When I first moved overseas from the United States, I brought the perspective of my American training and experience. I saw everything in my new blood bank through those eyes.
Yet, most of my staff were not American or even North American. Few were even native in English, and most of those were not American. They had different qualifications, many of which would not have been accepted by the American schemes. Still, they functioned well.
I also worked with the US military technologist staff during Gulf War One. Some did not even have a Bachelor’s degree; yet, they performed the work well.
I used many technologies that were not yet (or never) US FDA approved such as gel or glass bead typings and pooled buffy coat platelet production. There were rare reagents I could buy off the shelf (e.g. anti-Tja/PP1Pk).
Later, I adopted pathogen-reduction technology (Mirasol), automated component production (Atreus then Reveos), and platelet additive solution. I achieve a level of good manufacturing practice that would have been difficult to achieve by the FDA-approved methods.
My perspective had changed. In the Middle East, I studied many frameworks and came to the conclusion that the best approach was to customize them to our local needs. My particular experience was to start with one framework, i.e. Council of Europe CE, and then localize it.
To do this, I could not use an American turnkey blood bank software for either the donor or patient operations. I needed a flexible system that could be customized to my needs. Again, I chose a CE-marked system, Medinfo Hematos IIG that had already been adapted to many frameworks.
It is much easier to work solely within one system such as FDA. However, if I had done that, I would have lost so much flexibility and not had a system optimized for local conditions. I would not have used Mirasol, Reveos, Diamed, and many other reagents.
One big disappointment at such international meetings is the perspective by one country’s regulatory agency that they feel its regulations and framework will work well overseas. I would wager that those people were not well acquainted with international conditions.
Another frustration was attending another international meeting in which the presenters apologized for the source of information since it came from a foreign country (France) and not their own (United States).
No country has a monopoly on what is best for everyone. To share our experiences and compare is so valuable. No one assume his way is the best. In my career, I have had the richest experiences studying other perspectives and my organizations have benefited greatly from the exchange. We can all learn from each other. We are citizens of the world.
The Reveos buffy coat is not approved for clinical use. In my laboratory, I have offered this discard product to the stem cell laboratory and researchers as a quality control QC and a substrate to extract CD34+ cells for expansion and modification.
In this article (abstract attached) from Transfusion and Apheresis Science 59 (2020) 102682, the authors study pools of ABO-identical Reveos buffy coats for their granulocyte functionality and as a possible emergency replacement for granulocyte concentrates when the latter are not available.
I want to thank Terumo BCT (Brussels, Belgium) for referring me to this article and to the authors for a very interesting paper.
You can get the values off the therapeutic apheresis machine, but in the middle of the night when you have to write orders, it is convenient to estimate the volumes (whole blood, plasma, RBCs). These are the values from my lectures to hematology fellows while I was at HMC Doha:
Weight in kg X 70 ml/kg = whole (whole) blood volume adult
Weight in kg X 85 ml/kg =whole blood volume for child (prepubertal)
Weight in kg X 100 ml/kg = whole blood volume for neonates/premature
Example: 70 kg adult has 4900 ml blood volume (I round up to 5 liters)
Plasmacrit + hematocrit = 1.00 in fractions (100%), ignore buffy coat volume
Plasmacrit = 1- hematocrit
Plasma volume = whole blood volume x plasmacrit = whole blood volume X (1-hematocrit)
RBC volume = whole blood volume x hematocrit
Estimates for blood components:
The volumes will depend on the original amount collected (e.g. 450 vs 500 ml), original preservative solution used (e.g. CPD), use of automated component production such as Terumo Atreus or Reveos, use of RBC additive solution (e.g. SAGM), leukodepletion, platelet additive solution, pathogen inactivation.
At HMC Doha, the average values were:
300 ml for leukodepleted RBCs in SAGM prepared by Reveos
300 ml for platelet pools in Mirasol and platelet additive solution (residual WBC < 1E6)
300 ml for plateletpheresis concentrate (2.4E11) in Mirasol and platelet additive solution
250 ml for leukodepleted, pathogen inactivated plasma
A major advantage in using a specific blood bank computer software is to enforce the Good Manufacturing Processes. Medinfo is merciless: there are no exceptions without authorization and that is restricted by the security policies.
The following tables show the values established at HMC Doha during my tenure. These values were recommended by the Terumo BCT Reveos engineer after his direct, hands-on set-up of the equipment.
The minimum and maximum volumes for platelets are specifically designed to work for pooling the buffy coats before Mirasol pathogen inactivation. There are different settings for platelets suspended in plasma versus those suspended in platelet additive solution PAS.
Similarly, there are specific volume ranges for plasma so that pathogen inactivation can be performed according to Terumo BCT recommendations.
To Be Continued: 4/9/20
I resigned from HMC on 16/4/20. Here are a set of my major accomplishments during that period. None of my work after this date has any relationship to HMC.
Established automated component production using Atreus technology, plasma and platelet pathogen inactivation (Mirasol)—made HMC component production Good Manufacturing System GMP compliant
Adopted non-PCR-based NAT technology (Grifols/Novartis Tigress) and Qatar becomes world reference site for this
Based on the above, Qatar can now completely process all whole blood into blood components (red cells, platelets, and plasma) in as little as 5 hours from collection!
Prepared policies and procedures for the hospital blood banks/transfusion services, blood donor center, therapeutic apheresis, and laboratory information systems to bring HMC in compliance with the Council of Europe, international AABB, and other standards. I customized our own standards for our local needs based on them.
Implemented custom build of the multilingual blood bank computer system (Medinfo) for both patient and donor services, including development of interfaces to all production equipment including Atreus and Mirasol (world’s first) and a direct link to Ministry of the Interior to obtain patient demographics in English and Arabic—Qatar became the world’s first site to combine fully-interfaced, automated component production with pathogen inactivation: Qatar becomes world reference site for this.
Built, validated, and implemented laboratory build of hospital information system, Cerner Millennium
Replaced and updated Atreus with Reveos automated component production to allow faster throughput and capacity with a full bidirectional interface (world’s first), introduced platelet-additive solution PAS with pathogen inactivation (Mirasol)—Medinfo interfaces updated to Reveos for all equipment: this doubles the capacity to process whole blood into components using the same physical space
Updated dedicated blood bank software Medinfo Hematos IIG by several versions using Division Head, LIS, and internally trained Super Users—at great cost savings to HMC by not using outside consultants (e.g. Dell Consulting)
Established column absorption technology using Terumo Optia therapeutic apheresis machine for treatment of ABO-incompatible renal transplants: I validated using the Ortho Vision MAX to perform ABO antibody titers for this system and correlated it with the reference method at Karolinska Institutet in Stockholm (manual gel) to bring rapid throughput and labor savings—Qatar being the first-site in the world to do this. We saved money by using the same apheresis machine to use this column absorption technology (no need for second machine to use the columns)
Expedited setup (two weeks total) of COVID-19 convalescent plasma production, initially manual and then fully integrated into the Medinfo computer system as a customized module with separate quarantine collection, production, and transfusion service functions
I was awarded two HMC Star of Excellence Awards:
2013—Liver Transplantation Transfusion Support
2019—ABO-Incompatible Renal Transplantation Support
This Powerpoint file summarizes the past previous posts about the use of automated components, pathogen inactivation, and their synergism with the blood bank computer software Medinfo Hematos IIG
Automated Component Processing: Reveos and Mirasol Pathogen-Inactivation
The production instruments have more complicated interfaces than the testing equipment discussed in the previous post:
In the collection area (on-site or remote), the cvolume of the whole blood and collection time are recorded in Medinfo and based on the rules, production may only occur within specified volume and collection time. Otherwise, Medinfo will block further processing.
The ISBT unit number of the whole blood units are read by the Reveos. Only those units passing the collection criteria will proceed to separation.
In about 20 minutes, the Reveos machine will simultaneously process four units of whole blood into packed RBCs, leukodepleted plasma, buffy coat platelets, and residual buffy coat. The volumes of the RBCs, plasma, and platelets are recorded in Reveos. For the platelets, the platelet yield index is also provided.
Within Medinfo, these parameters are compared to criteria of acceptability according to the manufacturer. Volumes for the platelets and plasma must be within certain ranges to permit pooling and pathogen inactivation and additive solution. Medinfo will not permit these subsequent procedures if the values are out of range and the intermediate components will be discarded.
Here is a sample of Reveos acceptable ranges for component volumes:
E4207 – Whole Blood CPD 450 mL
< 400 mL Discard
400 – 500 mL OK
> 500 mL Discard
E5259 – Leukodepleted Packed Red Blood Cells
< 230 mL Discard
230 – 330 mL OK
> 330 mL Discard
E2807 – Platelets Concentrate 20-24°C
< 20 mL Discard
20 – 55 mL OK
> 55 mL Manual decision
E2555 – FP24: Plasma Frozen <= 24h
< 170 mL Discard
170 – 360 mL OK
> 360 mL Manual decision
All these production parameters are permanently stored in Medinfo as part of the production record of that unit. The actual location (bucket) of the whole blood unit in the Reveos is also available.
RBCs are manually leukodepleted and the final volumes recorded in Medinfo based on weight. Based on the platelet yield index, platelets are pooled and the final volume recorded. Those permissible volumes are next treated with platelet additive solution PAS and then pathogen inactivated. The acceptable volumes are based on the process used, e.g. platelets in plasma versus platelets in PAS.
How a sophisticated blood bank software like Medinfo enforces good manufacturing process at all stage of production will be a future topic.
To Be Continued:
Yesterday’s post showed my active blood inventory management scheme for my previous position in Qatar. I thought today I would elaborate on how I adjust the inventory based on critical shortages and planning for disasters and other major events.
I always review the critical shortages to check for atypical usage (e.g. a disaster situation) or production issues (equipment breakdown, shortage of donors during holiday period).
If it is due to increased utilization, I try to adjust the critical and desirable inventories upward to cover the shortfall for future events. However, it is not always possible if the event is a one-of-a-kind situation unlikely to recur. Also, I must take into account the available resources (supplies, kits, manpower, equipment) to see if I can cope with the increase.
If it is due to resource issues, I see if I can bolster those by recommending increases or improving utilization of what is available.
Very important is through-put: How quickly can I produce components from whole blood or apheresis components? This was one of the major reasons we shifted away from PCR to other NAT testing with single-well processes since to minimize the need to make additional runs (Grifols Panther System). Also, automated component processing can greatly speed production (one Reveos can process four whole blood units in about 23 minutes or about 12 units in 75 minutes.) Those staff can be busy with other tasks while the machines are working.
In the system I developed in Qatar, we could complete processing into components (RBCs, buffy coat platelet pools, leukodepleted plasma)–Reveos 3C Program, all marker and immunohematology testing, leukoreduction of the pools and RBCs, Mirasol pathogen inactivation, and platelet additive solution in as little as five hours!! There is great need for speed in a place that must be 100% self-sufficient in all blood components. We could even further reduce the total processing time if we only made RBCs and plasma, Reveos 2C Program
In rapid turn-around events, it is most helpful to have a robust blood bank computer system that can scale to the challenge. Also, it must mercilessly enforce all the rules starting with donor qualification, screening, collection through testing and production. At times of emergency, it is difficult to meet Good Manufacturing Processes manually.
After each major shortage, I recommend a “post-mortem” analysis of the situation with senior donor and quality staff to analyze our processes and see if we can further optimize them for the future. A report is prepared and reviewed by me as the Division Head/Medical Director of the Blood Bank. If possible, we implement our recommendations. If not, I request additional resources from the Administration.
As regards Disaster Planning, I always asked Administration how many victims did they want to save? When I got the response, I always try to adjust inventory by two extra RBCs and one adult platelet dose (> 2E11) per salvageable victim. This may come at the expense of increased wastage, especially in a region that cannot export the excess, unused stock.
The exasperating issue is that I didn’t get a clear answer on this last point. What number should I use? I made a spreadsheet showing calculations for a variety of endpoints, e.g. 100, 500, 1000 treatable victims and sent this to Administration to consider.
I am an independent consultant in Transfusion Medicine. Effective 16 April 2020, I am no longer associated with Hamad Medical Corporation or the State of Qatar.
I am willing to consider other opportunities in Transfusion Medicine (donor, patient, apheresis) and blood bank informatics.
Just before leaving HMC, I established the COVID19 convalescent plasma program with full good manufacturing practices using Medinfo Hematos IIG blood bank software.
I have 10 year’s experience in pathogen inactivation and blood component automated production. I established the first site using Terumo Atreus (later Reveos) with Mirasol pathogen inactivation AND platelet additive solution. I established Medinfo interfaces with all production equipment to achieve GMP.
I have worked with laboratory information systems, especially but not limited to blood bank systems (donor, component processing, donor marker testing, pathogen inactivation, platelet additive solutions) and serve as the Head of the Medinfo IIG (Nice, France) Software Users Group.
I was involved with planning for the national plasma fractionation project in Saudi Arabia. I have worked with this industry while I was practicing in the United States.
It is my philosophy to start with an international framework (e.g.FDA, CE) and localize it for the country’s particular needs. My operation sites have served as international reference sites for combined IT and medical/technical processes.