bloodpumper

Terri, We label all blood units whether sequestered during acute normovolemic hemodilution or from salvage shed blood as in cell saver units in the same manner as bank blood units with a patient label, blood band number, handwritten time of collection, expiration, volume, personnel, day, date, source and autologous. You can't make any mistakes this way in identification of blood and intended recipient. Mark Lucas, MPS, CCP Perfusionist Blood Management Consultant

We have been performing ANH for over 7 years now. Give me a little time to get to this and I'll share our protocol with you. It will be a year before we get the research published in the Journal of ExtraCorporeal Technology and everyone can have access. I've been swamped with work and my office is a mess. Mark Lucas, MPS, CCP Chief of Perfusion Denver Cardiovascular Perfusion Director, International Board of Blood Management www.intbbm.org

I'm not going to comment specifically on any protocol, but on the concept of washing stored, preservative red cells. All of these products are very acidic and have very high glucose loads. Both of which are detrimental to neonates and peds on ECMO. I am also assuming that fresh leukoreduced or less than seven day old blood is used. Stored blood has time dependent storage lesions that can harm the microcirculation and lungs. Acidity can be corrected with bicarb, but then you are adding a high sodium load to the ECMO prime. Again, not good for this patient population. Don't always think about THAM, tromethamine, it's contraindicated in uremia and anuria. In neonates it is also contraindicated in chronic respiratory acidosis and salicylate intoxication. It can cause a high water load if the kidneys aren't working well. The best method to remove the acidity and glucose in stored preservative red cells is to wash in a cell washing device with a balanced electrolyte solution. You will get a more physiologic product that will not require too much manipulation or cause too much patient harm. Consult with the physicians and perfusionists before considering any changes to a specialty that they are the medical experts in. Mark Lucas, MPS, CCP Blood Management Consultant

Hi guys, The AABB Standards for perioperative blood collection and handling states that you should have a working quality control program in place. If you use the manufacturer recommendations, then you won't be able to comply using potassium as a value signifying adequate wash unless you decrease the recommended percent washout from 80% to 60%. Albumin and plasma free hemoglobin or haptoglobin are the most sensitive markers of adequate wash, but are the most labor intensive and costly. We use potassium because we can run the sample on a point of care blood gas and electrolyte analyzer and get immediate results before the washed unit is transfused. You need one indicator of adequate wash and one to ascertain that you achieved the end product hematocrit in the specified range per the manufacturer. Using the visual means of a clear effluent line does not always work if the device has an autorun feature and you miss the wash cycle or your determination is different than mine. Everyone has a different view on what is a clear line. Not very scientific. Establish a means by which you can have consistency of results and actions in your quality procedure. Sampling is performed by inserting an adaptor between the reservoir and the wash disposable and also an adaptor in the product collection bag. All of which must be done under the usual sterile technique for assembly of the disposable on the device and aseptic technique should be used to remove those samples during the processes. Establish your own system and show how you came to your protocol for quality monitoring in autotransfusion. Until the AABB comes out with a definite and specific protocol, stating exactly how you should perform this function, then use what you have devised. Mark Lucas, MPS, CCP Blood Management Consultant Director, International Board of Blood Management www.intbbm.org

Essentially, having a massive transfusion protocol aids in having the necessary blood components available when needed. Timing is crucial in this setting and the usage of additional PRBC's, autotransfusion salvaged red cells, albumin or normal saline instead of FFP and platelets, only compounds the dilutional coagulopathy and places the patient in a more compromised position of volume overload, pulmonary compromise and multiorgan failure. A 1:1:1 ratio of red cells to FFP to platelets, helps to maintain the balance of oxygen carrying capacity, proteins and coagulation factors necessary to stop this vicious cycle of dilution, coagulopathy, hypothermia and acidosis by reducing the time to hemostasis and thereby reducing the volume of blood products given. The number of actual massive transfusion cases is low and often less severe in nature than in the battlefield of Iraq, but the consequences, mortality and morbidity are equally as high. It has been through the experiences in all of our past armed conflicts that modern trauma centers and the massive transfusion protocol have developed. Mark Lucas, MPS, CCP International Board of Blood Management

Look in the AABB Perioperative Standards for Autologous Blood Collection 3rd Ed. I hope I named that correctly. I'm not in front of my computer with the file containing the AABB standards. Anyway, you'll find the information you need to set up the quality and competency for this procedure. Typically, a perfusionist performs the procedure during open heart surgery or back surgeries in the hospital setting. In a Dentist office or any other physician office, a qualified person in phlebotomy such as a trained phlebotomist, nurse or physician and under the direct supervision of a physician should draw the blood. The physician can then direct a qualified individual that is medically trained to operate the equipment to process the blood. Make no mistake, this is a blood processing procedure and there may be medical practice acts that cover who is qualified by education and clinical competence as monitored by Joint Commission to be performing this procedure in your state. Treat this procedure as such. Joint Commission will soon be looking for compliance to safe medical practices directly on this procedure. Hope this helps.

Blood usage reviews and criteria for transfusion are two different things. I will address the transfusion of red cells criteria. There just isn't any Level I, Class A evidence to say one way or another what a transfusion trigger should be for red cells as no prospective randomized clinical trials have been conducted, for ethical reasons, to determine the benefit of transfusion. Animal studies and clinical experience with JW patients tells us that the critical level of hematocrit can be as low as 15% in healthy patients and as high as 30% for individuals with major complications of surgery or ischemia. Recent evidence has pointed to patients having a better outcome with a hematocrit greater than 21% but not greater than 27% and receiving a transfusion. Almost all studies state that a transfusion is associated with increased morbidity and mortality and is dose dependent in relation to severity of complications. We are moving toward using clinical indicators of tissue oxygenation with O2 difference and cardiac output instead of just treating a number to transfuse. Clinical evidence of tissue oxygen debt is far more justifiable than just giving blood because of a designated number with no proven evidence in its favor. Another thing to consider is that stored red cells acquire storage defects and they don't release oxygen readily. This may exacerbate tissue ischemia by decreased NO2 and red cell wall deformability. I know I haven't answered your question and may have given you more to ask, but the reality is that a transfusion trigger is far less accurate than a measured need for increased tissue oxygenation. The need for transfusion should be patient specific and not blanket therapy.

Hey Linda, We are a level one trauma center and even if it is a dire emergency we always check the blood before issue. The minimum is patient identification for uncross matched universal donor and the full Monty for cross matched. The problem you may be having is due to the low number of cases you get. Let your techs watch a trauma case to see the importance of speed and accuracy. Checking does slow things down a bit, but being prepared ahead of time when a trauma is on the way sure helps. Mark

Massive transfusion protocols (MSP) are not going by the wayside. We just completed a MSP and put it into motion for our hospital. It is just a means to prevent bleeding disorders from depleted coagulation factors and platelets in a trauma patient. Many drugs also require adequate serum protein levels to facilitate transport and function. In a trauma situation, not everyone is thinking about maintaining these variables and it then falls on the blood bank to help provide a failsafe. I've seen situations in trauma where the hematocrit is greater than 40%, but the patelets are less than 20K and all of the coagulation tests were extremely abnormal with considerable bleeding, including cerebral hemorrhage. The patient remained in the trauma room for hours just because of the bleeding and then required massive amounts of platelets, Cryo, FFP and Factor VII to get dry enough to be transferred to the intensive care unit. The patient's lungs and kidneys then shutdown and the results were not positive. Had they maintained a better ratio of blood products, they may have potentially not seen this outcome. Often times clear fluids are given along with PRBC's which exaccerbates the edema and further dilutes the platelets and coagulation factors, and also compounds the bleeding. There is a catch 22 in these situations because you need to maintain an adequate circulating blood volume to sustain life, so anesthesia gives more clear fluid which lowers blood pressure and causes more bleeding by diluting coagulation factors so more fluid needs to be given. FFP can be infused almost as fast and it helps maintain oncotic pressure in the blood reducing hypotension which is how anesthesia gauges how much fluid to give. Platelets can be given more slowly. You have to maintain hemostasis during and after repair of the torn or damaged bones and tissues to prevent further problems.

I feel that a medically trained individual should perform apheresis. It is a simple enough procedure if proper instruction and supervision is provided to a non-medical individual, but only a medically trained technician can recognize undiagnosed conditions that may arise during this or any large phlebotomy procedure. AABB, in the STANDARDS FOR PERIOPERATIVE AUTOLOGOUS BLOOD COLLECTION AND ADMINISTRATION 2nd Edition covers this in Section 2.

Hi BB, I am a perfusionist and if you want to consult the professionals in this arena you need to speak with the perfusionists at your facility. I will share my experience with you though. We perform a cardiotomy sample for albumin and a post product sample for albumin and hematocrit. This serves two functions, the albumin verifys that the device is washing properly and the hematocrit is to verify that you are returning a quality product. The manufacturers specifications on post wash product hematocrit should be readily available in the operating manual. AABB guidelines say that typically there is a 95% washout. We have set our own standards at 70% as there is often a large amount of saline in the cardiotomy. The AABB Guidelines are just that, guidelines. Check the AABB Perioperative Autologous second addition. JCAHO just asks that you have a QA process in place and functioning to address possible problems with the device or personnel training. Another function of the QC is to maintain that the patient does receive a quality product and that the staff are properly trained and maintain their proficiency by performing the QC and competency by testing, education and clinical experience. Ask your cell salvage device manufacturer for assistance in setting up your QC process or your facility perfusionists. Another marker for washout can be plasma free hemoglobin(expensive test) or potassium. There is usally a high potassium from hemolyzed red cells. We are constantly reviewing our process in our transfusion committee and updating it when necessary.