

Includes patient, donor, apheresis and related IT topics
This is a competency assessment for non-physician, non-nursing staff to transport blood from the hospital transfusion services/blood bank to the emergency department and operating rooms. This was designed by my Quality Manager, Ms. Edith Durante.
Below is a sample document specification for a document control process. It was originally designed but never implemented due to changes in the administrative structure in that organization. I want to thank Ms. Editha Durante, Quality Manager for preparing this.
Principle:
As part of good manufacturing process, we must trace everything in Transfusion Medicine, from registration through release of components. The adoption of the Medinfo Hematos IIG computer system allows us to document anyone and everyone who “touches” the blood components and all processes.
Policy:
References:
Principle:
Blood components must be maintained at specified temperatures to avoid hemolysis, bacterial contamination, and maintain full efficacy (e.g. coagulation factor activity.)
Policy:
Note the different temperature ranges for refrigerated components stored in the blood bank (1-6C) versus transport (1-10C).
References:
Section 5.6.5, Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA
This is a helpful Medscape diagram showing causes of direct-antiglobulin-test-positive hemolytic anemias. Note that not all cases of the conditions may consistently be DAT-positive, especially the ones that fix complement. Again, a negative result means non-detected, not necessarily not present.
In my own test algorithm, if hemolysis is suspected, I would perform monospecific IgG and C3 DATs. I might also include a special DAT card detecting both C3c and C3d and heavy-chains mu (IgM) and alpha (IgA) if the initial DAT is negative. C3c positivity would tell me that active complement activation is occurring.
Principle:
Therapeutic phlebotomy is a medical procedure that requires a written physician’s order and review/approval by a transfusion medicine physician. Transfusion Medicine is responsible for the procedure and makes the final decision of the conditions of the procedure (volume of whole blood and venue).
Policy:
References:
Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA.
Annual Review: Therapeutic Phlebotomy Criteria and Treatment Goals
Note: this is an updated version of a previous post.
Anyone reviewing antibody panels, especially in the Middle East/Gulf region, encounters many panels for which no antibody specificity is identified. As a transfusion medicine physician who often got called during the night for release of RBCs for patients with “nonspecific” pattern, this was a big headache.
Is it “nonspecific” because there isn’t a clinically significant antibody OR the technologist did not perform the testing or its interpretation correctly? Does it need further testing? Do I release blood components at this time?
In general, I do not routinely use polyspecific AHG for routine testing. My first choice is for a gamma heavy-chain specific AHG but this is not available for gels or glass beads. Then, I select the IgG AHG even though it does react with light chains and can detect IgM cold antibody reactions.
In general, with nonspecific reactions, I recommend the following:
Finally, if you still cannot define the specificity, consider repeating the testing after several days. Maybe it is a newly emerging or an anamnestic response.
I emphasize as a physician, I do not care to see all possible antibodies present in the specimen but rather only those likely to be clinically significant. In general, there is a shortage of labor in the blood banks so I want to eliminate unnecessary work.
This a revised version of a previous post for the processes of autologous transfusion that I developed at HMC Doha. It can serve as a template for other sites and was also a teaching document for the Transfusion Committee members.
Background:
There are four basic types of autologous transfusion: preoperative, perioperative hemodilution, intraoperative, and postoperative drainage/collection. The use of all of the above techniques can significantly decrease the need for homologous blood and as an added benefit reduce the risk of the disease transmission and immunosuppressive effects of such homologous transfusions.
Preoperative collection can make available packed red blood cells, whole blood, platelets, FFP, and/or cryoprecipitate. However, at most two units of blood per week can be collected. RBC’s can be stored for up to 42 days in the liquid state, frozen RBC’s up to ten years, platelets up to five days, and fresh frozen plasma and cryoprecipitate up to one year. The last collection cannot be less than 72 hours prior to the surgery time. Units can be collected as long as the patient’s hematocrit remains above 33%. Supplemental iron and erythropoietin can increase the number of units harvested. The biggest obstacle to using this service is the coordination of the patient scheduling for this procedure. The blood bank does not have the resources to prospectively analyze the surgical scheduling and make the various appointments, contact the attending physician, etc. Thus, this service is vastly underutilized.
PHD or Perioperative hemodilution (also called acute normovolemic hemodilution) is useful in cases when the anticipated blood loss is at least one liter and the initial hematocrit is at least 34%. This includes essentially all types of surgery, but in particular cardiac, vascular, orthopedic, and urologic cases. The patient’s hematocrit Hct. is lowered to the range of 20-25% and the blood is replaced by crystalloid in a ratio of 3:1–i.e. three times as much fluid as blood, or in the case of colloid replacement, a 1:1 ratio of colloid plus 0.5 to 1.0 ml. of crystalloid. Crystalloid has the advantage of being readily removed by diuretic use. However, this technique should not be undertaken when vascular access is inadequate or appropriate monitoring devices are lacking. The physician performing PHD must be familiar with the compensatory mechanisms normally invoked when the hemoglobin is acutely lowered.
Another new twist to PHD is the perioperative collection of platelets by a special attachment to a cell-saving machine. This could allow collection of a typical apheresis load, about 6 to 10 units of fresh platelets for potential use. There are currently studies underway to determine if this has particular clinical advantages to warrant the additional cost.
Intraoperative salvage may be performed with a number of canister or automated devices. The latter is usually used when there are large volumes (usually 3 or more units) of blood to be salvaged. Depending on the body site, the recovered material is at least filtered and may or may not be washed. Care must be taken to collect the blood at a low suction rate and with minimal turbulence to minimize hemolysis.
Postoperative drainage collection of certain sites such as post-knee replacement surgery or chest wounds involves a canister collection device. This blood may or may not be filtered before reinfusion.
Note that perioperative and intraoperative material can only be transfused up to six or eight hours at room temperature or 24 hours if refrigerated at 1-6 degrees (depending on the method used) post collection to minimize the risk of infection. Intraoperative collection may be contraindicated in cases of cancer and if the bowel has been violated.
Other Issues:
The transfusion criteria for autologous blood is the same as for allogeneic units.
The same compatibility testing algorithm applies both the autologous and allogeneic units.
Policy:
References: