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The aim of the study was to examine various haemostasis values to identify the most relevant biological indicators for detecting significant haemorrhage, to determine the effectiveness of fresh frozen plasma (FFP) transfusion. Our findings suggest that a low prothrombin time, elevated Von Willebrand Antigen, increased plasma fibrinogen, and reduced Ca2 + levels are associated with challenges in achieving proper haemostasis. However, measurements of factors II, V, VII, VIII, IX, X, XI, XIII, protein C, and protein S do not appear to be linked to difficulties in achieving adequate haemostasis. Additionally, the administration of FFP appears to impact factors V, VII, X, and II.Trial registration EudraCT number: 2019-002898-64., (© 2024. The Author(s).)

Background: Civilian acute trauma care has advanced in recent decades; however, traumatic injury remains the leading cause of death in individuals aged 15 to 29 years in the United States and worldwide. Uncontrolled hemorrhage is the leading preventable cause of death in trauma patients, with up to half of these deaths occurring before reaching a medical facility. The timely application of hemorrhage control measures is critical to enhance the survivability of trauma patients and is one of the major challenges faced by medical providers in austere environments. The purpose of this review is to explore if early resuscitation with cold-stored whole blood therapy reduces the need for component therapy in the first 24 hours postinjury in the civilian population., Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic literature search in Medline, EMBASE, and Transfusion Evidence Library for studies reporting data on 24-hour blood product usage in trauma patients in hemorrhagic shock receiving initial therapy with whole blood. Two reviewers independently performed the selection of eligible studies., Results: Of a total of 2,150 identified studies, 11 studies (n = 4,792) met the inclusion criteria. There was heterogeneity in the study design, interventions, and outcomes. Seven studies reported a statistically significant decrease in 24-hour transfusion requirements in the whole blood intervention group in comparison with the control component therapy group. Three studies reported no significant difference between the two groups. One of the studies reported an increase in 24-hour transfusion requirements in the whole blood group., Conclusion: Overall, there appears to be a decrease in component therapy use following initial resuscitation with whole blood in trauma patients with hemorrhagic shock. However, further research is needed to address this important practical question (PROSPERO registration no. CRD42023422173)., Level of Evidence: Systematic Review; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Whole blood (WB) resuscitation is increasingly used at trauma centers. Prior studies investigating outcomes in WB versus component-only (CO) resuscitation have been limited by small cohorts, low volumes of WB resuscitation, and unbalanced CO resuscitation. This study aimed to address these limitations using data from a high-volume Level I trauma center, which adopted a WB-first resuscitation paradigm in 2018. We hypothesized that the resuscitation method, WB or balanced CO, would have no impact on patient mortality., Methods: A single-center, retrospective cohort study of adults presenting as a trauma activation from July 2016 through July 2021 was performed. Receipt of three or more units of WB or packed red blood cells (RBC) within the first hour of resuscitation was required for inclusion. Patients were grouped into WB versus CO resuscitation and important clinical outcomes were compared. Mortality was evaluated with Kaplan-Meier analysis, log-rank testing, and multivariable Cox proportional hazards modeling., Results: There were 180 patients in the WB group and 170 patients in the CO group. Of the 180 WB patients, 110 (61%) received only WB during the first 24 hours. The WB group received a median of 5.0 units (interquartile range, 4.0-8.0) of WB and CO group received a median of 6.0 units (interquartile range, 4.0-11.8) of RBCs during the first 24 hours of resuscitation. In the CO group, median RBC/plasma and RBC/platelet ratios approximated 1:1:1. Groups were similar in clinicopathologic characteristics including age, Injury Severity Score, mechanism of injury, and requirement for hemorrhage control interventions (WB 55% vs. CO 59%, p = 0.60). Unadjusted survival was equivalent at 24 hours ( p = 0.52) and 30 days ( p = 0.70) between both groups on Kaplan-Meier analysis with log-rank testing. On multivariable Cox regression, WB resuscitation was not independently associated with improved survival after accounting for age, Injury Severity Score, mechanism of injury, and receipt of hemorrhage control procedure (hazard ratio, 0.85; 95% confidence interval, 0.61-1.19, p = 0.34)., Conclusion: Balanced CO resuscitation is associated with similar mortality outcomes to that of WB based resuscitation., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

SummaryThis article highlights the crucial role of blood transfusion in trauma care and explores the historical and contemporary use of whole blood and freeze-dried plasma in Canadian health care. Early use of whole blood and freeze-dried plasma during global conflicts led to advancements in transfusion medicine. The transition to blood component therapy improved transfusion safety and precision. However, there is an increasing interest in using whole blood and freeze-dried plasma, supported by recent evidence suggesting potential benefits over blood component therapy, particularly in trauma cases. Canadian initiatives, such as leukoreduced whole blood production for the military, indicate efforts to address logistical challenges in delivering trauma care, especially in remote areas. Challenges remain, including logistical issues and regulatory complexities, requiring coordinated efforts for effective implementation. Overall, there's growing support for integrating whole blood and freeze-dried plasma into trauma care across Canada., Competing Interests: Competing interests:: None declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Some studies in both children and adults have shown a mortality benefit for the use of low titer group O whole blood (LTOWB) compared with component therapy for traumatic resuscitation. Although LTOWB is not widely available at pediatric trauma centers, its use is increasing. We hypothesized that in children who received whole blood after injury, the proportion of whole blood in relation to the total blood product resuscitation volume would impact survival., Methods: The trauma database from a single academic pediatric Level I trauma center was queried for pediatric (age <18 years) recipients of LTOWB after injury (years 2015-2022). Weight-based blood product (LTOWB, red blood cells, plasma, and platelet) transfusion volumes during the first 24 hours of admission were recorded. The ratio of LTOWB to total transfusion volume was calculated. The primary outcome was in-hospital mortality. Multivariable logistic regression model adjusted for the following variables: age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score. Adjusted odds ratio representing the change in the odds of mortality by a 10% increase in the LTOWB/total transfusion volume ratio was reported., Results: There were 95 pediatric LTOWB recipients included in the analysis, with median (interquartile range [IQR]) age of 10 years (5-14 years), 58% male, median (IQR) Injury Severity Score of 26 (17-35), 25% penetrating mechanism. The median (IQR) volume of LTOWB transfused was 17 mL/kg (15-35 mL/kg). Low titer group O whole blood comprised a median (IQR) of 59% (33-100%) of the total blood product resuscitation. Among patients who received LTOWB, there was a 38% decrease in in-hospital mortality for each 10% increase in the proportion of WB within total transfusion volume ( p < 0.001) after adjusting for age, sex, mechanism of injury, Injury Severity Score, shock index, and Glasgow Coma Scale score., Conclusion: Increased proportions of LTOWB within the total blood product resuscitation was independently associated with survival in injured children. Based on existing data that suggests safety and improved outcomes with whole blood, consideration may be given to increasing the use of LTOWB over CT resuscitation in pediatric trauma resuscitation., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The benefit of targeting high ratio fresh frozen plasma (FFP)/red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP/RBC transfusion and the association with outcomes in children presenting in shock., Methods: A post hoc analysis of a 24-institution prospective observational study (April 2018 to September 2019) of injured children younger than 18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (≥1:2) ratio FFP/RBC. Nonparametric Kruskal-Wallis and χ 2 were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths., Results: Of 135 children with median (interquartile range) age 10 (5-14) years and weight 40 (20-64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (low-38%, high-46%, p = 0.34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = 0.01); however, hospital mortality was similar (low-24%, high-20%, p = 0.65) as was the risk of extended ventilator, intensive care unit, and hospital days (all p > 0.05)., Conclusion: Despite increased injury severity, patients who received a high ratio of FFP/RBC had comparable rates of mortality. These data suggest high ratio FFP/RBC resuscitation is not associated with worst outcomes in children who present in shock. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: to investigate the influence of the leukoreduction moment (preor post-storage) of blood components on the clinical outcomes of patients transfused in the emergency department., Methods: retrospective cohort study of patients aged 18 years or older who received preor post-storage leukoreduced red blood cell or platelet concentrate in the emergency department and remained in the institution for more than 24 hours. A generalized mixed-effects model was applied in the analyses., Results: in a sample of 373 patients (63.27% male, mean age 54.83) and 643 transfusions (69.98% red blood cell), it was identified that the leukoreduction moment influenced the length of hospital stay (p<0.009), but was not dependent on the transfused blood component (p=0.124). The leukoreduction moment had no effect (p>0.050) on transfusion reactions, healthcare-associated infections, or mortality., Conclusions: patients who received pre-storage leukoreduced blood components in the emergency department had a shorter length of hospital stay.

Objectives: To assess if transfusion with low-titer group O whole blood (LTOWB) is associated with improved early and/or late survival compared with component blood product therapy (CT) in bleeding trauma patients., Data Sources: A systematic search of PubMed, CINAHL, and Web of Science was performed from their inception through December 1, 2023. Key terms included injury, hemorrhage, bleeding, blood transfusion, and whole blood., Study Selection: All studies comparing outcomes in injured civilian adults and children who received LTOWB versus CT were included., Data Extraction: Data including author, publication year, sample size, total blood volumes, and clinical outcomes were extracted from each article and reported following the Meta-analysis Of Observational Studies in Epidemiology guidelines. Main outcomes were 24-hour (early) and combined 28-day, 30-day, and in-hospital (late) mortality rates between recipients of LTOWB versus CT, which were pooled using random-effects models., Data Synthesis: Of 1297 studies reviewed, 24 were appropriate for analysis. Total subjects numbered 58,717 of whom 5,164 received LTOWB. Eleven studies included adults-only, seven included both adults and adolescents, and six only included children. The median (interquartile range) age for patients who received LTOWB and CT was 35 years (24-39) and 35.5 years (23-39), respectively. Overall, 14 studies reported early mortality and 22 studies reported late mortality. LTOWB was associated with improved 24-hour survival (risk ratios [RRs] [95% CI] = 1.07 [1.03-1.12]) and late (RR [95% CI] = 1.05 [1.01-1.09]) survival compared with component therapy. There was no evidence of small study bias and all studies were graded as a moderate level of bias., Conclusions: These data suggest hemostatic resuscitation with LTOWB compared with CT improves early and late survival outcomes in bleeding civilian trauma patients. The majority of subjects were injured adults; multicenter randomized controlled studies in injured adults and children are underway to confirm these findings., Competing Interests: Dr. Spinella is a consultant for Cerus and Hemanext, on the advisory board for Haima and Octapharma, and is a Co-Founder and Chief Medical Officer of Kalocyte. He also has funding from Biomedical Advanced Research and Development Authority to perform a trial examining the safety and efficacy of whole blood. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Purpose: Balanced blood product resuscitation with red blood cells, plasma, and platelets can be achieved using whole blood (WB) or component therapy (CT). However, balanced resuscitation of younger children with severe traumatic hemorrhage may be complicated by delays in delivering all blood components and concerns regarding multiple product exposures. We hypothesized that WB achieves balanced resuscitation faster than CT, with fewer product exposures and improved clinical outcomes., Methods: Children younger than 12 years receiving balanced resuscitation within 4 hours of arrival were identified from the 2017 to 2019 Trauma Quality Improvement Program database. Time to balanced resuscitation was defined as the time of initiation of WB or all three components. Patient characteristics, resuscitation details, and outcomes were compared between WB and CT groups. Time to balanced resuscitation was compared using Kaplan-Meier analysis and Cox regression modeling to adjust for covariates. Additional multivariable regression models compared number of transfusion exposures, intensive care unit (ICU) length of stay, and mortality., Results: There were 390 patients (109 WB, 281 CT) with median age 7 years, 12% penetrating mechanism, 42% severe traumatic brain injury, and 49% in-hospital mortality. Time to balanced resuscitation was shorter for WB versus CT (median, 28 vs. 87 minutes; hazard ratio [HR], 2.93; 95% confidence interval [CI], 2.31-3.72; p < 0.0001). Whole blood patients received fewer transfusion exposures (mean, 3.2 vs. 3.9; adjusted incidence rate ratio, 0.82; 95% CI, 0.72-0.92; p = 0.001) and lower total product volumes (50 vs. 85 mL/kg; p = 0.01). Intensive care unit stays trended shorter for WB versus CT (median, 10 vs. 12 days; adjusted HR, 1.32; 95% CI, 0.93-1.86), while in-hospital mortality was similar (50% vs. 45%; adjusted odds ratio, 1.11; 95% CI, 0.65-1.88)., Conclusion: In critically injured preadolescent children receiving emergent transfusion, WB was associated with faster time to balanced resuscitation, fewer transfusion exposures, lower blood product volumes, and a trend toward shorter ICU stays than CT., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Plasma is overused as a blood product worldwide; however, data supporting appropriate use of plasma is scant. Its most common utilization is for treatment of coagulopathy in actively bleeding patients; it is also used for coagulation optimization prior to procedures with specific coagulation profile targets. A baseline literature review in PUBMED and Google Scholar was done (1 January 2000 to 1 June 2023), utilizing the following search terms: plasma, fresh frozen plasma, lyophilized plasma, indications, massive transfusion protocol, liver disease, warfarin reversal, cardiothoracic surgery, INR < 2. An initial review of the titles and abstracts excluded all articles that were not focused on transfusional medicine. Additional references were obtained from citations within the retrieved articles. This narrative review discusses the main indications for appropriate plasma use, mainly coagulation factor replacement, major hemorrhage protocol, coagulopathy in liver disease, bleeding in the setting of vitamin K antagonists, among others. The correlation between concentration of coagulation factors and INR, as well as the proper plasma dosing with its volume being weight-based, is also discussed. A high value approach to plasma utilization is supported with a review of the clinical situations where plasma is overutilized or unnecessary. Finally, a discussion of novel plasma products is presented for enhanced awareness.

Introduction: The World Health Organization has advocated that every country should make its own policy for ensuring safe and adequate supply of plasma derived medicinal products through mobilization and usage of locally collected plasma. The National Plasma Policy (NPP) of India was published in 2014 with a dual objective to achieve self sufficiency in the production of plasma derived medicinal products and at the same time to augment the component preparation facilities in India and overall upliftment of blood transfusion services in the country. Thus the present study was done to access the impact of implementation of NPP in our blood bank on the blood transfusion services in our hospital., Materials and Methods: The present study was a retrospective observational study conducted in the department of transfusion medicine of a tertiary care hospital in India involving analysis of data from 1st January 2019 till 31st December 2022. For the purpose of data analysis the time period was divided into 2 periods: (i) Pre-NPP implementation period from 1st January 2019 till 31st December 2020; (ii) Post-NPP period from 1st January 2021 till 31st December 2022. The following parameters were compared for the two periods: (i) component preparation rate; (ii) percentage of component therapy; (iii) total number of FFP transferred to plasma fractionation centers; (iv) total amount of exchange amount generated in lieu of transferred FFP to plasma fractionation centers., Results: The component preparation rate after NPP implementation was significantly higher as compared to the pre NPP implementation period (93.81% vs 56.70%; p = 0.007). The percentage of component therapy in the patients was also significantly higher as compared to the pre-NPP implementation period (97.9% vs 73.6%; p = 0.005). The total amount of exchange amount generation in Indian rupee (INR) after NPP implementation was INR 1419462 (15835€) while it was INR 636898 (7105€) in the pre NPP implementation period. This amount was utilized for procurement of various blood bank equipment, in addition 2 lab technicians were also hired for the blood bank., Conclusions: The implementation of NPP resulted in upliftment of blood transfusion services in our hospital. Other low and middle income countries can benefit from implementation of similar plasma policy in their countries., (Copyright © 2023 Société française de transfusion sanguine (SFTS). Published by Elsevier Masson SAS. All rights reserved.)

Background: Nearly 40% of trauma deaths result from uncontrolled hemorrhage. Most of these deaths occur within 24 hours, highlighting the importance of early resuscitation. Balanced component resuscitation has been shown to improve outcomes in hemorrhagic shock. However, hemostatic properties may then be decreased, leading to inadequate coagulopathy treatment or higher transfusion requirements. Data comparing the efficacy of component vs. whole blood (WB) resuscitation in early trauma is poor, particularly in the rural population. This study investigates WB use and resource utilization at a rural Level 1 trauma center., Methods: A prospective cohort study with historical controls (HC) was performed using patients over age 17 presenting as the highest priority trauma. Two units of WB were available to patients with signs of hemorrhagic shock, with subsequent transfusions via massive transfusion protocol or thromboelastography guidance. Component utilization, time to hemorrhage control, complications, and transfer times were examined., Results: Forty patients received WB vs. 153 HC. WB patients had lower complication rates (35% vs. 55.6%; P = .02), and a significant reduction in pRBC utilization in the emergency department (0 vs. 2; P < .0001) and throughout admission (2.0 vs. 4.0; P = .0003). All patients had prolonged transport times given the rural setting (1.42 hours HC vs. 2.03 hours WB; P = .002)., Discussion: Unlike most urban WB studies, this study occurred in a rural area with extended transportation times, when WB is inaccessible for patients. Despite this delay, WB patients demonstrated lower component utilization and complication rates. Further research is needed to characterize the impact of early WB access., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Objectives: Rail logistics transmission systems (RLTSs) are commonly used for the transportation of blood samples, pathological specimens and other medical materials in many hospitals, as they are rapid, secure, cost-effective and intelligent. However, few studies have evaluated blood component transportation from blood banks to the patient care areas of hospitals using RLTS. In this study, we evaluate the RLTS used for the transportation of blood components within a medical centre., Materials and Methods: The dispatch of blood components, including packed red blood cells (pRBCs), fresh frozen plasma (FFP), cryoprecipitate and platelet units, from a blood bank to critical care areas or general wards was done using RLTS. Parameters such as the delivery time, temperature, physical integrity and blood component quality were evaluated via analytical testing using specimens obtained before and after transportation by RLTS., Results: The turnaround time and temperature of all tested blood units via RLTS transportation were able to meet the clinical demands of blood component delivery (median time: 323 s [118-668 s]; temperature variation: 4.5-8.9°C for pRBCs and FFP and 21.5-23.5°C for cryoprecipitate and platelet units). Furthermore, parameters of pRBC quality, including the haemolysis index and potassium and lactate dehydrogenase levels in plasma, were not significantly different before and after transportation through RLTS. Similarly, RLTS transportation affected neither the basic coagulation test results in FFP and cryoprecipitate specimens nor platelet aggregation and activation markers in apheresis platelet specimens., Conclusion: Hospital-wide delivery of blood components via RLTS seems to be safe, reliable and cost-effective and does not have any negative impact on blood quality. Therefore, the establishment of standard criteria, protocols and guidelines based on further studies is needed., (© 2023 International Society of Blood Transfusion.)

Introduction: Blood component resuscitation is associated with hypocalcemia (HC) (iCal <0.9 mmol/L) that contributes to coagulopathy and death in trauma patients. It is unknown whether or not whole blood (WB) resuscitation helps mitigate the risk of HC in trauma patients. We hypothesized that calcium homeostasis is maintained and mortality improved in patients who only receive WB., Materials and Methods: This is a retrospective review of all adult trauma patients who received WB from July 2018 to December 2020. Variables included transfusions, ionized calcium levels, and calcium replacement. Patients were characterized as follows based on blood products received: WB or WB with other blood components. Groups were compared with respect to HC, correction of HC, 24 h, and inpatient mortality., Results: Two hundred twenty-three patients received WB and met the inclusion criteria. 107 (48%) received WB only. HC occurred in 13% of patients who received more than one WB unit compared to 29% of WB and other blood component patients (P = 0.02). WB patients received less calcium replacement (median 250 mg versus 2000 mg, P < 0.01). HC and total units transfused within 4 h were associated with mortality in the adjusted model. HC significantly increased after 5 units of blood products were transfused, regardless of product type. WB was not protective against HC., Conclusions: HC and failure to correct HC are significant risk factors for mortality in trauma. Resuscitations with WB only and WB in combination with other blood components are associated with HC especially when more than 5 units of any blood product are transfused. Calcium supplementation should be prioritized in any large volume transfusion, regardless of blood product type., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Low-titer group O whole blood (LTOWB) resuscitation is becoming common in both military and civilian settings and may represent the ideal resuscitation intervention. We sought to characterize the safety and efficacy of LTOWB resuscitation relative to blood component resuscitation., Study Design: A prospective, multicenter, observational cohort study was performed using 7 trauma centers. Injured patients at risk of massive transfusion who required both blood transfusion and hemorrhage control procedures were enrolled. The primary outcome was 4-hour mortality. Secondary outcomes included 24-hour and 28-day mortality, achievement of hemostasis, death from exsanguination, and the incidence of unexpected survivors., Results: A total of 1,051 patients in hemorrhagic shock met all enrollment criteria. The cohort was severely injured with >70% of patients requiring massive transfusion. After propensity adjustment, no significant 4-hour mortality difference across LTOWB and component patients was found (relative risk [RR] 0.90, 95% CI 0.59 to 1.39, p = 0.64). Similarly, no adjusted mortality differences were demonstrated at 24 hours or 28 days for the enrolled cohort. When patients with an elevated prehospital probability of mortality were analyzed, LTOWB resuscitation was independently associated with a 48% lower risk of 4-hour mortality (relative risk [RR] 0.52, 95% CI 0.32 to 0.87, p = 0.01) and a 30% lower risk of 28-day mortality (RR 0.70, 95% CI 0.51 to 0.96, p = 0.03)., Conclusions: Early LTOWB resuscitation is safe but not independently associated with survival for the overall enrolled population. When patients were selected with an elevated probability of mortality based on prehospital injury characteristics, LTOWB was independently associated with a lower risk of mortality starting at 4 hours after arrival through 28 days after injury., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Surgeons.)

Background and Objectives: Blood transfusion centres ensure the quality and safety of transfusable blood components. However, septic transfusion reactions involving environmental contaminants occur. An international survey issued by the ISBT Transfusion-Transmitted Infectious Diseases Working Party (ISBT-TTID-WP) Bacterial Subgroup aimed to collect information regarding microbiological environmental monitoring from transfusion services., Materials and Methods: A Form survey (English and Spanish) with 35 questions was sent to ISBT-TTID-WP members. The survey had four sections: (1) respondent personal information, (2) cleaning/disinfection practices during blood component manufacturing, (3) cleaning/disinfection practices during blood component storage and (4) blood component storage bag integrity. Respondents completed the survey electronically, and data were comparatively analysed using Microsoft Excel., Results: There were 49 responses from 20 countries. Five of 49 sites manufacture blood components in a cleanroom, and most use personal protective equipment, although the type varied between sites. Approximately 40% of sites perform environmental monitoring during blood component production, with seven sites providing details about frequency and methods. Most (~94%) centres have procedures for cleaning/disinfection of processing and storage facilities with varying responses regarding areas, frequency and methods. Inconsistency was reported regarding the orientation of platelet component incubation (portrait vs. landscape). Over 93% of sites assess storage bag integrity and report damage to manufacturers, and 49% of centres report septic transfusion reactions potentially linked to damaged storage containers., Conclusion: Data from this survey highlight the need for consensual guidelines for transfusion services regarding cleaning and disinfection practices. Environmental monitoring could be adopted to minimize the risk of blood component contamination for transfusion patient safety., (© 2023 The Authors. Vox Sanguinis published by John Wiley & Sons Ltd on behalf of International Society of Blood Transfusion.)

Background: The goal was to study the effect of early equal-proportion transfusion on the prognosis of trauma patients with bleeding., Methods: Emergency hospital trauma patients were randomly divided into two groups, a group based on assessment of blood consumption (ABC) to assess whether need to start the massive blood transfusion patients, such as proportion of blood transfusion (fresh frozen plasma: suspended red blood cells = 1:1), and the other group using traditional methods of blood transfusion, namely according to routine blood and clotting function and hemodynamic parameters, to decide when and what blood constituents should be transfused., Results: The coagulation got better in the early equal-proportion transfusion group, there were significant differences of PT and APTT (p < 0.05). The amount of 24 hours RBC and plasma transfusion was decreased in the early equal-proportion transfusion group, compared to the control group (p < 0.05), the length of ICU stay was shortened, the 24-hours SOFA score was improved, and there was no significant difference in 24-hours mortality, in-hospital mortality and total length of in-hospital stay (p > 0.05)., Conclusions: Early transfusion can reduce the total amount of blood transfusion and shorten ICU time, but has no significant effect on mortality.

Background: Major bleeding is the leading cause of preventable mortality among trauma patients. Several studies have recently shown that prehospital plasma transfusion improves the outcomes of severely injured patients. Although no consensus has been reached, prehospital transfusion is regularly considered to reduce avoidable mortality. The objective was to assess the status of prehospital transfusion practices in France., Study Design and Methods: A national survey among the 378 advance life support emergency teams (SMURs) in metropolitan France was conducted from December 15, 2020 to October 31, 2021. A questionnaire was distributed by e-mail to the physicians in charge of SMURs. The questions addressed the transfusion modalities, labile blood products (LBPs) used, and limitations encountered in implementing transfusion., Results: The response rate was 48%, and 82% of the respondents performed prehospital transfusions. A designated pack was used by 44% of the respondents. The LBPs used were packed red blood cells (100%), of which 95% were group 0 RH:-1, fresh frozen plasma (27%), lyophilized plasma (7%), and platelets (1%). The LBPs were transported in isothermal boxes (97%) without temperature monitoring in 52% of the cases. Nontransfused LBPs were discarded in 43% of the cases. Reported limitations in implementing transfusion were the delivery time (45%), loss of LBPs (32%), and lack of evidence (46%)., Discussion: Prehospital transfusion was developed in France but access to plasma remains difficult. Protocols allowing the reutilization of LBPs and improving conservation could limit the waste of a rare resource. Implementing the use of lyophilized plasma could facilitate prehospital transfusion. Future studies will need to specify the role of each LBP in the prehospital setting., (© 2023 AABB.)

Background and Aims: Recent guidelines recognize the limitations of standard coagulation tests in predicting bleeding and guiding pre-procedural blood component prophylaxis in cirrhosis. It is unclear whether these recommendations are reflected in clinical practice. We performed a nationwide survey to investigate pre-procedural transfusion practices and opinions of key health care stakeholders involved in managing cirrhosis., Methods: We designed a 36-item multiple-choice questionnaire to investigate the international normalized ratio and platelet cutoffs utilized to guide pre-procedural transfusion of fresh frozen plasma and platelets in patients with cirrhosis undergoing a range of low and high-risk invasive procedures. Eighty medical colleagues from all mainland States involved in managing patients with cirrhosis were invited by email to participate., Results: Overall, 48 specialists across Australia completed the questionnaire: 21 gastroenterologists, 22 radiologists, and 5 hepatobiliary surgeons. 50% of respondents reported that their main workplace did not have written guidelines relating to pre-procedural blood component prophylaxis in patients with cirrhosis. There was marked variation in routine prophylactic transfusion practices across institutions for the different procedures and international normalized ratio and platelet cutoffs. This variation was present both within and between specialty groups and held for both low and high-risk procedures. For scenarios where the platelet count was ≤ 50 × 109/L, 61% of respondents stated that prophylactic platelet transfusions would be given before low-risk and 62% before high-risk procedures at their center. For scenarios where the international normalized ratio was ≥2, 46% of respondents stated that prophylactic fresh frozen plasma would be routinely given before low-risk procedures and 74% before high-risk procedures., Conclusion: Our survey reveals significant heterogeneity of pre-procedural prophylactic transfusion practices in patients with cirrhosis and discrepancies between guidelines and clinical practice., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases.)

Continuous improvement has led to a very high degree of microbial safety of transfusion. Four issues are likely to impact the future of this safety. There will be further advances in the efficacy and efficiency of donation testing and pathogen reduction, increasing safety and hopefully eliminating unnecessary procedures. While system failures have been essentially eliminated, there will be ongoing, unpredictable issues that are inevitable. Emerging infections are likely the greatest concern and will continue, although advances in science and technology will permit increasingly rapid responses to outbreaks. Finally, the practice of transfusion may eventually impact safety as usage of blood is reduced and perhaps as alternatives to conventional blood components are developed., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Société française de transfusion sanguine (SFTS). Published by Elsevier Masson SAS. All rights reserved.)

Objective: Massive transfusion protocols are widely implemented in obstetrical practice in case of severe hemorrhage; however, different recommendations exist regarding the appropriate ratios of blood product components to be transfused. We report our extensive experience with massive component transfusion in a referral center in which the standard massive transfusion protocol is modified by ongoing clinical and laboratory evaluation., Study Design: A retrospective chart review of all patients who had massive transfusion protocol activation in a level 4 referral center for obstetrical practice was performed from January 2014 to January 2020. Data collected included the etiology of obstetrical hemorrhage, number of blood products of each type transfused, crystalloid infusion, and several indices of maternal morbidity and mortality. Data are presented with descriptive statistics., Results: A total of 62 patients had massive transfusion protocol activation, of which 97% received blood products. Uterine atony was found to be the most common etiology for massive hemorrhage (34%), followed by placenta accreta spectrum (32%). The mean estimated blood loss was 1,945 mL. A mean of 6.5 units of packed red blood cells, 14.8 units of fresh frozen plasma and cryoprecipitate, and 8.3 units of platelets were transfused per patient. No maternal deaths were seen., Conclusion: The ratios of transfused packed red blood cell to fresh frozen plasma/cryoprecipitate and of packed red blood cell to platelet units varied significantly from the fixed initial infusion ratio called for by our massive transfusion protocol resulting in universally favorable maternal outcomes. When rapid laboratory evaluation of hematologic and clotting parameters is available, careful use of this information may facilitate safe modification of an initial fixed transfusion ratio based on etiology of the hemorrhage and individual patient response., Key Points: · Massive transfusion protocols in obstetrics follow fixed ratios of blood products.. · Actual usage of blood components is different than the standardized protocols.. · We recommend to modify the initial fixed transfusion ratio according to clinical response.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background and Objectives: Plasma is often transfused to patients with bleeding or requiring invasive procedures and with abnormal tests of coagulation. Chart audits find half of plasma transfusions unnecessary, resulting in avoidable complications and costs. This multicentre electronic audit was conducted to determine the proportion of plasma transfused without an indication and/or at a sub-therapeutic dose., Methods: Data were extracted on adult inpatients in 2017 at five academic sites from the hospital electronic chart, laboratory information systems and the Canadian Institute for Health Information Discharge Abstract Database. Electronic criteria for plasma transfusion outside recommended indications were: (1) international normalized ratio (INR) < 1.5 with no to moderate bleeding; (2) INR ≥ 1.5, with no to mild bleeding and no planned procedures; and (3) no INR before or after plasma infusion. Sub-therapeutic dose was defined as ≤2 units transfused., Results: In 1 year, 2590 patients received 6088 plasma transfusions encompassing 11,490 units of plasma occurred at the five sites. 77.7% of events were either outside indications or under-dosed. Of these, 34.8% of plasma orders had no indication identified, and 62% of these occurred in non-bleeding patients and no planned procedure with an isolated elevated INR. 70.7% of transfusions were under-dosed. Most plasma transfusions occurred in the intensive care unit or the operating room. Inter-hospital variability in peri-transfusion testing and dosing was observed., Conclusion: The majority of plasma transfusions are sub-optimal. Local hospital culture may be an important driver. Electronic audits, with definitions employed in this study, may be a practical alternative to costly chart audits., (© 2022 International Society of Blood Transfusion.)

Although fresh frozen plasma (FFP) transfusions are common practice in neonatology, robust evidence on their use is lacking. The aim of this study was to systematically review the literature for data on the practice of FFP transfusions in neonates and their association with neonatal morbidity and mortality. The authors identified 40 studies, which met the inclusion criteria for this review. It was demonstrated that the practice of FFP transfusions significantly varies throughout the world. The majority of FFP transfusions are administered "prophylactically", without evidence of active bleeding. Although FFP transfusions may restore coagulation tests results, they do not alter the clinical outcome of the neonates. Reactions following transfusions are probably underestimated in neonates, often undiagnosed and thus, underreported. High quality RCTs aiming to evaluate the effectiveness of FFP in specific clinical conditions are urgently needed, as they could change long-standing FFP transfusion practices, and help reduce neonatal morbidity and mortality., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To analyze the use of packed red blood cells (PRBCs) for patients with pelvic fracture and evaluate factors associated with PRBC transfusion for patients with pelvic fracture., Methods: This retrospective cohort study collected 551 patients with pelvic fractures from six hospitals between September 1, 2012, and June 31, 2019. The age span of patients varied from 10 to 95 years old, and they were classified into two groups based on high-energy pelvic fractures (HE-PFs) or low-energy pelvic fractures (LE-PFs). The study's outcome was the use of PRBCs, fresh frozen plasma (FFP), and albumin. Demographic data, characteristics, laboratory tests, clinical treatment details, and clinical outcomes were compared between the two groups. Factors that were statistically associated with perioperative PRBCs in univariate analyses were included to conduct an optimal scale regression to determine the independent factors for perioperative PRBCs., Results: A total of 551 patients were screened from six hospitals, and after inclusion and exclusion, 319 were finally included and finished the follow-up from admission to discharge, while four patients died during hospitalization. Three hundred and nineteen patients were classified into two groups by their injury mechanisms. A total of 230/319 (72.1%) patients were classified into the HE-PF group, and 89/319 (27.8%) patients were classified into the LE-PF group. Patients in the HE-PF group were transfused with 4.5 (3-8) units of PRBCs, 300 (0-600) ml of FFP, and 0 (0-30) g of albumin, while patients in the LE-PF group were transfused with 3.5 (2-4.5) units of PRBCs, 0 (0-295) ml of FFP, and 0 (0-0) g of albumin (all P < 0.001). There were higher proportions of male patients and patients under 65 in the HE-PF group (all P < 0.001). HE-PF group patients were more severely injured and likely to take external fixation. The optimal scale regression revealed four significant factors associated with perioperative transfused PRBCs, which were patients on admission with hemorrhagic shock (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.148, P = 0.039), and methods of pelvic fixation (importance = 0.008, P = 0.026), ranked by the importance., Conclusion: Patients with HE-PFs had increased transfusions of PRBCs, FFP, and albumin, and hemorrhagic shock on admission, Tile classification, Hb levels, and stabilization methods were found to be associated with perioperative PRBCs., (© 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Purpose: To study the effect of interferon-α2 auto-antibodies (IFN-α2 Abs) on clinical and virological outcomes in critically ill COVID-19 patients and the risk of IFN-α2 Abs transfer during convalescent plasma treatment., Methods: Sera from healthy controls, cases of COVID-19, and other respiratory illness were tested for IFN-α2 Abs by ELISA and a pseudo virus-based neutralization assay. The effects of disease severity, sex, and age on the risk of having neutralizing IFN-α2 Abs were determined. Longitudinal analyses were performed to determine association between IFN-α2 Abs and survival and viral load and whether serum IFN-α2 Abs appeared after convalescent plasma transfusion., Results: IFN-α2 neutralizing sera were found only in COVID-19 patients, with proportions increasing with disease severity and age. In the acute stage of COVID-19, all sera from patients with ELISA-detected IFN-α2 Abs (13/164, 7.9%) neutralized levels of IFN-α2 exceeding physiological concentrations found in human plasma and this was associated with delayed viral clearance. Convalescent plasma donors that were anti-IFN-α2 ELISA positive (3/118, 2.5%) did not neutralize the same levels of IFN-α2. Neutralizing serum IFN-α2 Abs were associated with delayed viral clearance from the respiratory tract., Conclusions: IFN-α2 Abs were detected by ELISA and neutralization assay in COVID-19 patients, but not in ICU patients with other respiratory illnesses. The presence of neutralizing IFN-α2 Abs in critically ill COVID-19 is associated with delayed viral clearance. IFN-α2 Abs in COVID-19 convalescent plasma donors were not neutralizing in the conditions tested., (© 2021. The Author(s).)

Background: Thrombelastography (TEG) has emerged as a useful tool to diagnose coagulopathy and guide blood product usage during trauma resuscitations. This study sought to evaluate the correlation between TEG-directed blood product administration in severely injured pediatric trauma patients with blunt solid organ injuries (BSOIs)., Methods: Patients (≤18 years) with severe BSOIs who presented as highest-level trauma activations at two pediatric trauma centers were included. Thrombelastography results were evaluated to determine indications for blood product administration and rates of TEG-directed resuscitation. Tetrachoric correlations and regression modeling were used to correlate TEG-directed resuscitation with clinical outcomes., Results: Of 64 patients who met the inclusion criteria, 32.8% (21) had elevated R times and 23.4% (15) had shortened α angles. Maximum amplitude was shortened in 29.7% (19), and percent clot lysis 30 minutes after maximum amplitude that is >3% was seen in 17.0% (9). Thrombelastography-directed resuscitation of fresh frozen plasma was followed 54.7% of the time compared with 67.2% and 81.2% for platelets and cryoprecipitate, respectively. Thrombelastography-directed resuscitation with platelets (odds ratio, 0.56; 95% confidence interval, 0.33-0.93; p = 0.03) and/or cryoprecipitate (odds ratio, 0.09; 95% confidence interval, 0.01-0.42, p = 0.003) were associated with decreased hospital length of stay and mortality, respectively., Conclusion: Severely injured pediatric trauma patients with BSOIs were often coagulopathic upon presentation to the emergency department. Thrombelastography-directed resuscitation with platelets and/or cryoprecipitate was followed for the majority of patients and was associated with improved outcomes., Level of Evidence: Therapeutic/Care Management, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the effect of massive transfusion protocol on coagulation function in elderly patients with multiple injuries., Methods: In this retrospective cohort study, clinical data were collected from a total of 94 elderly patients with multiple injuries, including 44 cases who received routine transfusion protocol (control group) and 50 cases who concurrently received massive transfusion protocol in our hospital (research group). The changes in platelet parameters, coagulation function, and organ dysfunction scores at admission and 24 h after transfusion were compared between the two groups. The 24-hour plasma and red blood cell transfusion volume, length of stay, complications, and mortality of the two groups were analyzed statistically., Results: Twenty-four hours after blood transfusion, the hematocrit, platelets, and hemoglobin in the research group were higher than those in the control group, while the activated partial thromboplastin time, prothrombin time, thrombin time, fibrinogen, and scores of Marshall scoring system and Sequential Organ Failure Assessment were lower than those in the control group ( P < 0.01). The 24-hour plasma transfusion volume was higher, and the length of intensive care unit (ICU) stay and total length of stay were lower in the research group compared with the control group ( P < 0.01). No significant difference was found in the mortality rate between the research group and the control group (10.00% vs. 13.64%, P > 0.05). The incidence of complications in the research group was lower than that in the control group (12.00% vs. 31.82%, P < 0.05)., Conclusion: Massive transfusion protocol for elderly patients with multiple injuries can improve their coagulation function and platelet parameters, alleviate organ dysfunction, shorten length of ICU stay, and decrease the incidence of complications, which is conducive to improving the prognosis of patients., Competing Interests: The authors declare no competing interests., (Copyright © 2021 Danjie Li et al.)

Aim: Management of blood transfusions is a critical issue, especially in cirrhotic patients, because of the absence of national policies in many countries. Fresh frozen plasma (FFP) is a common blood component misused excessively in various clinical situations and cirrhosis patients without any scientific rationale. We evaluated the FFP transfusions in patients with cirrhosis at our tertiary care hospital., Material and Method: The cases with cirrhosis diagnosed between 2014 and 2020 were selected using the hospital database. The appropriateness of FFP transfusion was determined based on the Practice Guidance by the American Association for the Study of Liver Diseases and Italian guidelines., Result: Two hundred and six liver cirrhosis patients were identified who received FFP transfusion. The median age was 63 (22-94). Of the 206 patients, 79 (38.3 %) were female, and 127 (61.7 %) were men. The most common causes of liver cirrhosis were alcohol (27.7 %). 45.6 % of the patients were in Child-Pugh Class C. We found 62.1 % of FFP replacements were inappropriately used. Most inappropriate use of FFP (22.8 %, n = 47) occurred to correct prolonged INR in the absence of bleeding., Conclusion: To avoid inappropriate usage of FFP, regular utilization reviews and formal education programs can be helpful. Our clinic has planned to arrange educational programs for physicians to use blood products appropriately and minimize transfusion-related side effects., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare, commonly fatal complication of transfusion preventable by irradiation of blood units. The revision of the Dutch transfusion guideline addressed the question whether irradiation is still necessary if blood components are prestorage leukodepleted. We searched for published cases of TA-GVHD following transfusion of prestorage leukodepleted blood and through contacting haemovigilance systems. Six presumed cases were found, dating from 1998 to 2013. Four out of six patients had received one or more non-irradiated units despite recognised indications for irradiated blood components. In the countries providing information, over 50 million prestorage leukodepleted, non-irradiated, non-pathogen-reduced cellular components were transfused in a 10-year period. Potential benefits of lifting indications for irradiation were considered. These include reduced irradiation costs (€ 1.5 million annually in the Netherlands) and less donor exposure for neonates. Findings were presented in an invitational expert meeting. Recommendations linked to human leukocyte antigen similarity between donor and recipient or intra-uterine transfusion were left unchanged. Indications linked to long-lasting deep T-cell suppression were defined with durations of 6 or 12 months after end of treatment (e.g. autologous or allogeneic stem cell transplantation). Need for continued alertness to TA-GVHD and haemovigilance reporting of erroneous non-irradiated transfusions was emphasised., (© 2021 British Society for Haematology and John Wiley & Sons Ltd.)

Background: Trial outcomes should be relevant to all stakeholders and allow assessment of interventions' efficacy and safety at appropriate timeframes. There is no consensus regarding outcome measures in the growing field of prehospital trauma transfusion research. Harmonization of future clinical outcome reporting is key to facilitate interstudy comparisons and generate cohesive, robust evidence to guide practice. The objective of this study was to evaluate outcome measures reported in prehospital trauma transfusion trials., Methods: Data Sources, Eligibility Criteria, Participants, and InterventionsWe conducted a scoping systematic review to identify the type, number, and definitions of outcomes reported in randomized controlled trials, and prospective and retrospective observational cohort studies investigating prehospital blood component transfusion in adult and pediatric patients with traumatic hemorrhage. Electronic database searching of PubMed, Embase, Web of Science, Cochrane, OVID, clinical trials.gov, and the Transfusion Evidence Library was completed in accordance with Preferred Reporting Items for Meta-analyses guidelines.Study Appraisal and Synthesis MethodsTwo review authors independently extracted outcome data. Unique lists of salutogenic (patient-reported health and wellbeing outcomes) and nonsalutogenic focused outcomes were established., Results: A total of 3,471 records were identified. Thirty-four studies fulfilled the inclusion criteria: 4 military (n = 1,566 patients) and 30 civilian (n = 14,398 patients), all between 2000 and 2020. Two hundred twelve individual non-patient-reported outcomes were identified, which collapsed into 20 outcome domains with varied definitions and timings. All primary outcomes measured effectiveness, rather than safety or complications. Sixty-nine percent reported mortality, with 11 different definitions. No salutogenic outcomes were reported., Conclusion: There is heterogeneity in outcome reporting and definitions, an absence of patient-reported outcome, and an emphasis on clinical effectiveness rather than safety or adverse events in prehospital trauma transfusion trials. We recommend stakeholder consultation and a Delphi process to develop a clearly defined minimum core outcome set for prehospital trauma transfusion trials., Level of Evidence: Scoping systematic review, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study aims to determine the phlebotomy and procedural outcomes using a vein assessment tool (VAT) in Double Dose Platelet (DDP) collections by apheresis., Methods: VAT was based on assessing vein visibility, palpation and size with maximum score of 12 and the least being 0 and the scores were graded as adequate and inadequate. A vein-viewer was used for studying cubital vein patterns (type 1-5). Phlebotomy outcome was defined based on need for re-puncture. Procedural outcomes in terms of target yield attained and RBC reinfusion completed. Chi square test and Mann- Whitney U test were used to assess the vein score and pattern against phlebotomy and procedural outcome., Results: Out of 200 DDP collections, the phlebotomy was successful in 88 % with good procedural outcome in 94 % donations. The cut off in VAT scores for successful phlebotomy was ≥8 (AUC: 70 %). Median vein scores of the arm selected for phlebotomy was 9 and graded adequate in 154 (77 %) donations.Odds for successful phlebotomy was 3.7 times higher when donors had an adequate VAT grades(p = 0.003). Procedural outcomes was favourable when at least one arm had adequate VAT grade when compared to both arms being inadequate (98 % vs 82 %; p < 0.001). Phlebotomy failure was more with first time apheresis donors than repeat apheresis donors (p = 0.014)., Conclusion: This study indicated that a VAT score with a cut off of ≥8 had better phlebotomy and procedural outcomes in DDP collections and that donor with at least one arm having the VAT score of ≥8 are preferred for DDP collections., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

In 2014-2015, the Luxembourg Red Cross (LRC) implemented a fully automated system (FAS) able to process 4 whole blood units simultaneously, and a pathogen reduction technology (PRT) based on riboflavin and ultraviolet light to improve safety of platelet concentrates (PCs). In this observational study, the impact of both technologies to enable this centralised blood transfusion centre to provide safe and timely blood components supply for the whole country was analysed. Standard quality control parameters for blood components, productivity and safety were compared from data collected with the conventional semi- automated buffy coat method and with FAS/PRT. The FAS decreased processing time when compared with the buffy coat method and facilitated the daily routine at the LRC. Red blood cell concentrates, plasma units and PCs prepared with both methods were conform to the European Directorate for the Quality of Medicines & HealthCare specifications. PCs prepared by FAS showed high yields, with decreased variability when the device-related software (T-Pool Select) was used. PRT had minimal impact on platelet yields and product quality and induced no increase in transfusion reaction notifications. The FAS and PRT transformed the daily routine of blood component manufacture by allowing increased productivity and efficiency, notwithstanding resource containment and without impacting quality, yet promoting safety., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Low titer group O whole blood (LTOWB) is used as the initial resuscitative fluid in an increasing number of pediatric trauma and massive bleeding transfusion protocols. There is little data on adverse events following its transfusion in pediatric trauma patients., Study Design and Methods: Blood bank records were queried for pediatric recipients of at least one unit of red blood cells (RBCs) (component group) or LTOWB (LTOWB group) within 24 h of admission between May 2013 and August 2020. Subjects with early death (<72 h) were excluded. Propensity-score matching of LTOWB and component groups was performed. Adverse events were recorded, including transfusion reaction, thromboembolism, acute kidney injury, sepsis, and organ failure based on PELOD-2 score, along with hospital and ICU length of stay (LOS) and ventilator days., Results: Thirty-six LTOWB recipients were matched to 36 conventional component recipients. Subjects were 52% male, with blunt injury mechanism (82%), median (IQR) injury severity score = 27 (21-35), and 26% in-hospital mortality. The groups were well matched in terms of demographics and injury characteristics. There were no clinically or statistically significant differences in adverse outcomes including reported transfusion reaction, organ failure, acute kidney injury, sepsis/bacteremia, and venous thromboembolism. Hospital LOS, ventilator days, mortality, and functional disability at discharge were also not significantly different. The LTOWB group had significantly shorter ICU LOS compared to the component group., Conclusion: LTOWB transfusion did not increase the risk of adverse events in children. However, larger studies are required to confirm these results., (© 2021 AABB.)

Background: Fresh frozen plasma (FFP) contains proinflammatory mediators released from cellular debris during frozen storage. In addition, recent studies have shown that transfusion of never-frozen plasma (NFP), instead of FFP, may be superior in trauma patients. We hypothesized that FFP would have higher levels of inflammatory mediators when compared to NFP., Materials and Methods: FFP (n = 8) and NFP (n = 8) samples were obtained from an urban, level 1 trauma center blood bank. The cytokines in these samples were compared using a Milliplex (Milliplex Sigma) human cytokine magnetic bead panel multiplex assay for 41 different biomarkers., Results: Growth factors that were higher in NFP included platelet-derived growth factor-AA (PDGF-AA; 8.09 versus 108.00 pg/mL, P < 0.001) and PDGF-AB (0.00 versus 215.20, P= 0.004). Soluble CD40-ligand (sCD40L), a platelet activator and pro-coagulant, was higher in NFP (31.81 versus 80.45 pg/mL, P< 0.001). RANTES, a leukocyte chemotactic cytokine was higher in NFP (26.19 versus 1418.00 pg/mL, P< 0.001). Interleukin-4 (5.70 versus 0.00 pg/mL, P= 0.03) and IL-8 (2.20 versus 0.52 pg/ml, P= 0.03) levels were higher in were higher in FFP., Conclusions: Frozen storage of plasma may result in decrease of several growth factors and/or pro-coagulants found in NFP. In addition, the freezing and thawing process may induce release of pro-inflammatory chemokines. Further studies are needed to determine if these cytokines result in improved outcomes with NFP over FFP in transfusion of trauma patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To study the correlation of conventional point-of-care clotting test (POCCT) of whole blood with laboratory fibrinogen levels in women with primary major postpartum hemorrhage (PPH) to generate evidence regarding its potential in rationalizing transfusion of blood components for supplementing fibrinogen., Methods: A total of 68 samples were studied: 40 from women with primary major PPH, 20 from women without PPH, and eight samples of Fresh Frozen Plasma (FFP). POCCT was performed in the PPH and non-PPH groups and at the same time, sample for laboratory fibrinogen was sent. Values were correlated using Pearson's correlation coefficient (r). Depending upon the laboratory fibrinogen values, POCCT in the PPH group was divided into three subgroups of less than 7, 7-11, and more than >11 min as subgroups 1, 2, and 3, respectively., Results: Women in the PPH group (n = 40) had a mean fibrinogen level of 346.15 ± 143.37 mg% with a significant negative correlation with POCCT (r = -0.69, P < 0.001). Mean fibrinogen levels of non-PPH group and FFP samples were 602.1 ± 169.72 and 286.75 ± 103.42 mg%, respectively. PPH subgroups 1, 2, and 3 had mean fibrinogen of 452.2 ± 141.8, 332.58 ± 138.51, and 158.71 ± 145 mg%, respectively. These values may potentially guide FFP transfusions., Conclusion: POCCT is easy, costs nothing and has a potential role in rationalizing FFP transfusion in low- and middle-income countries., (© 2020 International Federation of Gynecology and Obstetrics.)

Background: The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a survival benefit to trauma patients who received thawed plasma as part of early resuscitation. The objective of our study was to examine the association between blood transfusion and nosocomial infections among trauma patients who participated in the PAMPer trial. We hypothesized that transfusion of blood products will be associated with the development of nosocomial infections in a dose-dependent fashion., Methods: We performed a secondary analysis of prospectively collected data of patients in the PAMPer trial with hospital length of stay of at least 3 days. Demographics, injury characteristics, and number of blood products transfused were obtained to evaluate outcomes. Bivariate analysis was performed to identify differences between patients with and without nosocomial infections. Two logistic regression models were created to evaluate the association between nosocomial infections and (1) any transfusion of blood products, and (2) quantity of blood products. Both models were adjusted for age, sex, and Injury Severity Score., Results: A total of 399 patients were included: age, 46 years (interquartile range, 29-59 years); Injury Severity Score, 22 (interquartile range, 12-29); 73% male; 80% blunt mechanism; and 40 (10%) deaths. Ninety-three (27%) developed nosocomial infections, including pneumonia (n = 67), bloodstream infections (n = 14), catheter-associated urinary tract infection (n = 10), skin and soft tissue infection (n = 8), Clostridium difficile colitis (n = 7), empyema (n = 6), and complicated intra-abdominal infections (n = 3). Nearly 80% (n = 307) of patients received packed red blood cells (PRBCs); 12% received cryoprecipitate, 69% received plasma, and 27% received platelets. Patients who received any PRBCs had more than a twofold increase in nosocomial infections (odds ratio, 2.15; 95% confidence interval, 1.01-4.58; p = 0.047). The number of PRBCs given was also associated with the development of nosocomial infection (odds ratio, 1.10; 95% confidence interval, 1.05-1.16; p < 0.001)., Conclusion: Trauma patients in the PAMPer trial who received a transfusion of at least 1 U of PRBCs incurred a twofold increased risk of nosocomial infection, and the risk of infection was dose dependent., Level of Evidence: Therapeutic/care management, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Massive bleeding remains a major source of morbidity and mortality worldwide. Recent studies have shed light on the pathophysiology of traumatic-induced coagulopathy and the central role of endotheliopathy. Transfusion therapy has changed dramatically in the last decade with use of red cells and plasma in a 1:1 ratio. The use of early transfusion increases the likelihood of a favorable outcome. Early intervention-preferably less than 60 min of injury-is a major factor in improved survival. Experience with dried plasma products-lyophilized or freeze-dried-in Europe and South Africa has demonstrated both safety and efficacy. Dry plasma products are not available in the United States but several products are in development. Spray-dried plasma contains clinically meaningful levels of coagulation activity and in vitro data suggest robust ability to generate thrombus. The decentralized, blood-center based manufacturing model of spray-dried plasma offers advantages for availability to meet routine and extraordinary demands., (© 2021 AABB.)

Background: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era., Methods: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality., Results: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%)., Conclusion: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication., Level of Evidence: Prognostic, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Low-titer group O whole-blood (LTOWB) is being used for children with life-threatening traumatic bleeding. A survey was conducted to determine current LTOWB utilization and interest in participation in a randomized control trial (RCT) of LTOWB versus standard blood component transfusion in this population., Study Design and Methods: Transfusion medicine (TM) directors and pediatric trauma directors at 36 US children's hospitals were surveyed by e-mail in June 2020. Hospitals were selected by participation in the Massive Transfusion Epidemiology and Outcomes in Children Study or being among the largest 30 children's hospitals by bed capacity per the Becker Hospital Review., Results: The response rate was 83.3% (30/36) from TM directors and 88.9% (32/36) from trauma directors. The median of massive transfusion protocol activations for traumatic bleeding was reported as 12 (IQR 5.8-20) per year by TM directors. LTOWB was used by 18.8% (6/32) of trauma directors. Survey responses indicate that 86.7% (26/30) of TM directors and 90.6% (29/32) of trauma directors either moderately or strongly agree that a LTOWB RCT is important to perform. About 83.3% (25/30) of TM directors and 93.8% (30/32) of trauma directors were willing to participate in the proposed trial. About 80% (24/30) of TM directors and 71.9% (23/32) of trauma directors would transfuse RhD+ LTOWB to male children, but fewer would transfuse Rh + LTOWB to females [20% (6/30) TM directors and 37.5% (12/32) of trauma directors]., Conclusions: A majority of respondents supported an RCT comparing LTOWB to component therapy in children with severe traumatic bleeding., (© 2021 AABB.)

Background: INR is traditionally used as a marker of clinical coagulopathy, but is suboptimal in liver disease patients due to rebalanced hemostasis and its ineffectiveness to predict bleeding. Rotational thromboelastometry (ROTEM) testing evaluates whole blood hemostasis, which may provide more accurate assessments with the EXTEM CT parameter than INR. Thus, in end-stage liver disease (ESLD) patients, we hypothesized that elevated INRs are associated with normal EXTEM CT values., Methods: A retrospective study assessing adult (>18) patients with ESLD and elevated INRs undergoing liver transplantation, was performed to assess correlations between INR and EXTEM CT. This included patients post-ROTEM implementation where all had pre-operative ROTEM testing; and patients up to one year pre-ROTEM implementation to compare transfusion utilization. Data abstracted also included patient demographics, coagulation testing results, liver disease etiology, and MELD score., Results: The study included 138 patients in the post-ROTEM group and 59 patients in the pre-ROTEM group. Normal EXTEM CT was observed in 95.3 % and 93 % of patients with INR of 1.3-1.8 and up to 3 respectively. There was no correlation between INR of 1.3-1.8 and EXTEM CT (⍴ = 0.239), and only moderate correlation was observed with higher INRs (⍴ = 0.617 with INRs >1.8). ROTEM-guided transfusion in liver transplant surgeries was associated with reduced plasma transfusion (OR 0.27, 95 % CI 0.12-0.58, p = 0.001) after adjusting for red cell utilization and coagulation testing., Conclusion: Our study suggests ROTEM may be advantageous for evaluating coagulopathy in patients with liver disease and ROTEM-guided transfusion reduces plasma transfusion., (Copyright © 2021. Published by Elsevier Ltd.)

Background: In late 2019, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus emerged in China and quickly spread into a worldwide pandemic. Prior to the development of specific drug therapies or a vaccine, more immediately available treatments were sought including convalescent plasma. A potential improvement from convalescent plasma could be the preparation of anti-SARS-CoV-2 hyperimmune globulin (hIVIG)., Study Design and Methods: Convalescent plasma was collected from an existing network of plasma donation centers. A caprylate/chromatography purification process was used to manufacture hIVIG. Initial batches of hIVIG were manufactured in a versatile, small-scale facility designed and built to rapidly address emerging infectious diseases., Results: Processing convalescent plasma into hIVIG resulted in a highly purified immunoglobulin G (IgG) product with more concentrated neutralizing antibody activity. hIVIG will allow for the administration of greater antibody activity per unit of volume with decreased potential for several adverse events associated with plasma administration. IgG concentration and IgG specific to SARS-CoV-2 were increased over 10-fold from convalescent plasma to the final product. Normalized enzyme-linked immunosorbent assay activity (per mg/ml IgG) was maintained throughout the process. Protein content in these final product batches was 100% IgG, consisting of 98% monomer and dimer forms. Potentially hazardous proteins (IgM, IgA, and anti-A, anti-B, and anti-D) were reduced to minimal levels., Conclusions: Multiple batches of anti-SARS-CoV-2 hIVIG that met regulatory requirements were manufactured from human convalescent plasma. The first clinical study in which the hIVIG will be evaluated will be Inpatient Treatment with Anti-Coronavirus Immunoglobulin (ITAC) [NCT04546581]., (© 2021 The Authors. Transfusion published by Wiley Periodicals LLC. on behalf of AABB.)

Background and Objectives: Hospitals prepare for emergencies, but the impact on transfusion staff is rarely discussed. We describe the transfusion response to four major incidents (MIs) during a 6-month period. Three events were due to terrorist attacks, and the fourth was the Grenfell Tower fire. The aim of this paper was to share the practical lessons identified., Methods: This was a retrospective review of four MIs in 2017 using patient administration systems, MI documentation and post-incident debriefs. Blood issue, usage and adverse events during the four activation periods were identified using the Laboratory Information Management System (TelePath)., Results: Thirty-four patients were admitted (18 P1, 4 P2, 11 P3 and 1 dead). Forty-five blood samples were received: 24 related to nine MI P1 patients. Four P1s received blood components, three with trauma and one with burns, and 35 components were issued. Total components used were six red blood cells (RBC), six fresh frozen plasma (FFP) and two cryoprecipitate pools. Early lessons identified included sample labelling errors (4/24). Errors resolved following the deployment of transfusion staff within the emergency department. Components were over-ordered, leading to time-expiry wastage of platelets. Careful staff management ensured continuity of transfusion services beyond the immediate response period. Debriefing sessions provided staff with support and enabled lessons to be shared., Conclusions: Transfusion teams were involved in repeated incidents. The demand for blood was minimal. Workload was related to sample handling rather than component issue. A shared situational awareness would improve stock management. A laboratory debriefing system offered valuable feedback for service improvement, staff training and support., (© 2021 The Authors. Transfusion Medicine published by John Wiley & Sons Ltd on behalf of British Blood Transfusion Society.)

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is wreaking havoc on public health systems worldwide. The diagnosis of COVID-19 is well defined, but efficacious treatment is lacking. There is a big gap in knowledge regarding COVID-19 patients receiving convalescent plasma transfusion (CPT), especially those also suffering from diabetes mellitus (DM). In this study, among 3059 COVID-19 patients admitted to Wuhan Huoshenshan Hospital of China, we documented the characteristics of 39 COVID-19 patients with DM receiving CPT and compared their baseline information and clinical outcomes to COVID-19 patients with DM receiving conventional treatment. We also performed the propensity-matched comparison of COVID-19 patients with DM between conventional treatment and CPT. The CPT was efficacious and beneficial for COVID-19 patients with DM, including severe or critically ill patients, without obvious adverse effects. Our data demonstrated that CPT significantly improved the clinical outcomes of COVID-19 patients with DM, especially the cure rate and duration of hospitalization compared with that in COVID-19 patients with DM receiving conventional treatment. This study not only provided a deeper understanding of characteristics in COVID-19 patients with DM receiving CPT but also highlighted the efficaciousness of CPT for COVID-19 patients with DM., (© 2020 Wiley Periodicals LLC.)

Due to the patients' underlying illness, in combination with circuit-induced coagulopathy, as well as PLT dysfunction, children supported by ECMO are a risk of receiving large volumes of blood components. Given the increasing use of modified blood products and newer biologics, it is unknown whether these products have equal efficacy and safety, in ECMO. The majority of guidance for transfusion therapy is based on expert opinion alone, and research on indications for RBC, plasma, and PLT transfusions for children on ECMO should be a priority., (© 2021 AABB.)

Background: Plasma resuscitation ameliorates hyperfibrinolysis (HF) and trauma-induced coagulopathy (TIC). However, the use of other blood components to reduce HF has not been evaluated. Therefore, our aim was to determine the effect of individual blood components and whole blood (WB) on an in vitro model of severe HF/TIC., Methods: A "TIC" solution was made with 1:1 dilution of WB with saline and exacerbated with tissue plasminogen activator (tPA). Components were added in proportions equivalent to the thromboelastography (TEG) based goal-directed resuscitation used at our institution. Whole blood was added at proportions equal to what has been transfused in injured patients. Samples (n = 9) underwent citrated native and tPA-challenge (75 ng/mL) TEG with analysis of R-time, angle, MA, and LY30. Statistical analyses were completed employing the nonparametric Kruskal-Wallis and Dunn's multiple comparisons tests., Results: TIC solution, when compared to control, had a decrease in clot strength (MA 41 mm versus 51.5 mm, P < 0.01). The addition of tPA resulted in a severe coagulopathy (MA 24.5 mm versus 41 mm and LY30 52.8% versus 2.4%, P < 0.03 for all). The addition of 4U of WB improved clot strength compared to TIC + tPA (P = 0.03). No individual blood component resulted in improved fibrinolysis (P > 0.7). Cryoprecipitate improved R-time (7.5 versus 11.9 min, P < 0.01), angle (56.8 versus 30.2°) and MA (49 mm versus 36.25 mm), while platelets improved MA (44 mm versus 36.25 mm) compared to TIC + tPA (P < 0.03 for all)., Conclusions: No single blood component or volume of whole blood led to attenuation of tPA-mediated fibrinolysis in an in vitro model of TIC. Cryoprecipitate was the most effective at improving coagulation function., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: During the COVID-19 outbreak, most hospitals deferred elective surgical procedures to allow space for the overwhelming number of COVID-19 patient admissions, expecting a decrease in routine blood component requirements. However, because transfusion support needs of COVID-19 patients are not well known, its impact on hospital blood supply is uncertain. The objective of this study was to assess the effect of the COVID-19 pandemic on transfusion demand., Study Design and Methods: Transfusion records during the peak of the COVID-19 pandemic (March 1-April 30, 2020) were reviewed in our center to assess changes in blood requirements., Results: During this period 636 patients received a total of 2934 blood components, which reflects a 17.6% reduction in transfusion requirements with regard to the same period of 2019, and blood donations in Madrid dropped by 45%. The surgical blood demand decreased significantly during the outbreak (50.2%). Blood usage in the hematology and oncology departments remained unchanged, while the day ward demand halved, and intensive care unit transfusion needs increased by 116%. A total of 6.2% of all COVID inpatients required transfusion support. COVID-19 inpatients consumed 19% of all blood components, which counterbalanced the savings owed to the reduction in elective procedures., Conclusion: Although only a minority of COVID-19 inpatients required transfusion, the expected reduction in transfusion needs caused by the lack of elective surgical procedures is partially offset by the large number of admitted patients during the peak of the pandemic. This fact must be taken into account when planning hospital blood supply., (© 2020 AABB.)

BACKGROUND This retrospective study aimed to describe the effects of convalescent plasma therapy in 24 patients diagnosed with coronavirus disease 2019 (COVID-19) pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during February and March 2020 in Wuhan, China. MATERIAL AND METHODS The confirmation of SARS-CoV-2 infection was made by the reverse transcription-polymerase chain reaction test. We retrospectively analyzed the clinical data and laboratory test reports of patients with severe COVID-19 pneumonia who received a convalescent plasma transfusion. RESULTS A total of 24 patients with COVID-19 pneumonia who were transfused with ABO-compatible convalescent plasma were enrolled in the study. Convalescent plasma transfusion showed an effective clinical outcome in 14 of 24 patients (an effective rate of 58.3%). No patients had an adverse reaction to the transfusion. Compared with before convalescent plasma transfusion, the lymphocyte count after convalescent plasma transfusion increased to a normal level (median: 0.80×10⁹/L vs. 1.12×10⁹/L, P=0.004). Other laboratory indicators such as white blood cells, high-sensitivity C-reactive protein, procalcitonin, alanine aminotransferase, and aspartate transaminase showed a decreasing trend after transfusion. CONCLUSIONS This retrospective observational clinical study showed that convalescent plasma therapy could have beneficial effects on patient outcomes. Recently, regulatory authorization has been given for the use of convalescent plasma therapy, and clinical guidelines have been developed for the collection and use of convalescent plasma and hyperimmune immunoglobulin in patients with COVID-19.