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Study objective The transfusion of older packed RBCs may be harmful in critically ill patients. We seek to determine the association between packed RBC age and mortality among trauma patients requiring massive packed RBC transfusion. Methods We analyzed data from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. Subjects in the parent trial included critically injured adult patients admitted to 1 of 12 North American Level I trauma centers who received at least 1 unit of packed RBCs and were predicted to require massive blood transfusion. The primary exposure was volume of packed RBC units transfused during the first 24 hours of hospitalization, stratified by packed RBC age category: 0 to 7 days, 8 to 14 days, 15 to 21 days, and greater than or equal to 22 days. The primary outcome was 24-hour mortality. We evaluated the association between transfused volume of each packed RBC age category and 24-hour survival, using random-effects logistic regression, adjusting for total packed RBC volume, patient age, sex, race, mechanism of injury, Injury Severity Score, Revised Trauma Score, clinical site, and trial treatment group. Results The 678 patients included in the analysis received a total of 8,830 packed RBC units. One hundred patients (14.8%) died within the first 24 hours. On multivariable analysis, the number of packed RBCs greater than or equal to 22 days old was independently associated with increased 24-hour mortality (adjusted odds ratio [OR] 1.05 per packed RBC unit; 95% confidence interval [CI] 1.01 to 1.08): OR 0.97 for 0 to 7 days old (95% CI 0.88 to 1.08), OR 1.04 for 8 to 14 days old (95% CI 0.99 to 1.09), and OR 1.02 for 15 to 21 days old (95% CI 0.98 to 1.06). Results of sensitivity analyses were similar only among patients who received greater than or equal to 10 packed RBC units. Conclusion Increasing quantities of older packed RBCs are associated with increased likelihood of 24-hour mortality in trauma patients receiving massive packed RBC transfusion (≥10 units), but not in those who receive fewer than 10 units.

Higher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients.Retrospective observational study. Patients with isolated severe blunt TBI (AIS head≥3, AIS extracranial3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution's trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis.A total of 385 patients were included. Median age was 32 years (IQR 2-50), 71.4% were male, and 76.6% had an ISS≥16. Plasma:PRBC transfusion ratios≥1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22-0.81]). PLT:PRBC transfusion ratios≥1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08-1.92]).This study revealed plasma to PRBC transfusion ratios≥1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.

Objective To evaluate the spectrum and antibiotic susceptibility panel of infectious keratitis at a major tertiary care referral eye center and a major county hospital in Southern California. Design Retrospective case series. Participants All cultured infectious keratitis cases from July 1, 2008, through December 31, 2012, from the Doheny Eye Institute (DEI) and the Los Angeles County + University of Southern California Medical Center (LAC+USC) were evaluated. Methods Microbiology records were reviewed retrospectively. Main Outcome Measures Microbial isolates as well as antibiotic susceptibility patterns were analyzed. Results One hundred eighty-four (63%) of 290 cases showed positive culture results at DEI and 152 (82%) of 186 cases showed positive culture results at LAC+USC. Gram-positive pathogens were found to be the most common at both DEI (70%) and LAC+USC (68%), with coagulase-negative Staphylococcus being the most common gram-positive organism (58% at DEI and 44% at LAC+USC). Pseudomonas aeruginosa was the most common gram-negative organism (57% at DEI and 43% at LAC+USC). Ciprofloxacin and levofloxacin susceptibility for all tested pathogens was 73% at DEI and 81% at LAC+USC ( P = 0.16). Oxacillin-resistant Staphylococcus aureus (ORSA) was found in 42% of cases at DEI and in 45% of cases at LAC+USC ( P = 1.00). Conclusions There is no significant difference in the spectrum of pathogens or antibiotic susceptibility of pathogens at DEI versus LAC+USC, and ORSA was found in approximately half of all S. aureus samples.

Background Few studies have examined the impact of balanced resuscitation in pediatric trauma patients requiring massive transfusions. Adult data may not be generalizable to children. Methods Retrospective analysis assessed patients seen at a level I trauma center between 2003 and 2010 aged ≤18 years requiring massive packed red blood cell (PRBC) transfusion, defined as transfusion of ≥50% total blood volume. After excluding mortalities in the first 24 hours, the impact of plasma and platelet ratios on mortality was evaluated. Results Of 6,675 pediatric trauma patients, 105 were massively transfused (mean age, 12.4 ± 6.3 years; mean Injury Severity Score, 25.8 ± 11.4; mortality rate, 18.1%). All deceased patients sustained severe head injuries. Plasma/PRBC and platelet/PRBC ratios were not significantly associated with mortality. Conclusions In this study, higher plasma/PRBC and platelet/PRBC ratios were not associated with increased survival in children. The value of aggressive blood product transfusion for injured pediatric patients requires further prospective validation.

Despite evolving evidence that transfusion risks outweigh benefits in some patients, the critically injured continue to receive large quantities of blood. The present study evaluated patterns of red blood cell transfusions and risk factors for transfusions at various stages of admission in trauma patients.Prospective, observational study of transfusion practices in patients (n = 120) admitted to a single Level 1 academic trauma centre. Patients were expected to remain in the surgical intensive care unit for greater than 48 h.Patients had a mean age of 34.1+/- 16.0 years, a mean injury severity score (ISS) of 21.5 +/- 9.5, and were equally distributed by major injury type (48% blunt, 52% penetrating). One hundred and four patients (87%) received a total of 324 transfusions, 20 (6%) of which were given in the emergency room, 186 (57%) in the SICU, 22 (7%) post-SICU and 96 (30%) in the operating room. The mean volume of blood per patient transfused was 3144 +/- 2622 mL. One hundred and one patients received an allogeneic transfusion (mean volume 3126 +/- 2639 mL) and 10 patients received an autotransfusion (844 +/- 382 mL). The mean pre-transfusion Hb level was 9.1 +/- 1.4 g/dL. Transfusion volumes correlated with injury severity score (p = 0.011). Patients with an admission Hbor =12 g/dL or age55 years were at significant risk to receive increased transfusions (P.001 and P = .035, respectively). An admission Hbor =12 g/dL and any mention of long bone orthopedic operations or laparotomy or thoracotomy were associated with increased risk of blood transfusion during the first week of admission. Logistic regression analysis identified transfusion of4 units of blood as a significant risk factor for SIRS. After 1 week of ICU stay, ISS20 and blunt injury were associated with increased risk of transfusion.Trauma patients are heavily transfused with allogeneic blood throughout the course of their hospital stay and transfusions are administered at relatively high pre-transfusion haemoglobin levels (mean of 9 g/dL). Transfusion of4 units of blood is an independent risk factor for SIRS. Strategies to limit blood transfusions should be investigated in this population.

Current risk from transfusion is largely because of noninfectious hazards and defects in the overall process of delivering safe transfusion therapy. Safe transfusion therapy depends on a complex process that requires integration and coordination among multiple hospital services including laboratory medicine, nursing, anesthesia, surgery, clerical support, and transportation. The multidisciplinary hospital transfusion committee has been traditionally charged with oversight of transfusion safety. However, in recent years, this committee may have been neglected in many institutions. Resurgence in hospital oversight of patient safety and transfusion efficacy is an important strategy for change. A new position, the transfusion safety officer (TSO), has been developed in some nations to specifically identify, resolve, and monitor organizational weakness leading to unsafe transfusion practice. New technology is becoming increasingly available to improve the performance of sample labeling and the bedside clerical check. Several technology solutions are in various stages of development and include wireless handheld portable digital assistants, advanced bar coding, radiofrequency identification, and imbedded chip technology. Technology-based solutions for transfusion safety will depend on the larger issue of the technology for patient identification. Devices for transfusion safety hold exciting promise but need to undergo clinical trials to show effectiveness and ease of use. Technology solutions will likely require integration with delivery of pharmaceuticals to be financially acceptable to hospitals.

N SOME metropolitan areas of the United States, approximately 1 in 9,000 blood donations is obtained from a donor who is seropositive for specific antibodies to Trypanosoma cruzi. In some areas of Los Angeles, nearly 1 in every 550 eligible blood donors is seropositive. The transfusion of seropositive blood products can lead to transfusion-transmitted Chagas disease, because at least half 6f Tcruzi-seropositive donors are parasitemic. Transfusion-associated transmission of Chagas disease has occurred on at least four occasions in the United States and once in Canada during the past 12 years. It has been suggested that the risk of transfusiontransmitted Chagas disease could be reduced if donors were questioned for a history of birth, extended stay, or transfusion in a geographic area endemic for Chagas disease, or were tested for serological evidence of antibodies to T cruzi. However, a policy to question or test donors for evidence of T cruzi infection should only be implemented if it can be shown to improve the overall safety of the US blood supply; without causing a deleterious reduction in the availability of blood.

Purpose: Transfusion practice in patients with iron deficiency was reviewed. Patients and methods: During the Study period, records of 265 consecutive patients with an unsaturated iron-binding capacity of greater than 53.7 μmolL were evaluated for possible iron-deficiency anemia. Results: Two hundred sixty-three patients met the study criteria for iron deficiency. Of these patients, 50 received 1 or more units of red blood cells (RBCs). The transfusion therapy of 12 patients could not be justified; physicians used laboratory results rather than the clinical status of the patients to initiate transfusion therapy. As a result, units of RBCs were transfused to raise the hematocrit to an arbitrarily chosen level. Furthermore, iron therapy was not prescribed for 97 of the 263 iron-deficient patients, including 11 of the patients for whom transfusion was justifiable and 2 patients for whom transfusion could not be justified. Based on records reviewed, no work-up was initiated to identify the cause of iron deficiency in 13 patients, including 4 patients who received transfusions. Conclusion: These findings suggest that the evaluation and treatment of iron deficiency, including transfusion therapy for that condition, may be problematic. In view of the risks of blood transfusion therapy, improvement in transfusion practices for iron deficiency should be emphasized.

Pretransfusion red blood cell compatibility testing consists of several elements, each of which must be performed properly so that the risk of a hemolytic transfusion reaction can be minimized. The various elements of compatibility testing should be monitored to detect system flaws and random errors that might compromise patient safety. When errors in the compatibility testing routine are detected, they should be analyzed for their cause, and corrective steps should be taken.

Five percent dextrose in water (D5W) and lactated Ringer's (RL) are two intravenous solutions that are incompatible with citrate phosphate dextrose (CPD) anticoagulated RBCs. Hemolysis, agglutination, and clotting can occur when RBCs are mixed with, infused together with, or transfused in the same line following administration of these fluids. Although minimal plasma remains in units of RBCs containing adenine-saline-dextrose solution (ADSOL; Fenwal Laboratories, Deerfield, IL), clots are seen immediately after contact is made with RL. Clumping and hemolysis are seen when ADSOL-stored RBCs or saline-washed RBCs are mixed with D5W. This study reinforces the unsafe practice of mixing RBCs with certain intravenous solutions.