren't detectable at ahg either.