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Blood transfusions save lives. Scientific advancements in infectious disease testing, immunohematology, and blood processing, coupled with an altruistic blood donor model, blood transfusion has become a safe and effective therapeutic intervention. Blood establishments are an integral part of the health care continuum. However, challenges related to access to blood as well as diversity of blood donors can reflect the broader issues within our health care system. An awareness of the social injustices while using medical evidence-based data to support change will be essential for ensuring equitable access to life-saving treatments for all individuals and the communities we serve., Competing Interests: Disclosure The authors have no conflict of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Administering platelets through a rapid infuser is proven to be safe. However, the clinical significance of infusing ABO-incompatible platelets with red blood cells (RBCs) in a rapid infuser remains unclear. There is a theoretical risk that isoagglutinin in the plasma of a platelet unit can interact with RBCs and induce hemolysis., Materials and Methods: Seven in vitro studies were performed including five cases (type A RBCs and type O platelets) and two controls (type A RBCs and platelets). Anti-A titers were measured in platelet units. An RBC unit and a platelet unit were mixed in the rapid infuser reservoir and incubated for 30 min. The primary outcome was the presence of hemolysis based on the following parameters: free hemoglobin concentration, hemolysis check, direct antiglobulin test (DAT), and direct agglutination., Results: The post-mix DAT was positive for IgG in all test samples (5/5), and weakly positive for complement in 3/5. The changes in free Hb in test cases between measured and calculated post-mix spanned -2.2 to +3.4 mg/dL. Post-mix hemolysis check was negative in 3/5 and slightly positive in 2/5 cases, with no significant differences compared to the control case. Anti-A titers ranged from 16 to 512 and were not associated with hemolysis. All samples were negative for direct agglutination., Conclusion: Our study suggested that mixing ABO-incompatible platelets with RBCs in a rapid infuser does not induce in vitro hemolysis. These findings support the use of rapid infusers regardless of platelet compatibility in support of hemostatic resuscitation., (© 2024 AABB.)

Context.—: Substantial variability between different antibody titration methods has been identified since the development and introduction of the uniform procedure in 2008., Objective.—: To determine whether more recent methods or techniques decrease interlaboratory and intralaboratory variation measured using proficiency testing., Design.—: Proficiency test data for antibody titration between 2014 and 2018 were obtained from the College of American Pathologists. Interlaboratory and intralaboratory variations were compared by analyzing the distribution of titer results by method and phase, comparing the results against the supplier's quality control titer, and by evaluating the distribution of paired titer results when each laboratory received a sample with the same titer twice., Results.—: A total of 1337 laboratories participated in the antibody titer proficiency test during the study period. Only 54.1% (5874 of 10 852) of anti-D and 63.4% (3603 of 5680) of anti-A reported responses were within 1 titer of the supplier's intended result. Review of the agreement between laboratories of the same methodology found that 78.4% (3139 of 4004) for anti-A and 89.0% (9655 of 10 852) of laboratory responses for anti-D fell within 1 titer of the mode response. When provided with 2 consecutive samples of the same titer (anti-D titer: 16), 85% (367 of 434) of laboratories using the uniform procedure and 80% (458 of 576) using the other method reported a titer difference of 1 or less., Conclusions.—: Despite advances, interlaboratory and intralaboratory variance for this assay remains high in comparison with the strong reliance on titer results in clinical practice. There needs to be a reevaluation of the role of this test in clinical decision-making., (© 2023 College of American Pathologists.)

Importance: Red blood cell transfusion is a common medical intervention with benefits and harms., Objective: To provide recommendations for use of red blood cell transfusion in adults and children., Evidence Review: Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed., Findings: For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence)., Conclusions and Relevance: It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.

Background: Meta-analyses of randomized controlled trials (RCTs) evaluating thresholds for red blood cell (RBC) transfusion typically focus on mortality; however, other outcomes are highly relevant. The aim of this study is to summarize the effects of different transfusion thresholds on the outcomes of quality of life (QoL) and function., Study Design: We extracted data from RCTs identified in a recently published Cochrane systematic review. Primary analysis was descriptive., Results: A total of 23 RCTs with 13,743 adult participants were included. Fifteen RCTs included patients in the postoperative period, of which 9 RCTs were conducted in hip (n = 3024) and 6 (n = 8672) in cardiac surgeries; 5 RCTs (n = 489) were in patients with hematological malignancies; 2 in the setting of bleeding (gastrointestinal bleed [n = 936] and postpartum [n = 521]); and one RCT (n = 936) included critically ill patients. QoL and function were reported using a variety of questionnaires and tools. The timing of assessments varied between trials. No clear clinical differences in QoL outcomes were identified in comparisons between restrictive and liberal transfusion thresholds., Discussion: There is no evidence that a liberal transfusion strategy improves QoL and functional outcomes. However, the substantial limitations of many included studies indicate the need for further well-designed and adequately powered trials., (© 2023 AABB.)

Background: The Association for the Advancement of Blood and Biotherapies Clinical Transfusion Medicine Committee (CTMC) composes a summary of new and important advances in transfusion medicine (TM) on an annual basis. Since 2018, this has been assembled into a manuscript and published in Transfusion., Study Design and Methods: CTMC members selected original manuscripts relevant to TM that were published electronically and/or in print during calendar year 2022. Papers were selected based on perceived importance and/or originality. References for selected papers were made available to CTMC members to provide feedback. Members were also encouraged to identify papers that may have been omitted initially. They then worked in groups of two to three to write a summary for each new publication within their broader topic. Each topic summary was then reviewed and edited by two separate committee members. The final manuscript was assembled by the first and senior authors. While this review is extensive, it is not a systematic review and some publications considered important by readers may have been excluded., Results: For calendar year 2022, summaries of key publications were assembled for the following broader topics within TM: blood component therapy; infectious diseases, blood donor testing, and collections; patient blood management; immunohematology and genomics; hemostasis; hemoglobinopathies; apheresis and cell therapy; pediatrics; and health care disparities, diversity, equity, and inclusion., Discussion: This Committee Report reviews and summarizes important publications and advances in TM published during calendar year 2022, and maybe a useful educational tool., (© 2023 AABB.)

Background: The clinical significance of serologic reactivity of unidentified specificity (SRUS) in pregnancy is not clear based on available literature. The aim of this study is to determine if SRUS is associated with hemolytic disease of the fetus and newborn (HDFN)., Study Design and Methods: Retrospective data were collected from eight institutions over an 11-year study period (2010-2020), when available (5/8 sites). The outcome of the pregnancies with SRUS-no, mild, moderate, or severe HDFN-was determined., Results: SRUS was demonstrated in 589 pregnancies. After excluding those with incomplete data, a total of 284 pregnancies were included in the primary HDFN outcome analysis. SRUS was detected in 124 (44%) pregnancies in isolation, and none were affected by HDFN. Of 41 pregnancies with SRUS and ABO incompatibility, 37 (90%) were unaffected, and 4 (10%) were associated with mild HDFN. Of 98 pregnancies with SRUS and concurrent identifiable antibody reactivity(s), 80 (81%) were unaffected, and 19 (19%) were associated with mild to severe HDFN. There was 1 case of mild HDFN and 1 case of severe HDFN in the 21 pregnancies with SRUS, ABO incompatibility, and concurrent identifiable antibody reactivity(s), and 19 (90%) were unaffected by HDFN. Among all patients with repeat testing, newly identified alloantibodies or other antibodies were identified in 63 of 212 (30%) patients. Although most were not clinically significant, on occasion SRUS preceded clinically significant antibody(s) associated with HDFN (3%, 5/188)., Conclusion: The antenatal serologic finding of SRUS in isolation is not associated with HDFN but may precede clinically significant antibodies., (© 2023 AABB.)

Context.—: Modern RHD genotyping can be used to determine when patients with serologic weak D phenotypes have RHD gene variants at risk for anti-D alloimmunization. However, serologic testing, RhD interpretations, and laboratory management of these patients are quite variable., Objective.—: To obtain interlaboratory comparisons of serologic testing, RhD interpretations, Rh immune globulin (RhIG) management, fetomaternal hemorrhage testing, and RHD genotyping for weak D-reactive specimens., Design.—: We devised an educational exercise in which 81 transfusion services supporting obstetrics performed tube-method RhD typing on 2 unknown red blood cell challenge specimens identified as (1) maternal and (2) newborn. Both specimens were from the same weak D-reactive donor. The exercise revealed how participants responded to these different clinical situations., Results.—: Of reporting laboratories, 14% (11 of 80) obtained discrepant immediate-spin reactions on the 2 specimens. Nine different reporting terms were used to interpret weak D-reactive maternal RhD types to obstetricians. In laboratories obtaining negative maternal immediate-spin reactions, 28% (16 of 57) performed unwarranted antiglobulin testing, sometimes leading to recommendations against giving RhIG. To screen for excess fetomaternal hemorrhage after a weak D-reactive newborn, 47% (34 of 73) of reporting laboratories would have employed a contraindicated fetal rosette test, risking false-negative results and inadequate RhIG coverage. Sixty percent (44 of 73) of laboratories would obtain RHD genotyping in some or all cases., Conclusions.—: For obstetric and neonatal patients with serologic weak D phenotypes, we found several critical problems in transfusion service laboratory practices. We provide recommendations for appropriate testing, consistent immunohematologic terminology, and RHD genotype-guided management of Rh immune globulin therapy and RBC transfusions., (© 2023 College of American Pathologists.)

Bacterial contamination of platelet units has been one of the most common transfusion-transmitted infections. Approximately 4 to 7 fatalities are being reported to the US Food and Drug Administration (FDA) annually, which cites bacterially contaminated platelet units as the cause. Over the past 3 decades, different mitigation strategies have been introduced to minimize the risk of morbidity and mortality related to contaminated platelet units. The process of platelet collection and manufacturing as well as storage at 20°C to 24°C contributes to higher prevalence of contaminated units. The risk of transfusing bacterially contaminated platelets can be lowered using different types of interventions. Prevention of bacterial contamination can be done by strict adherence to techniques that minimize contamination during unit collection. The detection of bacteria in platelet products can be improved with a combination of rapid testing and bacterial cultures that involve large volume and delayed sampling. Finally, pathogen reduction can inactivate bacteria or other pathogens present in the unit. This article describes different strategies that blood centers and transfusion services have undertaken since October 2021 to meet FDA guidance requirements. Market forces as well as feasibility of different FDA-proposed approaches have limited the number of practical solutions to just a few. In addition, the blood product availability required hospitals to adopt more progressive strategies to provide patients with needed platelet products., (Copyright © 2022 by The American Society of Hematology.)

Evidence of the effectiveness of prophylactic use of tranexamic acid (TXA) in thrombocytopenia is lacking. To determine whether TXA safely reduces bleeding incidence in patients undergoing treatment for hematologic malignancies, a randomized, double-blind clinical trial was conducted from June 2016 through June 2020. Of 3120 screened adults, 356 patients were eligible and enrolled, and 337 patients (mean age, 53.9; 141 [41.8%] women), randomized to 1300 mg TXA orally or 1000 mg TXA through IV (n = 168) vs placebo (n = 169) thrice daily for maximum 30 days. Three hundred thirty patients were activated when their platelet counts fell below 30 000 per µL; 279 (83%) had complete outcome ascertainment. World Health Organization (WHO) grade ≥2 bleeding was observed in the 30 days following activation in 50.3% (73/145) and 54.2% (78/144) of patients in the TXA and placebo groups, with an adjusted odds ratio of 0.83 (95% confidence interval [CI], 0.50-1.34; P = .44). There was no statistically significant difference in the mean number of platelet transfusions (mean difference, 0.1; 95% CI, -1.9 to 2.0), mean days alive without grade ≥2 bleeding (mean difference, 0.8; 95% CI, -0.4 to 2.0), thrombotic events (6/163 [3.7%] TXA, 9/163 [5.5%] placebo), or deaths due to serious bleeding. Most common adverse events were: diarrhea (116/164 [70.7%] TXA and 114/163 [69.9%] placebo); febrile neutropenia (111/164 [67.7%] TXA, 105/163 [64.4%] placebo); fatigue (106/164 [64.6%] TXA, 109/163 [66.9%] placebo); and nausea (104/164 [63.4%] TXA, 97/163 [59.5%] placebo). Among patients with hematologic malignancy undergoing chemotherapy or hematopoietic stem cell transplantation, prophylactic treatment with TXA compared with placebo did not significantly reduce the risk of WHO grade ≥2 bleeding., (© 2022 by The American Society of Hematology.)

Description: Coronavirus disease 2019 convalescent plasma (CCP) has emerged as a potential treatment of COVID-19. However, meta-analysis data and recommendations are limited. The Association for the Advancement of Blood and Biotherapies (AABB) developed clinical practice guidelines for the appropriate use of CCP., Methods: These guidelines are based on 2 living systematic reviews of randomized controlled trials (RCTs) evaluating CCP from 1 January 2019 to 26 January 2022. There were 33 RCTs assessing 21 916 participants. The results were summarized using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. An expert panel reviewed the data using the GRADE framework to formulate recommendations., Recommendation 1 (outpatient): The AABB suggests CCP transfusion in addition to the usual standard of care for outpatients with COVID-19 who are at high risk for disease progression (weak recommendation, moderate-certainty evidence)., Recommendation 2 (inpatient): The AABB recommends against CCP transfusion for unselected hospitalized persons with moderate or severe disease (strong recommendation, high-certainty evidence). This recommendation does not apply to immunosuppressed patients or those who lack antibodies against SARS-CoV-2., Recommendation 3 (inpatient): The AABB suggests CCP transfusion in addition to the usual standard of care for hospitalized patients with COVID-19 who do not have SARS-CoV-2 antibodies detected at admission (weak recommendation, low-certainty evidence)., Recommendation 4 (inpatient): The AABB suggests CCP transfusion in addition to the usual standard of care for hospitalized patients with COVID-19 and preexisting immunosuppression (weak recommendation, low-certainty evidence)., Recommendation 5 (prophylaxis): The AABB suggests against prophylactic CCP transfusion for uninfected persons with close contact exposure to a person with COVID-19 (weak recommendation, low-certainty evidence)., Good Clinical Practice Statement: CCP is most effective when transfused with high neutralizing titers to infected patients early after symptom onset.

Background: At the start of the coronavirus disease 2019 (COVID-19) pandemic, widespread blood shortages were anticipated. We sought to determine how hospital blood supply and blood utilization were affected by the first wave of COVID-19., Study Design and Methods: Weekly red blood cell (RBC) and platelet (PLT) inventory, transfusion, and outdate data were collected from 13 institutions in the United States, Brazil, Canada, and Denmark from March 1st to December 31st of 2020 and 2019. Data from the sites were aligned based on each site's local first peak of COVID-19 cases, and data from 2020 (pandemic year) were compared with data from the corresponding period in 2019 (pre-pandemic baseline)., Results: RBC inventories were 3% lower in 2020 than in 2019 (680 vs. 704, p < .001) and 5% fewer RBCs were transfused per week compared to 2019 (477 vs. 501, p < .001). However, during the first COVID-19 peak, RBC and PLT inventories were higher than normal, as reflected by deviation from par, days on hand, and percent outdated. At this time, 16% fewer inpatient beds were occupied, and 43% fewer surgeries were performed compared to 2019 (p < .001). In contrast to 2019 when there was no correlation, there was, in 2020, significant negative correlations between RBC and PLT days on hand and both percentage occupancy of inpatient beds and percentage of surgeries performed., Conclusion: During the COVID-19 pandemic in 2020, RBC and PLT inventories remained adequate. During the first wave of cases, significant decreases in patient care activities were associated with excess RBC and PLT supplies and increased product outdating., (© 2022 AABB.)

Background: Anticoagulation requires urgent reversal in cases of life-threatening bleeding or invasive procedures., Study Design and Methods: Network meta-analysis for comparing the safety and efficacy of warfarin reversal strategies including plasma and prothrombin complex concentrates (PCCs)., Results: Seven studies including 594 subjects using reversal agents plasma, 3-factor-PCC (Uman Complex and Konyne), and 4-factor-PCC (Beriplex/KCentra, Octaplex, and Cofact) met inclusion criteria. Compared with plasma, patients receiving Cofact probably have a higher rate of international normalized ratio (INR) correction (risk difference [RD] 499 more per 1000 patients, 95% confidence interval [CI], 176-761, low certainty[LC]); higher reversal of bleeding (323 more per 1000 patients, 11-344 more, LC); and fewer transfusion requirements (0.96 fewer units, 1.65-0.27 fewer, LC). Patients receiving Beriplex/KCentra probably have a higher rate of INR correction (476 more per 1000 patients, 332-609 more, LC); higher reversal of bleeding (127 more per 1000 patients, 43 fewer to 236 more); and similar transfusion requirements (0.01 fewer units, 0.31 fewer to 0.28 more, high/moderate certainty). Patients receiving Octaplex probably have a higher rate of INR correction (RD 579 more per 1000 patients, 189-825 more, LC)., Conclusions: PCCs probably provide an advantage in INR reversal compared to plasma. There was no added risk of adverse events with PCCs., (© 2022 AABB.)

Background: Each year the AABB Clinical Transfusion Medicine Committee (CTMC) procures a synopsis highlighting new, important, and clinically relevant studies in the field of transfusion medicine (TM). This has been made available as a publication in Transfusion since 2018., Methods: CTMC members reviewed and identified original manuscripts covering TM-related topics published electronically (ahead-of-print) or in print from December 2020 to December 2021. Selection of publications was discussed at committee meetings and chosen based on perceived relevance and originality. Next, committee members worked in pairs to create a synopsis of each topic, which was then reviewed by additional committee members. The first and senior authors assembled the final manuscript. Although this synopsis is extensive, it is not exhaustive, and some articles may have been excluded or missed., Results: The following topics are included: blood products; convalescent plasma; donor collections and testing; hemoglobinopathies; immunohematology and genomics; hemostasis; patient blood management; pediatrics; therapeutic apheresis; and cell therapy., Conclusions: This synopsis highlights and summarizes recent key developments in TM and may be useful for educational purposes., (© 2022 AABB.)

Objectives: Blood transfusion is life-saving for patients experiencing acute blood loss and severe anaemia. In low-income and middle-income countries (LMICs), low blood donation rates and unavailability of whole blood and blood components (blood products) impairs timely blood transfusion. To fulfil patient-specific blood orders, a hospital blood transfusion service (HBTS) receives orders from a prescriber for blood transfusion, tests and prepares blood products for the patient. This study sought to describe the current state of LMIC HBTS., Design: A cross-sectional survey explored LMIC HBTS access to blood products, testing methods, policies and structure. Surveys were administered in English, Spanish, French and Russian, followed by a mixed-methods analysis., Setting: HBTS within LMICs., Participants: From among 124 public and private facilities invited to participate, we received 71 (57%) responses. Of these responses, 50 HBTS from 27 LMICs performed on-site blood transfusions., Results: Most LMIC HBTS perform blood collection to generate blood products for their patients (36/47, 77%); few relied exclusively on an external supply of blood products (11/47, 23%). The primary reason for blood transfusion was adult anaemia for non-malignant conditions (17/112, 15%). Testing methods varied by gross national income per capita. Blood transfusion delays to patients were common (17/30, 57%) attributed to inadequate blood inventories (13/29, 45%). Other barriers included lack of regular clinician education about transfusion (8/29, 28%) and sustainable financial models for the HBTS (4/29, 14%)., Conclusion: This survey describes the status of HBTS in diverse LMICs, illustrating that the availability of blood products remains a principal problem, requiring HBTS to generate its own facility's blood supply. Currently, blood shortages are not reported as a patient-specific adverse event making systematic tracking of delays in transfusion difficult. These findings highlight areas for further exploration related to the lack of available blood inventories for transfusions at HBTS in LMICs., Competing Interests: Competing interests: LSB reports personal fees and non-financial support from X-CellSystem, GLG, and AABB; LSB is a technical advisor to PAHO. JS is a contractor at Roche Molecular Systems. EB reports personal fees and non-financial support from Terumo BCT, Grifols Diagnostics Solutions and Abbott Laboratories outside of the submitted work; EB is a member of the US Food and Drug Administration (FDA) Blood Products Advisory Committee. TSI is a consultant for Terumo Blood Cell Technologies and Alexion Pharmaceuticals Inc., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Context.—: ABO mistransfusions are rare and potentially fatal events. Protocols are required by regulatory agencies to minimize this risk to patients, but how these are applied in the context of massive transfusion protocols (MTPs) is not specifically defined., Objective.—: To evaluate the approaches used by transfusion services for switching from universally compatible to patient ABO type-specific blood components during massive hemorrhage., Design.—: We added 1 supplemental multiple-choice question to address the study objective to the 2019 College of American Pathologists proficiency test J-survey (J-A 2019). We also reviewed the available literature regarding this topic., Results.—: A total of 881 laboratories responded to the supplemental question. Approximately 80% (704 of 881) reported a policy for ABO-type switching during an MTP. Policies varied considerably between responding laboratories, but most (384 of 704, 55%) required 2 ABO types to match before switching from universal to recipient-specific blood components. Additional safety measures used in a minority of these protocols included reaction strength criteria (103 of 704, 15%), on-call medical director approval (41 0f 704, 5.8%), universal red cell unit number limits (12 of 704, 1.7%), or the presence of a mixed field (3 of 704, 0.4%)., Conclusions.—: This survey reveals that significant heterogeneity exists regarding the available approaches for ABO-type switching during an MTP. Specific expert guidance regarding this issue is very limited, and best practices have not yet been established or rigorously investigated.

Background: The SARS-CoV-2 pandemic disrupted hospital operations, affected the blood supply, and challenged the health care system to develop new therapeutic options, including convalescent plasma (CCP). The aim of this study is to describe and analyze blood supply fluctuations and the use of convalescent plasma in 2020., Methods: AABB distributed a weekly and biweekly questionnaire through email to hospital-based members (HBM)., Results: The survey was sent to 887 HBM with 479 unique respondents, most of the hospitals served pediatric and adult patients, and all states of the country participated, except Idaho and Vermont. Fifty four percent of HBM reported increased wastage in the early phase of the pandemic (May), which decreased to 4% by the end of June and throughout the rest of the year. The majority of HBM reported receiving alerts from their blood suppliers reporting blood shortages throughout the year. During March and April, only 12% of HBM were performing elective surgical procedures. The top reasons to delay procedures were: bed availability (28%); COVID-19 caseload (23%; and blood availability (19%). By mid-April, 42% HBM had transfused CCP and reported >24 h delay in getting the units; the vast majority obtained CCP using the Expanded Access Protocol, and later, the Emergency Use Authorization. HBM consistently prioritized the most severe patients to receive CCP, but the proportion of severely ill recipients fell from 52% to 37% between May and October, with an increase from 5% to 21% of HBM providing CCP transfusion early in the course of the disease., Discussion: Blood utilization and availability fluctuated during the pandemic. The fluctuations appeared to be related to the number of COVID-19 in the community. The use and regulatory landscape of CCP rapidly evolved over the first 8 months of the pandemic., (© 2021 AABB.)

Background: Wrong blood in tube (WBIT) errors can lead to ABO mistransfusions. It is unknown if WBIT errors are more likely in specific healthcare locations or if specific collection practices influence the commission of WBIT errors., Study Design and Methods: Data on pretransfusion samples from calendar year 2019 were collected retrospectively by 39 transfusion services in nine countries. We compared the proportion of WBIT errors made in emergency departments (EDs), inpatient wards, and outpatient clinics., Results: In total, 143 WBIT errors were detected among 1,394,862 samples for an unadjusted aggregate WBIT proportion of 1.03/10,000 samples. Using a pooled random effects model, the WBIT proportion was estimated to be significantly higher in EDs (1.23/10,000 samples, 95% CI 0.62-2.43) than inpatient wards (0.71/10,000, 95% CI 0.44-1.14; p < .001) or outpatient clinics (0.24/10,000, 95% CI 0.08-0.65; p < .001) and significantly higher in inpatient wards than outpatient clinics (p = .043). The use of electronic positive patient identification (ePPID) systems was associated with a significantly lower WBIT proportion in the ED (odds ratio, OR: 0.32, 95% CI: 0.11-0.96, p = .041), but not in inpatient wards (OR: 0.45, 95% CI: 0.20-1.01, p = .054) or outpatient clinics (OR: 1.95, 95% CI: 0.39-9.74, p = .415)., Discussion: Normalized for the number of samples drawn per location, the WBIT proportion in EDs was 1.7 times higher than inpatient wards and 5.1 times higher than outpatient clinics. EDs represent higher-risk clinical locations for WBIT errors, and electronic positive patient identification (ePPID) may provide a greater impact on safety in EDs relative to other clinical areas., (© 2021 AABB.)

Background: The AABB Clinical Transfusion Medicine Committee (CTMC) compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine (TM), which has been made available as a manuscript published in Transfusion since 2018., Methods: CTMC committee members reviewed original manuscripts including TM-related topics published electronically (ahead) or in print from December 2019 to December 2020. The selection of topics and manuscripts was discussed at committee meetings and chosen based on relevance and originality. Next, committee members worked in pairs to create a synopsis of each topic, which was then reviewed by two additional committee members. The first and senior authors of this manuscript assembled the final manuscript. Although this synopsis is extensive, it is not exhaustive, and some papers may have been excluded or missed., Results: The following topics are included: COVID-19 effects on the blood supply and regulatory landscape, COVID convalescent plasma, adult transfusion practices, whole blood, molecular immunohematology, pediatric TM, cellular therapy, and apheresis medicine., Conclusions: This synopsis provides easy access to relevant topics and may be useful as an educational tool., (© 2021 AABB.)

Background: Plasma is frequently administered to patients with prolonged INR prior to invasive procedures. However, there is limited evidence evaluating efficacy and safety., Study Design and Methods: We performed a pilot trial in hospitalized patients with INR between 1.5 and 2.5 undergoing procedures conducted outside the operating room. We excluded patients undergoing procedures proximal to the central nervous system, platelet counts <40,000/μl, or congenital or acquired coagulation disorders unresponsive to plasma. We randomly allocated patients stratified by hospital and history of cirrhosis to receive plasma transfusion (10-15 cc/kg) or no transfusion. The primary outcome was change in hemoglobin concentration within 2 days of procedure., Results: We enrolled 57 patients, mean age 56.0, 34 (59.6%) with cirrhosis, and mean INR 1.92 (SD = 0.27). In the intention to treat analysis, there were 10 of 27 (38.5%) participants in the plasma arm with a post procedure INR <1.5 and one of 30 (3.6%) in the no treatment arm (p < .01). The mean INR after receiving plasma transfusion was -0.24 (SD 0.26) lower than baseline. The change from pre-procedure hemoglobin level to lowest level within 2 days was -0.6 (SD = 1.0) in the plasma transfusion arm and -0.4 (SD = 0.6) in the no transfusion arm (p = .29). Adverse outcomes were uncommon., Discussion: We found no differences in change in hemoglobin concentration in those treated with plasma compared to no treatment. The change in INR was small and corrected to less than 1.5 in minority of patients. Large trials are required to establish if plasma is safe and efficacious., (© 2021 AABB.)

Background: This report evaluates hospital blood use trends during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, and identifies factors associated with the need for transfusion and risk of death in patients with coronavirus 2019 (COVID-19)., Methods: Overall hospital blood use and medical records of adult patients with COVID-19 were extracted for two institutions. Multivariate logistic regression models were conducted to estimate associations between the outcomes transfusion and mortality and patient factors., Results: Daily blood use decreased compared to pre-COVID-19 levels; the effect was more significant for platelets (29% and 34%) compared to red blood cells (25% and 20%) at the two institutions, respectively. Surgical and oncologic services had a decrease in average daily use of platelets of 52% and 30%, and red blood cells of 39% and 25%, respectively. A total of 128 patients with COVID-19 were hospitalized, and 13 (10%) received at least one transfusion due to anemia secondary to chronic illness (n = 7), recent surgery (n = 3), and extracorporeal membrane oxygenation (n = 3). Lower baseline platelet count and admission to the intensive care unit were associated with increased risk of transfusion. The blood group distribution in patients with COVID-19 was 37% group O, 40% group A, 18% group B, and 5% group AB. Non-type O was not associated with increased risk of mortality., Conclusion: The response to the SARS-CoV-2 pandemic included changes in routine hospital operations that allowed for the provision of a sufficient level of care for patients with and without COVID-19. Although blood type may play a role in COVID-19 susceptibility, it did not seem to be associated with patient mortality., (© 2020 AABB.)

Every day, new surveys are planned, distributed, or reported by health care professionals. Surveys are an inexpensive and convenient research tool used with increasing frequency as an approach to gather and collate information on attitudes and behaviors for a specific topic. However, surveys can squander the valuable time of respondents who may derive little, if any, benefit from participation. Similar to any other research methodology, a careful design is needed to avoid introducing bias and to obtain meaningful information. A recent study evaluating the quality of surveys addressing clinical topics in transfusion medicine (TM) identified common deficiencies in the quality and design, including the failure to report validity and reliability, to address nonresponse error, to report funding and ethics/consent considerations, and to discuss the generalizability of results. Instructions to authors for reporting survey results are lacking in most journals. Inadequate survey design, analysis, and reporting can prevent accurate data collection and compromise the interpretation of the results, which is of critical relevance considering the high citation rates for some of these surveys. Further, survey results might be used to inform policies when no higher level of evidence is available. In this article, the authors seek to provide practical recommendations for designing high-quality surveys based on personal experience and published literature and to address frequently missing key elements in survey-based studies related to clinical TM., (© 2020 AABB.)

Background: Entrustable professional activities (EPAs) are well-defined, executable, observable, and measurable activities that are performed by a trainee and can be performed independently as training progresses. The purpose of this study is to develop EPAs specific for the practice of apheresis medicine (AM)., Methods: Members of the American Society for Apheresis Graduate Medical Education subcommittee developed a list of 28 apheresis medical activities linked to Accreditation Council for Graduate Medical Education milestones and competencies in five areas: (a) consultation, (b) clinical care for therapeutic apheresis, (c) clinical care for donor collections, (d) test optimization, and (e) vascular access. Ten AM experts using a validated tool to measure the quality of the EPAs (QUEPA) evaluated these activities with use of a Likert scale. Per group consensus, an activity was considered acceptable for each domain if it had received an average score greater than 3.7, and it was rated 4 or 5 (agree or strongly agree) by at least 70% of experts., Results: Of the 28 activities, 11 did not have acceptable QUEPA scores: 7 activities were rated as unobservable, 4 were rated unfocused, 2 were rated unrealistic and not generalizable, and 2 were rated as not addressing multiple competencies. Four activities had unacceptable scores in more than one domain. Subcommittee members edited these 11 activities over two review cycles to produce a final list of 26 activities., Conclusion: A set of practical, focused, and observable EPAs in AM were systematically developed. These EPAs can be used to assess and support trainee performance in AM., (© 2020 AABB.)

Background: The AABB Clinical Transfusion Medicine Committee (CTMC) compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine (TM) for the board of director's review. This synopsis is now made available as a manuscript published in TRANSFUSION., Study Design and Methods: CTMC committee members review original manuscripts including TM-related topics published in different journals between late 2018 and 2019. The selection of topics and manuscripts are discussed at committee meetings and are chosen based on relevance and originality. After the topics and manuscripts are selected, committee members work in pairs to create a synopsis of the topics, which is then reviewed by two committee members. The first and senior authors of this manuscript assembled the final manuscript. Although this synopsis is comprehensive, it is not exhaustive, and some papers may have been excluded or missed., Results: The following topics are included: infectious risks to the blood supply, iron donor studies, pre-transfusion testing interference and genotyping, cold agglutinin disease (CAD), HLA alloimmunization in platelet transfusions, patient blood management, updates to TACO and TRALI definitions, pediatric TM, and advances in apheresis medicine., Conclusion: This synopsis provides easy access to relevant topics and may be useful as an educational tool., (© 2020 AABB.)

Introduction: Red cell exchange (RCE) therapy is increasingly used to treat patients with acute or chronic manifestations of sickle cell disease (SCD). However, little is known regarding the most safe and effective practice parameters associated with this particular therapy., Methods: A SCD subcommittee of members of the American Society for Apheresis (ASFA) developed a 122-question survey and administered it via email to other ASFA members. The survey inquired about clinical indications for treatment, practice patterns, and transfusion policies for RCE when used for patients with SCD., Results: Ninety-nine distinct institutions completed the survey. Twenty-one (21%) were from outside of the US. Twenty-two (22%) provided chronic transfusion therapy to >10 patients, and both adult (25%) and pediatric-focused services (20%) were represented. Common acute indications for RCE included acute chest syndrome, acute ischemic stroke, and pre-surgical prophylaxis. Common chronic indications included primary stroke prophylaxis, secondary stroke prophylaxis, and recurrent acute chest syndrome. Respondents most commonly set a post-RCE treatment target of 30% for the hematocrit and hemoglobin S levels, regardless of the therapeutic indication. Units for RCE were phenotypically matched in 95% of cases. About 40% of respondents reported using isovolemic hemodilution., Conclusions: This survey solicited the current practice variations in RCE from a diverse range of practice sites. Many sites reported similar practice patterns and challenges but some variations emerged. To our knowledge, this survey represents the largest and most in-depth investigation of the use of RCE for patients with SCD, and could inform future studies in the field., (© 2020 AABB.)

Background: The first coronavirus (COVID-19) case was reported in United States in the state of Washington, approximately 3 months after the outbreak in Wuhan, China. Three weeks later, the US federal government declared the pandemic a national emergency. The number of confirmed COVID-19 positive cases increased rather rapidly and changed routine daily activities of the community., Study Design and Methods: This brief report describes the response from the hospital, the regional blood center, and the hospital-based transfusion services to the events that took place in the community during the initial phases of the pandemic., Results: In Washington State, the first week of March started with four confirmed cases and ended with 150; by the end of the second week of March there were more than 700 cases of confirmed COVID-19. During the first week, blood donations dropped significantly. Blood units provided from blood centers of nonaffected areas of the country helped keep inventory stable and allow for routine hospital operations. The hospital-based transfusion service began prospective triaging of blood orders to monitor and prioritize blood usage. In the second week, blood donations recovered, and the hospital postponed elective procedures to ensure staff and personal protective equipment were appropriate for the care of critical patients., Conclusion: As community activities are disrupted and hospital activities switch from routine operations to pandemic focused and urgent care oriented, the blood supply and usage requires a number of transformations., (© 2020 AABB.)

Background and Objectives: D-negative patients are at risk of developing an alloantibody to D (anti-D) if exposed to D during transfusion. The presence of anti-D can lead to haemolytic transfusion reactions and haemolytic disease of the newborn. Anti-D alloimmunization can also complicate allogeneic haematopoietic stem cell transplantation (HSCT) with haemolysis and increased transfusion requirements. The goal of this study was to determine whether cancer centres have transfusion practices intended to prevent anti-D alloimmunization with special attention in patients considered for HSCT., Methods and Materials: To understand transfusion practices regarding D-positive platelets in D-negative patients with large transfusion needs, we surveyed the 28 cancer centres that are members of the National Comprehensive Cancer Network ® (NCCN ® )., Results: Nineteen centres responded (68%). Most centres (79%) avoid transfusing D-positive platelets to RhD-negative patients when possible. Four centres (21%) avoid D-positive platelets only in D-negative women of childbearing age. If a D-negative patient receives a D-positive platelet transfusion, 53% of centres would consider treating with Rh immune globulin (RhIg) to prevent alloimmunization in women of childbearing age. Only one centre also gives RhIg to all D-negative patients who are HSCT candidates including adult men and women of no childbearing age., Conclusion: There is wide variation in platelet transfusion practices for supporting D-negative patients. The majority of centres do not have D-positive platelet transfusion policies focused on preventing anti-D alloimmunization specifically in patients undergoing HSCT. Multicentre, longitudinal studies are needed to understand the clinical implications of anti-D alloimmunization in HSCT patients., (© 2020 International Society of Blood Transfusion.)

Importance: Neuromyelitis optica/neuromyelitis optica spectrum disorder patients' response to therapeutic plasma exchange (TPE) is currently incompletely characterized., Objective: Our study aims to understand the clinical status improvement of neuromyelitis optica/neuromyelitis optica spectrum disorder patients treated with TPE., Design, Setting, and Participants: This is a multicenter retrospective study conducted between 1 January 2003 and 31 July 2017 at 13 US hospitals performing apheresis procedures. Subjects studied were diagnosed with neuromyelitis optica/neuromyelitis optica spectrum disorder who received TPE during presentation with acute disease., Main Outcomes and Measures: The primary outcome was clinical status improvement in patients treated with TPE. Secondary measures were procedural and patient characteristics associated with response to treatment., Results: We evaluated 114 patients from 13 institutions. There was a female predilection. The largest ethnic group affected was non-Hispanic Caucasian. The average age of diagnosis was 43.1 years. The average time to diagnosis was 3.1 years. On average, five procedures were performed during each treatment series. The most commonly performed plasma volume exchange was 1.0 to 1.25 using 5% albumin as replacement fluid. Most patients (52%) did not require an additional course of TPE and noted "mild" to "moderate" clinical status improvement. Maximal symptom improvement appeared by the fourth or fifth TPE treatment., Conclusion and Relevance: TPE improved the clinical status of patients. Adults responded more favorably than children. Procedural characteristics, including number of TPEs, plasma volume exchanged, and replacement fluid used, were similar between institutions. TPE was well-tolerated and had a low severe adverse event profile., (© 2019 Wiley Periodicals, Inc.)

Context.—: The Kleihauer-Betke (KB) test is validated for estimating the dose of Rh immune globulin needed for Rh-negative pregnant females. However, some clinicians are also ordering the test for Rh-positive women. The degree to which this practice occurs is unknown., Objective.—: To evaluate the number of laboratories that perform the KB test on Rh-positive pregnant women, and to establish current ordering practices for this indication., Design.—: We added 9 supplemental questions regarding KB test use for fetomaternal hemorrhage to the 2016 College of American Pathologists proficiency test survey. We also reviewed the available literature regarding the diagnostic utility of the KB test for Rh-positive women., Results.—: A total of 1578 surveys were evaluated and revealed that 52% (824) of respondents perform these tests for Rh-positive women, and more than 50% (440 of 819; 53.7%) of these laboratories report that the results for Rh-positive women are treated as important or very important., Conclusions.—: The KB test is commonly used for Rh-positive women, and the information obtained from the test is considered as urgent and important. However, the available literature in support of this practice is still nonconclusive.

ABO incompatibility (ABOi), the most common cause of hemolytic disease of the newborn (HDN), is nearly always mild and treatable with phototherapy. Reports of ABOi HDN requiring neonatal exchange transfusion are extremely rare since the inception of modern guidelines. Here, a case of ABOi HDN clearly met criteria for exchange transfusion. An O-positive African American mother delivered a B-positive neonate that quickly developed hyperbilirubinemia. The neonatal DAT was positive from anti-B and anti-A,B, and maternal IgG titer was 1024. Double volume exchange transfusion resulted in a favorable outcome. Given early discharge of newborns, further understanding of factors predicting severe disease is needed.

Introduction: Anti-heparin/platelet factor 4 antibody immune complexes resulting from heparin-induced thrombocytopenia (HIT) are removed by therapeutic plasma exchange (TPE). We sought to define TPE in HIT practice patterns using an international survey., Methods: A 31-item online survey was disseminated through the American Society for Apheresis. After institutional duplicate responses were eliminated, a descriptive analysis was performed., Results: The survey was completed by 94 respondents from 78 institutions in 18 countries. Twenty-nine institutions (37%) used TPE for HIT (YES cohort) and 49 (63%) did not (NO cohort). Most NO respondents (65%) cited "no requests received" as the most common reason for not using TPE. Of the 29 YES respondents, 10 (34%) gave incomplete information and were excluded from the final analysis, leaving 19 responses. Of these, 18 (95%) treated ≤10 HIT patients over a 2-year period. The most common indications were cardiovascular surgery (CS; 63%) and HIT-associated thrombosis (HT; 26%). The typical plasma volume processed was 1.0 (63% CS and 58% HT). For CS, the typical replacement fluid was plasma (42%) and for HT, it was determined on an individual basis (32%). For CS, patients were treated with a set number of TPE procedures (37%) or laboratory/clinical response (37%). For HT, the number of TPE procedures typically depended on laboratory/clinical response (42%)., Conclusion: In a minority of responding institutions, TPE is most commonly used in HIT to prophylactically treat patients who will undergo heparin re-exposure during CS. Prospective studies are needed to more clearly define the role of TPE in HIT., (© 2019 Wiley Periodicals, Inc.)

Background: A small body of literature assessing the efficacy and safety of pathogen reduced (PR) plasma has been published., Study Design and Methods: An AABB committee systematically reviewed the literature and graded the clinical trial evidence with the assistance of a GRADE expert., Results: Most studies identified were low quality and had a small sample size; in addition, efficacy and safety were monitored in many different ways making it difficult to quantify therapeutic benefit and risk. The data analyzed in this systematic review showed that pathogen inactivation did not adversely affect the efficacy of S/D or amotosalen plasma transfusions in any patient population studied. In addition, there were no significant safety issues for these patient populations, other than the specific contraindications noted in their respective package inserts., Conclusion: Larger, well-designed trials are needed to further evaluate the efficacy and safety of all of the PR plasma products., (© 2019 AABB.)

Background: The AABB compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine. An abridged version of this work is being made available in TRANSFUSION, with the full-length report available as Appendix S1 (available as supporting information in the online version of this paper)., Study Design and Methods: Papers published in late 2017 and 2018 are included, as well as earlier papers cited for background. Although this synopsis is comprehensive, it is not exhaustive, and some papers may have been excluded or missed., Results: The following topics are covered: "big data" and "omics" studies, emerging infections and testing, platelet transfusion and pathogen reduction, transfusion therapy and coagulation, transfusion approach to hemorrhagic shock and mass casualties, therapeutic apheresis, and chimeric antigen receptor T-cell therapy., Conclusion: This synopsis may be a useful educational tool., (© 2019 AABB.)

Background: It is unknown how pooled platelets (PPs) compare to random apheresis platelets (RAPs) when HLA-selected platelets (PLTs) are unavailable for HLA-sensitized patients. The aim of this study was to compare patient responses to RAPs, HLA-selected PLTs, and PPs in HLA-sensitized patients., Study Design and Methods: This is a single-institution retrospective study of patients from January 2014 to April 2017 with a class I calculated panel-reactive antibody of 60% or more. Response to transfusion was determined by a corrected count increment (CCI) up to 1 hour after completion of transfusion. A CCI of 5 or more was considered successful., Results: Seventy-seven units of RAPs, 412 units of HLA-selected PLT, and 388 units PPs were transfused. Mean CCIs when transfusing RAPs, HLA-selected PLTs, and PPs were 2.82, 11.44, and 4.77, respectively (p < 0.0001). Posttest comparison between RAPs and PPs revealed no significant difference in mean CCI while there was a significant difference between HLA-selected PLTs versus RAPs and HLA-selected PLTs versus PPs. The success rates of RAPs, HLA-selected PLTs, and PPs were 31%, 80%, and 35% respectively. There was no significant association of type of PLT and success rate when comparing RAPs versus PPs (p = 0.51) while there was a significant association between success rate and type of PLT transfusion when comparing HLA-selected PLTs with RAPs and PPs., Conclusion: HLA-selected PLTs resulted in higher mean CCIs and more successful transfusions. There was no significant difference in mean CCI or success rate when transfusing RAPs versus PPs to HLA-sensitized patients. Future studies should assess clinical outcomes in HLA-sensitized patients receiving each type of PLT product., (© 2019 AABB.)

Background: Antibody-mediated haemolysis due to passenger lymphocyte syndrome arising in the setting of solid organ transplant can be devastating. Some degree of passenger lymphocyte syndrome is said to occur in up to 10% of ABO mismatched renal transplants, 40% of ABO mismatched liver transplants, and 70% of ABO mismatched heart-lung transplants; a reflection of the number of memory B cells transplanted with the organ. Passenger lymphocyte syndrome is less common with minor red cell antigens but can still be severe., Materials and Methods: We review a series of patients who developed passenger lymphocyte syndrome after solid organ transplantation. Conventional serological testing was performed using tube and solid-phase testing. Molecular testing was performed using a gene-chip array., Results: In patients receiving a minor antigen mismatched organ transplant and multiple allogenic red cell transfusions, serological methods proved insufficient to resolve the source of minor blood group antibodies that arose in the aftermath of the transplant. Genetic testing was able to clearly resolve donor and recipient types., Discussion: Passenger lymphocyte syndrome after mismatched organ transplantation is not rare, but the syndrome associated with non-ABO antibodies occurs in a much smaller subset of these cases. The mixtures of organ donor, recipient, and other transfused red blood cells profoundly limit the usefulness of serological testing. Genetic assignment of minor blood types to donor and recipient can guide therapy and inform prognosis.

Background: Platelet inventory constraints can result in minor ABO incompatibility and possible hemolysis. The aims of this study were to determine the reduction of isoagglutinin in titers of platelets stored in additive solution (PAS) and compare its safety, efficiency, and cost-effectiveness with full-volume and plasma-reduced platelets., Study Design and Methods: Isoagglutinin titers were performed in paired whole blood donor samples and apheresis platelets collected in PAS (PAS-PLT) aliquot samples by the tube method., Results: A total of 149 pairs of donor/platelet samples were tested: 75 group O, 59 group A, and 15 group B. For group O donor samples, the median anti-A IgG and IgM were 64 and 16, respectively, and the median anti-B IgG and IgM were 64 and 16, respectively. For group O PAS-PLT samples the mean anti-A IgG and IgM, and anti-B IgG and IgM were 32 and 8, and 16 and 8, respectively. For group A donor samples, the mean anti-B IgG and IgM was 8 in both cases; and both titers decreased to 2 in PAS-PLT. For group B donor samples, mean anti-A IgG and IgM was 16 in both cases; and both titers decreased to 4 in PAS-PLT. PAS-PLT demonstrated a net reduction in cost and improved efficiency when compared to plasma reduction. The use of PAS-PLT resulted in a 40% reduction of allergic transfusion reactions., Conclusion: The use of PAS decreases plasma isoagglutinin titers, transfusion reactions, and is cost-effective when compared to routine plasma reduction as a strategy to mitigate hemolysis risk from minor incompatible platelet transfusion., (© 2018 AABB.)

Background: Chest pain is a common clinical dilemma and is rarely reported as part of suspected adverse events in transfusion recipients. The aim of this study is to describe and characterize the clinical presentation of transfusion-associated chest pain and how it relates to currently defined National Healthcare Safety Network hemovigilance entities., Study Design and Methods: This is a retrospective chart review at a single large academic institution of patients who reported chest pain during or after a transfusion that resulted in a transfusion reaction investigation during the period January 2004 to December 2016., Results: Of approximately 500,000 transfusions occurring during the study period and 3220 suspected transfusion reactions reported, 23 (0.7%) reactions involving chest pain were identified, of which 20 had medical records available for analysis. Ninety percent of cases presented with chest pain within 2.5 hours of the start of transfusion, with a mean time of onset of 92.2 minutes. Fourteen RBC units and 6 platelet units were implicated, and all transfusions were ABO identical. All posttransfusion workups were negative for hemolysis or agglutination on direct antiglobulin testing. Twenty percent of cases showed evidence of acute coronary ischemia that was first detected during transfusion with rising troponins or electrocardiographic abnormalities, all in association with RBC transfusion for anemia. For most reactions, the signs and symptoms did not fit any hemovigilance definitions for transfusion reactions., Conclusion: Chest pain is an infrequently reported chief complaint for transfusion reactions. Increased circulatory volume due to transfusion may be an important contributor to myocardial demand ischemia in at-risk patients. Additional studies are necessary to determine the clinical significance of chest pain during transfusion and to elucidate potential mechanisms., (© 2018 AABB.)

Introduction: Performing therapeutic plasma exchange (TPE) with albumin replacement decreases coagulation factor and platelet levels. No defined guidelines exist regarding laboratory testing to assess hemostasis in patients undergoing TPE., Materials and Methods: A survey to evaluate hemostasis testing with TPE was distributed using online survey software. One response per institution was analyzed based on a hierarchical algorithm, excluding membrane filtration users, resulting in a maximum of 120 respondents per question. Descriptive analysis was performed with results reported as the number and/or frequency (%) of respondents to each question., Results: The practices represented vary by institution type, number of apheresis procedures per year, and performance of TPE on children. Prior to TPE planned with albumin replacement, many respondents obtain laboratory studies for almost all patients (54.9% outpatients and 68.7% inpatients); however, some do not routinely obtain laboratory studies (9.7% outpatients and 4.4% inpatients). Hemoglobin/hematocrit, platelet count, fibrinogen, partial thromboplastin time (aPTT), and international normalized ratio (INR) are obtained prior to all TPE by 62.5%, 53.4%, 31.0%, 18.1%, and 17.7% of respondents, respectively; however, 1.0%, 8.7%, 29.0%, 38.3%, and 35.4%, respectively, do not routinely obtain these studies. Variation was observed in laboratory threshold values for action; the most common reported were hemoglobin/hematocrit <7 g/dL or 21% (31.0%), platelet count <50 × 10 9 /L (24.1%), fibrinogen <100 mg/dL (65.3%), aPTT >reference range and >1.5 times reference range (tied, 28.1%), and INR >1.5 (20.7%)., Conclusions: Practice variation exists in hemostasis laboratory testing and threshold values for action with TPE. Further studies are needed to determine optimal hemostasis testing strategies with TPE., (© 2018 Wiley Periodicals, Inc.)