Welcome, everyone, to TCAA's webinar today, What You Need to Know About Transfusions but Are Afraid to Ask. So thank you for being with us. And today we have Dr. Mick Scanlon from Oregon Health Science University to talk to us about this topic. Thanks, Dr. Scanlon, for being with us. Thank you. I'm honored to be here, and it's a pleasure to talk to you. I'll tell you a little bit about myself. I live in Portland, Oregon, where we have two trauma centers. And one of them I was in private practice for 15 years at as the transfusion medical director and more recently up at OHSU for another 20 years. So I've been up to my ears in the trauma and blood for all of that time. And during that time, I faced a lot of misunderstandings and solving problems that come up on the trauma service. And I thought I'd try to help you understand what goes on in the lab and also keep you from stepping in a few potholes that could be dangerous to your patients. OHSU is a level one trauma center. This is a coaster here, which is a gondola ride that takes you from the main campus up on Markham Hill down to the riverside where we have a second campus. Our numbers are over here. These are within a year or two of being current. About 2,600 trauma admits a year, 700 massive transfusion protocols with about two-thirds of them coming from the trauma service and one-third from other services. The topics I want to cover today are pre-transfusion testing, what do you order, how long does it take, and sample expiration. These are all areas that cause confusion, and I thought we could lay out the rules on those. Then I'm going to talk about blood products, when and how much to give, and what expected response do you give. We'll talk about adverse effects of transfusion a lot, recognizing the symptoms and signs, and focus in on some of the serious transfusion reactions and how to recognize them. We'll talk about errors and accidents that happen and how they are dangerous and can lead to fatalities. And then finally, I'm just going to say a word on consent for transfusion. This is an important slide, and I tried to summarize this. In the right-hand column is what I want you to focus on. How long does it take for these things? The lab has kind of mandatory incubation periods that I have to incubate this test for 40 minutes, and no matter how many phone calls you make about when your blood is going to be ready, it's going to be a period of time. And the turnaround times I'm quoting here are what I produce in my laboratory now. Local results may vary, but I've been in a lot of laboratories, and this is pretty typical. So an ABORH is a test that determines what your ABO type is, and then RH type. And that takes about an hour in my facility. The reason it takes an hour, it can be done more quickly, but we pair it with the antibody screen, and that is the thing that has the 40-minute incubation. So we say all of those type and screen would be about an hour. This antibody screen is an important test because it detects the presence of unexpected antibodies, and I just want to distinguish what an expected antibody is from an unexpected antibody. An expected antibody is an ABO antibody that is reciprocal to your ABO type. So if you are a type A, we expect you to have an anti-B. So that's an expected antibody. Unexpected antibodies are antibodies in other red cell systems, such as RH system, Cal, Duffy, KID, all of these things. And those typically come up from some exposure to blood and are not expected. So the antibody screen detects those antibodies, and the screen basically says you have them. It doesn't tell us what they are. It doesn't put a name on them. So once your screen is positive, then we go down to the antibody identification, and this can take a longer time period, at least an hour. And if there are multiple antibodies and we have to do additional cells, it can take up to four to six hours. So identifying the exact antibody and finding blood that's compatible with it gets a little complicated. The crossmatch tests for the compatibility of the red cells that you're giving the patient with the plasma. Now there's a thing called an electronic crossmatch, which if the patient doesn't have any antibodies, it's just the flash of an eye. It's a computer crossmatch, and we just issue ABO-compatible products. But if there is a serologic crossmatch that's required, then additional hour or more of antibodies testing is needed before we can turn that out. We also have the ABO-confirm up here, and this is something that we do here. Not everybody does this, but I think it makes me sleep better in the morning, in the evening. When we don't have an ABO type on a patient, which is pretty typical of a trauma admit, we don't know who they are. They come in as a John Doe, some kind of thing. And so we want a second sample that we can retype to confirm. So if the patient types as an A, then I want a second sample that that patient actually is an A before I will give them A blood. And that's this last item here, type-specific blood. I will not shift to non-O blood until I have two types on the patient. Now if the patient is identified subsequently and we find that we've got a record on it, then all is good. But that is a safety feature, and we'll talk about that in the errors and accidents section. A mislabeled tube comes in a lot, and we need to kind of protect ourselves from that. Just a little bit more, type and screen is needed for all red cell transfusions. It's not needed for other products like plasma, platelets, and cryo, but it is needed for all red cell transfusions. The sample itself expires three days after it's drawn at midnight. And that's a potential pothole that causes delays. A trauma admit comes in, you're doing great, and then you order a product on that fourth day and there's no sample in the lab. And that causes delays and people get agitated. So you just need to kind of have a visual of those, especially if somebody's returning to the OR for some kind of subsequent procedure, just to make sure you have an in-date sample there. A cross-match or prepare order needs to be done. And essentially what this is, is we do any serologic testing and then we tag up those units and reserve them for the patient. It's very important that you have a type and screen when you order the cross-match. And a common mistake is cross-match two units of red cells and there's no order for the type and screen. So you just need to kind of bundle those together so you don't have those types of things. And then that transfuse order is the give order. So when the lab gets that transfuse order, we know you want to give the product now. We'll dispense it to a courier, send it through a pneumatic tube, or however we're going to get the blood to the patient. So that's the normal workflow in routine cases. Let's move over more to your neck of the woods in the emergency issue area. Here we're going to be giving uncross-match blood. And this is more dangerous than cross-match blood. We haven't completed all the testing. We don't know if that patient has these unexpected antibodies. So a physician needs to sign off that, yes, I know I'm ordering uncross-match blood and it's important. We used to have a process where we would try to run down the attending to sign those things. And we obviously didn't do it right in the middle of the case, but we'd try to catch them and we'd never get them. So what we ended up doing is just putting a blurb in the order for the uncross-match blood that says, I'm taking responsibility for this. And we don't allow the phone orders because we don't have those documentation. So what do you get when you order uncross-match blood? At our facility, females of childbearing age will get O negative blood and everybody else gets O positive blood. We do that because O negative blood is in short supply and our blood supplier gets agitated if we're burning through too many O negs. So that's that. We have a massive transfusion protocol, as I'm sure everyone on the call has. And this is a system for rapid preparation and delivery of a balanced box of blood. And at our facility, that includes transportation. So it's a team effort moving samples and product. We have two couriers, one in the operating room and one in the lab, and they kind of ping pong back and forth so we can shuffle the blood very rapidly to and fro. What we start with is five units of whole blood by default. And if we're out of whole blood, which happens from time to time, then we'll give an equally balanced box with six units of red cells, six units of plasma, and one unit of platelet. When we do these balanced resuscitations, that's usually sufficient to maintain the coagulase status during the act of bleeding. We use those components only when no low titer O whole blood is available. I find LTOWB a mouthful, so I'm just going to call that LTO, if that's OK with you. So why LTO? This is Dr. Schreiber, who many of you may know, a trauma surgeon, worked in the army and Afghanistan and Iraq. And he was convinced from his experience there that whole blood was available and asked me if we could do that at OHSU. And eventually I convinced our blood center to manufacture it. And so we started doing this. The civilian studies at that time had shown non-inferiority to component-based products. And what I really found appealing about this product is how fast it is. One of my technologists, I said, how do you like this new whole blood massive resuscitation? And she says, hey, I can do this alone. It used to take three people thawing products and labeling things and getting them out faster. We participated in the proper study. And I'll admit with my shame that we were near the bottom of the turnaround time with getting blood to the scene of the crime. We were 15 minutes away from any of the action. And plus all that time tagging up all those units, we just didn't do a good job with that. We moved closer. And with the whole blood, we're banging that stuff out in a hurry. It's much easier to administer. So if you're not using LTOs, I think you should definitely consider that. Well, let's do a case study here. So take a second to read. I'll read this for you. But look at it and see what you think. And we'll follow this up with some questions. So a 32-year-old male, gunshot wound to the abdomen, arrives in the ED, shocky, clammy. And you administer four units of LTO. Pressure stabilizes somewhat. And you take the patient to the OR. Now, this is a John Doe admit. And after he's already in the OR, they identify who he is. And the blood bank calls into the OR and tells you that the patient has a history of anti-D after receiving O positive blood from a prior stabbing. So what would you do if you find you gave incompatible uncross-matched? What are you going to do with the stuff that's sitting in that OR? Are you going to give it? Are you not? The poll shows us that everybody says assess the clinical situation and continue to transfuse, if you must. And that is the correct answer. Let's just briefly discuss the other one. Waiting for incompatible blood is not the right answer. We have to go ahead and transfuse. The patient can bleed out if you wait to get the compatible stuff. Antigen-negative blood would be a good choice if it's available. But in the meantime, blood that is on hand is better than nothing at all. And this is an obvious distractor. Patients usually tolerate incompatible blood. Actually, that's true. Most of the time they do, but some of the time they don't. And that's the kind of thing that we worry about, the some of the time stuff. So, transfusion service will notify you if they identify unexpected antibodies or if there's some kind of a typing discrepancy. After the antibody is identified, that's one to two hours later, then we can give antigen-negative blood because we can type those units very quickly and send them out. And send them out, whereas the crossmatches are getting us into that 40-minute incubation thing, and that's going to take longer. RHD is a little bit different than everything else. That's the only blood product that we have antigen-type before we ever get it. So, it's easy for us to pull O-negative blood off the shelf and send it down. Now, depending on the clinical situation, if the patient's bleeding to death, you just keep giving it, you can sequester that RH-positive blood and give the negative blood. But I've generally found if somebody returns that blood to the blood bank, eventually something opens up and they end up getting short. So, my feeling is always leave the stuff in the room in the back corner or something, but try to give the best available stuff that you have. Keep the patient alive. I've had a case early on in my career where somebody had three antibodies and an expanding hematoma in their groin, and they were calling for blood from the Red Cross. And the pathologist was like a deer in the headlights. He kept saying, oh, it's coming, it's coming, it's coming. And the patient died. So, my rule is compatible blood in a dead patient is not a medical triumph. Give the blood. Document why you did that so that somebody can't second guess you. But if the patient's bleeding out, you got to give it. So, you guys, you got that one perfect. This is another chart that I like to include. It's just sort of what is the standard adult dose. Now, if you're in a massive transfusion protocol, this stuff is all off the boards. You're just transfusing to keep the patient's pressure and pulse okay and whatnot. But the next day in the ICU, this kind of information is helpful. I think everybody knows that a unit of red cells will bump your hematocrit by 3%. Plasma is a little more irregular, but the standard dose is a couple of units, and it'll lower your INR by about 0.5. So, if somebody is in the two to three range, probably two units is not going to get you down below 1.5, and you might want to give four for that. Platelets typically will give you a bump of 30,000 with a single unit of ferecious products. When do we do that? If somebody's an oncology patient, we use 10,000. 50,000 is pretty typical for invasive procedures, and neurosurgery likes their patients to have platelet counts over 100. If your platelet count is 10,000 and you want to go to interventional radiology or something, they're going to want that count above 50,000. So, you're probably better off ordering two units of platelets than one, just to make sure you get above that 50,000 mark. If it's a neurosurgery patient, you're going to give a lot more than that. Cryoprecipitate is generally used for treatment of low fibrinogen. We use 150 as our threshold. So, if somebody is bleeding and it's below that level, then we would give 10 units or two pools of cryoprecipitate, which should bump your fibrinogen about 50. If it's an OB catastrophe that suddenly during labor starts hemorrhaging, and you're thinking of amniotic fluid embolism, I typically come in with four pools of cryo, which should get that fibrinogen from zero up to 100. So, that's what I do. And then with whole blood, we just give them five at a time and send them out. Okay, so take home lessons here. Always order the type and screen at the earliest possible moment when transfusions might be needed. Product orders can follow. It's that type and screen we've got to have. And that's the important thing. This detects these irregular antibodies. These antibodies that are relatively rare in a tertiary care practice, like a university hospital, 6 to 8% of people have antibodies. That's because they're oncology patients and they've been multiply transfused. In a community setting, it's more like 2 to 3%. You want to be on the alert for a reaction if the patient has been previously transfused. Now, it has been said that trauma is a recurring illness in some patient populations. And many people have been trauma victims and gotten RH positive blood before. If they're RH negative, they may have that anti-D like our first patient had. Female patients not transfused are still at risk for having antibodies if they've been pregnant. The bottom line here is that you need to kind of be aware when you're giving the uncross matched blood that it's less safe and just monitor carefully. And if you see signs of a transfusion reaction, recognize them and do something about it. So let's try case number two. 62-year-old A positive female involved in a motor vehicle accident versus pedestrian. Patient's in shock. Abdomen is distended and tender and there are lower extremity and pelvic fractures suspected. Low LTO MTP is initiated. And upon receiving the fourth unit, the patient developed a fever to 39 degrees, dark red urine, and no other symptoms. Transfusion reaction was ordered. And the findings were as we spun that tube of blood down, we could see that the plasma was pink. We tested the urine for free hemoglobin and found that it was positive for that. And we did the direct anti-globulin test, which tells us that there are antibodies on top of the red cells in the post-transfusion sample. And then we identified those antibodies and we found anti-A. So what's going on? Okay. The correct answer is that the patients have an acute hemolytic transfusion reaction from incompatible plasma. And that's different than a hemolysis of the transfused red cells. The discolored urine is likely due to rhabdomyolysis. It's possible that's that. It's a little early for that, but never attribute something that could be a hemolytic transfusion reaction to something else without ruling out the transfusion reaction. A delayed transfusion reaction we'll talk about later, but that's something that happens hours or days after transfusion, not while you're getting them. With the packed red cells or O-hole blood, the cells are O in there. And so they're ABO compatible with all recipients. On the other hand, with O-hole blood, you've got the plasma in there. And remember that O patients have anti-A and anti-B. So they're not plasma compatible with anyone but an O. This patient types as an A. And because we eluded donor anti-A from her cells, we can conclude that this is a hemolytic transfusion reaction caused by that infused plasma we had. We try to take precautions for that. And this was one of the hesitations about using O-hole blood first. And the innovative thing was that we decided what we would do is measure the concentration of the antibodies in the plasma. And there's a cutoff above which someone is not eligible to donate whole blood. Those antibodies are still in the bag. And that's what happened here. Hemolysis can occur with LTOs. But when it happens, reactions are usually mild, as in this case. So a follow-up question. How can you monitor for hemolysis in asymptomatic patients getting low LTOs? And again, this is in asymptomatic patients. Now, we can look for hemolysis using the answer B, fever and hypotension. Those are good things to look for. But those patients would be symptomatic. So that answer is the trick answer. And the distractor, other ones, don't worry about it. It's entirely safe. Forget about it. And order a transfusion reaction on everyone getting O-hole blood. I will haunt you if you do that. So don't do that. The right answer is, this is a trick I learned when we first came up with long-term O-hole blood, low titer. LTO, I hate that term. OK. So for symptomatic patients, standard transfusion reactions work. For asymptomatic patients, this is often the best way to see if somebody has had hemolysis from this is to actually look at the basic metabolic panel or a comprehensive metabolic, which is typically ordered after somebody arrives in the ICU. And most modern systems have a channel that measures hemolysis. And we do that because if you have hemolysis, it can falsely elevate your potassium and your enzyme levels. So we measure that ahead of time. And most labs also report that for information. So if you want to know if there's hemolysis or not, that's an easy place to look and very reliable. And we actually did that as part of our validation of the low titer O-hole blood. And we looked at 20 consecutive non-O patients who received LTOs. And we did not find any hemolysis in there. So it's a kind of a one percenter thing that this patient popped up. I think it came in at about the 40th incompatible O plasma thing. And we haven't really had another transfusion reaction like this one. So we felt that we validated that it was safe. And we don't continue to look at that. I'm not recommending that you look for hemolysis unless you're curious. But that's a place to look. But if your hematocrit is falling and you're wondering if it's hemolysis versus ongoing bleeding, that channel can give you a clue of what's going on. So let's move into transfusion reactions. And this is a very important thing. And I think this was actually the original request for this talk. I hope I'm not cramming in too much extraneous information. So there are known risks of transfusion, including infectious diseases, transfusion reactions, and immunomodulation, which results in increased rates of post-operative infection or tumor progression. So there are problems giving blood. There are also unknown risks, and this is in the emerging pathogen field. We've had a number of these come up over the year, just examples, Jacob Creutzfeldt and West Nile virus. And so we can't test ourself into 100% safety because there's always that next thing that's coming along. So no implied warranty of safety with blood products. It's a dangerous product, and you use it when you have to. Unfavorable outcomes have been linked to transfusion. Long-term survival is adversely impacted. I always think of these things as I'm giving a bunch of foreign proteins, which is causing some kind of blockade in the reticuloendothelial system, and they're so busy dealing with those foreign proteins that they miss whatever it is they're missing, bacteria or something like that. So that's my mental mindset on these unfavorable outcomes. Blood transfusions are safe and effective, potentially life-saving. Rarely they have bad effects, and most of these cannot be avoided, and some can lead to patient death. So that's always why an informed consent is required. In order to avoid the avoidable, patients need to be carefully monitoring transfusions, and staff need to recognize the symptoms and sign of a reaction as early as possible so they can stop the transfusion. Key, stop the transfusion. If you're having a reaction with a particular unit of blood, ditch that unit of blood. If it's in a level one infuser, what are you gonna do? But we just need, in a chaotic trauma situation, I'm not sure this is at the forefront of everybody's mind, but if you do recognize that that urine is turning red or something visible that just doesn't seem right with the clinical situation, then a transfusion reaction needs to be ordered. And we'll talk about that in a second. So these are recent risk factors. People worry about HIV and hepatitis C. Those are lottery level odds, one in two million of getting one of those infections. Hepatitis B, a little more common, and bacterial infections are the most common things that happen. That's mostly with platelets. So if suddenly the patient's pressure tanks and he spikes a fever to 39, 40, think about a bacterially contaminated unit and stop that transfusion. Other risks are spelled out here. I'm not gonna go into all that, but that's just there for your information. This is a busy slide, but we'll take some time on this. So the big kahuna here is an intravascular hemorrhagic hemolytic transfusion reaction. This is where the red cells are being destroyed by antibodies and those antibodies fix complement and the red cells lice in the plasma. This causes a significant problem for the patient depending on how much hemolysis there is. Pain in the back or infusion site, impending sense of doom, not a lot of value when somebody's intubated and anesthetized. Fever, chills, rigors, hypotension, watch that urine. And with trauma, oftentimes you're gonna have hematuria. And so you need to kind of think, is this red blood from trauma or is it from hemolysis? And that's an important differential. And then a severe case that's agonal is gonna go into DIC and death. So that's an acute hemolytic transfusion reaction. Typically starts right away. An extravascular hemolytic transfusion reaction is a nothing burger. It's usually asymptomatic. It may be appearing within hours or more typically delayed for two or three days later. This is when that antibody coats the red cells but does not fix complement. And then those cells are destroyed in the spleen and other reticular endothelial organs. So it doesn't cause all these symptoms that we saw with the intravascular. So it's really kind of an asymptomatic thing typically associated with a falling hemoglobin and elevation of bilirubin. Now we go up to the second column and I wanna talk a lot about respiratory compromise. This is a big deal and it's more common. And it's requiring supplemental oxygen. So if somebody is sitting in the ICU, gets a transfusion and then an hour later, you gotta intubate them and put them on oxygen. That's where we're getting at it. A chest X-ray will typically show pulmonary infiltration. Differential diagnosis here is between transfusion-associated acute lung injury or TRALI and circulatory overload, which we'll call TACO. Also in the differential unrelated to transfusion, of course, is shock lung from the trauma. So we're gonna spend a little time with that. Another big deal is a hypotransitive transfusion reaction. So this is where the pressure tanks immediately upon giving the product. Anaphylactic transfusion reactions from somebody who's deficient in IgA are occasional things. I think I've seen two of them in 30 years. So it's not a big deal, but it is a life-threatening situation when it happens to you. Septic transfusion reactions, I've talked about with the platelets. So again, a problem which you might have. And then there's these drug-related things. People who are on ACE inhibitors for hypertension have difficulty clearing bradykinin from their bloodstream. And the bag is full of the bradykinin and you infuse it in and you get a dose response curve. The clue that you're dealing with that is obviously the history, but also when you turn the transfusion off, the blood pressure comes right back up. The most common transfusion reactions are either fever or rash. And about 1% of transfusion reactions do this. Fever obviously overlaps with the symptoms of an acute hemolytic transfusion reaction. So it should not be ignored. A rash, however, can never be the first symptom of an acute hemolytic transfusion reaction. So that is less of a big deal. Very uncomfortable for the patients with the rigors and shaking and itching and all this stuff, but no lasting harm from these little guys here. Treatment. First, stop the transfusion. A little factoid I'd just like to throw out here is that the 50% of people die, the LD50 of incompatible unit of blood going into an O patient is about 50 mLs. So if you catch the transfusion reaction before 50 mLs has gone in, you're probably gonna be fine. The more you infuse after that, the more likely you are to get into trouble. Now in your business, I know stuff goes in fast, but once you start switching over to those type specific A's, you wanna just be a little careful. So what is the transfusion reaction workup? We do a clerical check. Is the name on the bag the same as the name of the patient who's getting the blood? Does the bag match the tag? This whole thing is a very complicated thing we do before we give the blood and time-consuming and manpower-consuming, but that clerical check should happen before the transfusion. But if somebody overlooks something, then you got trouble. We're gonna make sure that's good. We repeat the ABO type and do a direct antiglobulin test. There are some other tests that we'll order in situations. We look for a urine hemoglobin and we're looking for free hemoglobin, not hematuria. So that's an important distinction. And then if we're thinking there's a contaminated unit, we'll do a gram stain and culture the patient in the unit. BNP is a test that we'll occasionally order when we're trying to distinguish between trolley and taco. And that differential is laid out here. It is difficult to distinguish these two. I don't find that chest X-ray interpretations really help that much. Both of them have shortness of breath and need oxygen. The one thing about trolley is it's an inflammatory reaction and you're infusing HLA antibodies that are incompatible with the patient's neutrophils. They explode, release inflammatory cytokines and you get a fever. So if you have pulmonary compromise with fever and the patient had been afebrile before the transfusion, then trolley is the most likely. And fluid overload is not associated with fevers typically. So if there's no fever, you're more in the taco column. Symptoms of congestive heart failure, age. If it's a young gladiator, it ain't taco. If it's an elderly person who fell and broke her hip and you gave a lot of blood, then it's likely to be a taco. And the BNP can help you there. It's a little fuzzy because people with congestive heart failure can get trolley. So they'll have that elevated BNP beforehand and it's a little hard to sort all that out. Trolley is a diagnosis of exclusion. We can't test our way into it. We just don't know. So if ARDS is happening due to a shock or something like that, it's always gonna be in the differential diagnosis. And it's not that important to make this decision because it's just supportive care. And we will look at the history and try to pull out which one it is and make our best guess. But a lot of times we'll just say respiratory compromise temporarily associated with transfusion because we can't really say what it is. TRIM. This is the immunomodulation I was talking about. And increased cancer resurgence rates in transfused patient cabbages with five-year mortality increases after those who are matched controls compared to match controls. So transfusion has evil humors in it. And we wanna be... If somebody got in a knife fight and it's an 18-year-old and his hematocrit is 18 or something, does he really need to be transfused? He'll live with it. So if you don't need to transfuse, don't. Febrile reactions most common, about 1%. We have problems with this. We're about 0.25%. It would be nice if we had more of these reactions. They should be happening much more commonly. So again, under-reporting is a problem and Tylenol and Benadryl for those two. Delayed hemolytic, no special management needed. I wanna talk about citrate reactions. This is an important thing to focus on. Citrate is what we anticoagulate the blood with. It binds ionized calcium. And ionized calcium is needed for the heart to beat efficiently. And if you ignore this, then you're gonna get a person who is hypotensive and tachycardic from that electrolyte abnormality. And that sounds a lot like hypovolemia and you might wanna push more blood in or check for a pericardial tamponade or something like that. So typically about every 10 units, we're gonna give some calcium gluconate or at least measure in ionized calcium. Very important common thing that happens commonly. So keep an eye out for that. Units of blood come out of the refrigerator cold. I don't think I need to spend any time telling you to keep your patients warm and fix the acidosis. You already know that. So we'll just move right along here. How do we avoid acute hemolytic transfusion reaction? Well, be more careful. 99% of these are due to human error, administrating blood to the wrong, administering blood to the wrong patient can be mitigated by using a barcode blood administration program. That's pretty tedious in an operating room and is typically not done. But that always makes me a little bit nervous. We're gonna have two people signing off and making sure they check things. You wanna make sure that you're checking a document that belongs to the patient. If you're not actually going to the wristband, that's another error. Collection errors are a big problem with us. And technical errors used to be common in the lab, but this is a picture of one of our beasts that does all our testing for it. And it's pretty reliable turning out results. So we don't have these clerical errors in the lab so much anymore. Emergency rooms are dangerous places. Trolley is something that happens independent of human error and it's one of the leading causes of death. But ED and L&D are the frequently places where we get transfusion samples with someone else's label on the tube. The common errors are labels left in the room from a previous patient. There was a fatality down in Houston not so long ago that was exactly that thing. Somebody had ordered a type and screen on first patient and left the label in the room. They did order the one on the second patient, that label goes on the second patient, an ABO mismatch, boom. So those labeling errors are dangerous. It's a matter of process, cleaning, carefulness. And that is all problems that is apt to break down in those really busy areas where things fall to pieces in a hurry. So just kind of keep your heads clear as you do these things. Try another case study here. 18-year-old motor vehicle accident, prolonged extraction, arrives unconscious and is a direct admit to the OR. We start with an MTP of 20 units. The following morning, the patient is stable, conscious, and his family is in the waiting room anxious to know how he's doing. An intern looks at the patients. He sees a value of 5.5 and orders two units of red cells. The ICU nurse balks at giving the red cells because there is no transfusion consent. The intern think this is ridiculous because the patient already received 20 units. Formed consent for blood is always required. The reason I emphasize that blood is not safe is because the patients have to be told that and agreed to that treatment. The key consideration for you guys is the patient's capacity to refuse treatment. If no one is available to provide consent and the need for transfusion is considered medically necessary, then we have this doctrine of implied consent that the patient would agree to the transfusion if they could. The emergent need for transfusion needs to be documented in the medical record and advanced directives need to be respected. So if somebody pulls something out of a wallet, you gotta go along with that because they've kind of refused ahead of time. You mentioned that you do not require ATNS for products other than RBCs. Do you not worry about Rh incompatibility in platelets, especially in females of childbearing potential or ABO plasma incompatibility? I got going a little fast there. We require a historical type on file in the laboratory, but not an end date type and screen. So if we know the ABO type, then we will give the right platelets to people of childbearing age. Okay. Dr. Schreiber actually commented fantastic talk, Mick, and it has been a pleasure working with you for nearly 20 years. We have given about 2,600 LTOWB units to about 600 patients. Since we started in July, 2018, do you think we have had any transfusion reactions? Thank you. Just that one that I, that case that I showed on the, of the patient with the hemolysis was an LTO whole blood. It was actually, I kind of modified the thing, the history a little bit. That was a large sarcoma resection that got into trouble and they were using the whole blood. That's the only one I saw. And it was very interesting that there was no, none of that toxic storm that happens with acute hemolysis, just the fever. So yeah, just the one out of all of those transfusions. We've given a lot of this stuff. Okay. Any validity to the concerns of high risk of TRALI from FFP from female donors? Yes, that is a legitimate, and we get our whole blood from males. Now with plasma, the screening that is done now is fairly effective. So I used to direct the lab that did the blood testing a while ago. And any multiparous females, first time donors are screened for HLA antibodies and they're excluded from donating plasma products. Now, we also have liquid A plasma and we keep that around for being able to put, if we're having to do a component-based resuscitation, we wanna be able to push stuff out the door quickly without having to thaw it first. And those are not male donor plasma units, the whole blood is. So a little more risk as you go down market on that. Okay. I don't know if you answered this yet. Are you using whole blood in initial resuscitation and then product specific as measured by TAG later? We're a little different than some people. Some people limit the amount of whole blood that they give and we don't. We'll let you use everything we've got. And the reason I do that is, yes, it'd be better if we switched to components, but that's such a drag on productivity to get that stuff down and get it into the patient that my preference is give the patient the blood they need and whatnot. So we do use TAG throughout all of our massive transfusion protocol and that's the guiding feature. If somebody needs platelets, for instance, we don't base that on a platelet count, we base it on the TAG. Well, we are using platelets, spared leukodepleted O's, but they don't have the full punch of a non-leukoreduced product. We did that because it's so hard at a university with so much cancer to make that happen. But, right. Okay, what are the age cutoffs for pediatric versus adult transfusion recommendations? I didn't wanna get in too deep in that. With our massive transfusion protocol, we use LTOs down to two years of age and then we use components below that. The neonatal transfusion thresholds are higher hemoglobins typically and the dose per kilogram is 15 to 20 mLs per kg of product. The other secondary to that is how do you mitigate the potential loss of unused whole blood in trauma at your hospital? Is it discarded or salvaged? How long do you keep the whole blood before discarding it or salvaging it? Sure, we allow the blood to be used for massive transfusion protocol up to 14 days. We base that on the fact of studies that show that that was when platelets were most active and then you sort of get a drop off after that. So, we keep them on the shelf as best we can for 14 days. If we have leftovers, then what we do is we prop them up in a little plastic container in the blood bank. We put the refrigerator, the cells all sediment to the bottom and we extract, when we have a give order for a unit of red cells, we extract the plasma off and issue them as a packed cell to get rid of them. And we're on a standing order and it's a fine balancing act in the blood bank. We don't wanna be converting too many things to packed cells but on the other hand, I don't wanna run out either. That's kind of a really tricky balance to make. And we can't just order refills. We have a standing order based thing. So, it's a little tricky but you are gonna have to use components at some time and sometimes you're gonna recycle them for another patient. And you may have already answered this with Dr. Shriver's question but what bad things have you seen with whole blood? I haven't seen anything, honestly. It's been the best decision we've ever made. We wanted to, I'll tell you a story since nothing is not a good answer but we had a desire to start this. They became available in the spring and we wanted to do it before the summer trauma season started and the biggest problem we had was getting our information technology group to embrace this thing. We were saying, God, it's the same. Just build the test and everything. And boy, was that a nightmare to get. I think Dr. Shriver might share something over a drink someday telling you more about that but that was the worst part of it was getting the test built. But we got it up pretty quickly and I'm just so happy we did that. It really was a blow for freedom. And that was all because Dr. Shriver was pushing for it, by the way. How do you source your LTOWB? How do I? Source. How do you source it? Oh, source it. We have our primary contract with our Red Cross facility in town. And I don't know what we ordered, two shipments a week at 20 or something like that. We don't go out for it. Anytime you're gonna go away from your blood center, you're gonna get older products. And since I wanna make everything I can out of that 14 day period, I like to get them as fresh as possible. Okay. Dr. Shriver also asked, what are your thoughts on walking blood banks in the civilian setting with increasing blood shortages due to COVID and other issues? Well, this ain't the army, Marty. You know, the military does do that stuff where they test people ahead of time and then they keep them isolated in the boondocks of the deserts of the Middle East so that they're unlikely to get into too much trouble. That is the opposite of what happens in the States. So I think that one's a stretch. Our approach to blood shortages, and we have had them as we have entered into contractual relationship with a transfusion center up in Seattle. And we're also supporting a private business that's going to dedicate their activity to collecting platelets. And we're committed to taking a large chunk of them from there. It's been extremely frustrating, the product shortages we've been having in the last year. And I think my solution to this is more sources. Don't just rely on one provider because they haven't done a very good job so far. I shouldn't have said that. Strike that comment. But I'm ticked off, so we're taking corrective action.

Transfusions

Pre-transfusion testing

Blood products

Adverse effects of transfusion

Errors and accidents

Consent for transfusion

Trauma

Transfusion reactions

Level one trauma center