Search

Background: Intravenous Immune Globulin (IVIG) is used to treat numerous immune‐mediated and inflammatory conditions. There is growing awareness of hemolysis, occasionally severe, as a side‐effect of this therapy. While most cases are associated with anti‐A and/or anti‐B isoagglutinins, the frequency and mechanism of hemolysis remain poorly characterized. Study Design and Methods: A prospective observational study was conducted to determine incidence, natural history and risk factors for IVIG‐mediated hemolysis. A total of 99 infusions of high‐dose IVIG (2 g/kg or higher) administered to 78 non‐group O patients were monitored and graded according to Canadian IVIG Hemolysis Pharmacovigilance Group. Serum ferritin and C3/C4 levels were monitored as indicators of macrophage activation and complement consumption, respectively. Supplementary investigations included assessment for ABO zygosity, Secretor status, FcR polymorphisms, eluate IgG subclass, monocyte monolayer assay, and a panel of cytokines. Results: Hemolysis was observed in 32 of 99 (32%) of infusions, with 19 of 99 (19%) grade 2 or higher. Hemolysis was only apparent 5‐10 days after a completed IVIG infusion in 84% of cases and was associated with increases in serum ferritin without complement‐consumption. In univariate analysis, increased risk was observed in group AB patients, first‐time IVIG recipients, those not taking immuosuppressive medications, or patients treated with a specific IVIG brand; however, in multivariate analysis, product association was no longer observed. No other patient‐ or practice‐related risk factors were identified. Conclusion: IVIG‐mediated hemolysis is common and frequently severe. Monitoring for 5‐10 days following an infusion should be considered in non‐O patients receiving high‐dose IVIG with known risk factors. See editorial on page 993–995, in this issue [ABSTRACT FROM AUTHOR]

Background and Objectives: Transfusion‐associated circulatory overload (TACO) is the leading cause of transfusion‐related morbidity and mortality. A recently completed pilot trial randomized patients to pre‐transfusion furosemide versus placebo but had a slower than expected enrollment rate. We sought to determine whether the lack of recruitment was due to a paucity of eligible patients or excessively restrictive eligibility criteria. Materials and Methods: At 10 sites, eligible patients were retrospectively identified by first screening blood bank databases over one month for all transfusion episodes meeting trial inclusion criteria, defined as non‐surgical patients receiving single RBC unit transfusions. The age threshold was decreased from 65 to 50 years. The first 10 patients meeting inclusion criteria then underwent detailed chart review for the exclusion criteria. The incidence of TACO and furosemide use was also recorded. Results: At the 10 sites, 11 969 red cell units were transfused over 1 month and 1356 met the inclusion criteria. Of the 100 charts reviewed, 60 (60%) had no exclusion criteria. Active bleeding was the most common reason for ineligibility. There were 813 eligible transfusion episodes. Of the eligible patients, 17 (28·3%) had evidence of congestive heart failure, and furosemide was prescribed in 24 (40%). Despite the use of a lower age threshold, three cases of TACO were detected with an incidence of 3%. Conclusion: A large number of transfusion episodes met eligibility criteria. With a 3% incidence of TACO, 50% decrease through the use pre‐transfusion furosemide and a target consent rate of 30%, a definitive trial of approximately 3000 patients could be completed within 1 year. [ABSTRACT FROM AUTHOR]

Background: Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%.Study Design and Methods: A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined.Results: Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P < .0001). Pre- and post-transfusion hemoglobin levels and the total number of RBCs transfused decreased from baseline (P < .05). The median pre-transfusion hemoglobin decreased from a baseline of 72.0 g/L to 69.0 g/L in the post-intervention period (P < .0001). RBC transfusions per acute inpatient days decreased significantly in intervention hospitals, but not in control hospitals (P < .001). The intervention had no impact on patient length of stay, need for intensive care support, or in-hospital mortality.Conclusion: This multifaceted intervention demonstrated a marked improvement in RBC transfusion appropriateness and reduced overall RBC utilization without impacts on patient safety. [ABSTRACT FROM AUTHOR]

Background: Hemolysis following the administration of intravenous immunoglobulin (IVIG) is an important adverse event (AE). While the monocyte monolayer assay (MMA) has been used to predict in vivo hemolysis when serologically incompatible blood may be transfused, it has also been shown to correlate with IVIG-associated hemolysis. In this study, the MMA was examined for its utility in assessing the risk of hemolysis after IVIG.Study Design and Methods: Forty-two non-blood group O patients receiving high-dose IVIG (≥2 g/kg) were examined using an autologous and allogeneic MMA. Hemolysis was defined by a drop in hemoglobin of ≥1 g/L, a positive direct antiglobulin test (DAT) and eluate, and a decrease in haptoglobin or increase in lactate dehydrogenase and/or reticulocytes.Results: Forty-two patients provided 50 assessable postinfusion samples, with hemolysis observed in 20 (40%) of cases. Autologous MMA using post-IVIG red blood cells significantly correlated with clinical outcomes when compared to allogeneic MMA (P = .0320 vs .5806, t test). No significant difference in receiver operating characteristics was observed when comparing autologous MMA testing against DAT for the diagnosis of IVIG-associated hemolysis. However, when using samples collected 5 to 10 days after receipt of high-dose IVIG, the autologous MMA had higher sensitivity than the DAT.Conclusion: MMA testing with autologous monocytes collected 5 to 10 days after receipt of high-dose IVIG can be used for the diagnosis of IVIG-associated hemolysis and may be of particular value in cases in which the Day 5 to 10 DAT is negative. [ABSTRACT FROM AUTHOR]

Background and Objectives Maximal surgical blood order schedules (MSBOS) are prepared to assist surgeons and anaesthesiologists with pretransfusion test orders. The literature on the prevalence and usefulness of MSBOS in international settings is lacking. We developed a survey to understand the prevalence of MSBOS in hospitals and to analyse compliance with MSBOS recommendations. Method and Materials A survey tool was developed by the Biomedical Excellence for Safer Transfusions (BEST) collaborative. The survey link was distributed to BEST members who were encouraged to forward the link to colleagues. Survey respondents were asked to contribute data regarding their hospital’s MSBOS and MSBOS compliance. Results There were 174 completed surveys. Greater than half of respondents did not have an MSBOS. The total number of beds was significantly different (P = 0.04) in hospitals with (N = 81) or without (N = 93) an MSBOS. Less than a quarter of respondents felt that their MSBOS was being followed despite widespread access to the MSBOS. Over 60% of type and screen orders were MSBOS compliant; however, just 42% of cross-match orders were compliant. There was a significant difference between the number of red-blood-cell units returned to the blood bank when comparing MSBOS compliant and MSBOS non-compliant cross-match orders (227 versus 788 units, respectively, P = 0.0026). Conclusions An MSBOS could be a useful tool to help with pretransfusion test orders; however, the majority of respondents lacked a MSBOS. In hospitals with a MSBOS, it was reported to be under-utilized, which might contribute to the low compliance rates seen for cross-match orders. [ABSTRACT FROM AUTHOR]

Summary Red blood cell (RBC) antigen matching beyond ABO and RhD is commonly recommended for patients with sickle cell disease (SCD) and thalassaemia. We present an updated systematic literature review to inform evidence‐based guidelines on RBC matching. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool was used to develop recommendations. Six new observational studies (4 prospective, 2 retrospective) were identified. The six studies reported on 583 patients in total, including cross‐over designs, with sample sizes from 10 to 343. Studies were heterogeneous, utilising varying degrees of RBC matching and different definitions for ‘extended’ matching. All reported on alloimmunisation. One study reported on molecular matching. The reported prevalence of alloimmunisation using limited matching was 0%–50% and with extended matching was 0%–24%. Eighty‐two patients were alloimmunised before study entry. The risk of bias across studies was moderate to critical. The guideline panel recommends that ABO, RhDCcEe, and K‐compatible RBCs are selected for individuals with SCD and thalassaemia, even in the absence of alloantibodies, and that RBCs which are antigen‐negative to already existing clinically significant antibodies are chosen. There is a need for comparative research to define the benefit, impact, cost‐effectiveness, and feasibility of extended RBC matching strategies to prevent alloimmunisation. [ABSTRACT FROM AUTHOR]

The article offers information on the clinical study of Intravenous immunoglobulin (IVIG)-associated hemolysis. It mentions Immunoglobulin G (IgG) subclasses possess different characteristics in terms of binding to their different receptors in immune cells and activation of complement; and also mentions the predominant antibody opsonizing the patients' autologous red blood cells (RBCs) is an isoagglutinin of IgG2 subclass.