Infusion of P-Capt prion-filtered red blood cell products demonstrate acceptable in vivo viability and no evidence of neoantigen formation

BACKGROUND: Transmission of variant Creutzfeldt‐Jacob disease (vCJD) is a major concern in blood transfusion. The P‐Capt filter has been shown to remove around 4 log ID₅₀ prion infectivity from prion‐spiked human red blood cells (RBCs). STUDY DESIGN AND METHODS: Two independent, single‐center, randomized, open‐label studies were designed to analyze the safety of P‐Capt–filtered RBCs. RBCs prepared from leukoreduced whole blood from 43 eligible subjects were randomly assigned to P‐Capt filtration and/or storage in plasma or SAGM and stored for 28 or 42 days. Stored RBCs were analyzed for in vivo 24‐hour recovery, hemolysis, metabolic variables, blood group antigen expression, neoantigen formation, and safety after autologous infusion. RESULTS: Mean P‐Capt filtration times for leukoreduced RBCs were 41 (SAGM) to 51 (plasma) minutes. Thirteen of 14 subjects receiving P‐Capt–filtered RBCs had 24‐hour RBC recoveries of 75% or more after 42‐day storage, with a mean hemolysis of less than 0.6%. No loss of RBC antigen expression or formation of neoantigens was observed. In both studies, RBCs had white blood cell counts of less than 1 × 10⁶/unit after leukofiltration. P‐Capt prion filtration provided an additional greater than 0.8 log leukoreduction. No serious or unexpected adverse events were observed after infusion of P‐Capt–filtered full‐volume RBC units. CONCLUSIONS: P‐Capt–filtered, stored RBCs demonstrated acceptable viability and no detectable neoantigen expression, immunogenic responses. or safety issues after infusion of a complete unit. The additional filtration time and modest reduction in RBC content are within acceptable levels for implementation in countries with transfusion transmission of vCJD.     

Prion reduction of red blood cells: impact on component quality

BACKGROUND: A filter has been developed (P‐Capt, MacoPharma) to remove infectious prions from red blood cells (RBCs). We sought to assess 1) its operational use, 2) the quality of filtered components, and 3) whether filtration resulted in any significant changes to blood group antigens. STUDY DESIGN AND METHODS: A total of 272 leukoreduced RBC units, including units processed using “top‐and‐top” (TAT) and “bottom‐and‐top” (BAT) methods, were prion reduced using the P‐Capt filter. All RBCs were assessed using standard in vitro tests of RBC quality. Changes to blood group antigen expression were also investigated, including the exposure of cryptantigens and the ability of filtered RBCs to be crossmatched. RESULTS: Ninety‐nine percent of TAT units and 58% of BAT units had a hemoglobin (Hb) content of more than 40 g. Hemolysis increased immediately after filtration, but units remained within UK specification throughout storage. Prion reduction resulted in the loss of 7 to 8 g of Hb and reductions in hematocrit of 6% to 9% due to the filter containing 40 mL of saline, adenine, glucose, and mannitol. Other RBC quality data, including extracellular potassium, 2,3‐diphosphoglycerate, and adenosine triphosphate were similar to historical control data. There was no evidence of any immunologic changes of clinical relevance to the RBC membrane after filtration. CONCLUSIONS: Prion filtration does not appear to have a detrimental effect on basic in vitro measures of RBC quality or on blood group antigens as assessed by in vitro methods. However, prion filtration using the P‐Capt filter results in loss of Hb.     

Ten‐year pattern of red blood cell use in the North of England

BACKGROUND: An understanding of current and changing patterns of red blood cell (RBC) use will help predict future demands and aid future planning for transfusion services. It can also highlight areas where efforts to optimize RBC use are most likely to be productive. STUDY DESIGN AND METHODS: Surveys were conducted in two 14‐day periods of all RBC transfusions in a geographic region of England supplied by a single blood center. Data collection was prospective and used preprinted paper forms. Results were compared with two previous studies covering a period of 10 years. RESULTS: The clinical fate of 8025 units of RBCs was recorded consistent with data on more than 99% of units issued and transfused during the survey period. The overall RBC transfusion rate has decreased from 45.5 to 36 units per 100,000 population from 1999 and 2009. Twenty‐nine percent were used for surgical indications indicating a further decrease in surgical use compared to previous surveys. This decrease was limited solely to recipients of 50 to 80 years of age. Use for medical and obstetric/gynecologic indications has not changed significantly over 10 years. CONCLUSION: Further decreases in surgical RBC use may be achievable but the aging population is likely to demand more blood for nonsurgical indications and efforts should be directed to optimizing use in these recipients. Comparative data on transfusion rates between regions or countries may be a useful tool for improving blood use.     

Implications of demographics on future blood supply: a population‐based cross‐sectional study

BACKGROUND: Data on blood recipients are sparse and unconnected to data on blood donors. The objective was to analyze the impact of the demographic change on future blood demand and supply in a German federal state. STUDY DESIGN AND METHODS: A population‐based cross‐sectional study was conducted. For all in‐hospital transfused red blood cells (RBCs; n = 95,477), in the German federal state Mecklenburg‐Pomerania in 2005, characteristics of the patient and the blood donor (118,406 blood donations) were obtained. Population data were used to predict blood demand and supply until 2020. RESULTS: By 2020 the population increase of those aged 65 years or more (+26.4%) in Mecklenburg‐Pomerania will be paralleled by a decrease of the potential donor population (18‐68 years; ?16.1%). Assuming stable rates per age group until 2020, the demand for in‐hospital blood transfusions will increase by approximately 25% (24,000 RBC units) while blood donations will decrease by approximately 27% (32,000 RBC units). The resulting, predicted shortfall is 47% of demand for in‐hospital patients (56,000 RBC units). Validation using historical data (1997‐2007) showed that the model predicted the RBC demand with a deviation of only 1.2%. Demographic changes are particularly pronounced in former East Germany, but by 2030 most European countries will face a similar situation. The decrease of younger age groups requires an increase of blood donation rates and interdisciplinary approaches to reduce the need for transfusion to maintain sufficient blood supply. CONCLUSIONS: Demography is a major determinant of future transfusion demand. All efforts should be made by Western societies to systematically obtain data on blood donors and recipients to develop strategies to meet future blood demand.     

Reduction of allogeneic red blood cell usage during cardiac surgery by an integrated intra‐ and postoperative blood salvage strategy: results of a randomized comparison

BACKGROUND: The amount of allogeneic blood transfusion may relate to worse outcome in cardiac surgery. The reinfusion of red blood cells (RBCs) lost by patients, including those of chest drains, is a promising strategy to minimize allogeneic transfusions. STUDY DESIGN AND METHODS: To verify this hypotheis, 1047 cardiac surgery patients were randomly assigned to either traditional intraoperative blood salvage followed by chest drain insertion or intra‐ and postoperative strategy with the Haemonetics cardioPAT system. Allogeneic RBC transfusion rate (primary endpoint) and postoperative complications (secondary endpoint) were recorded at the time of discharge from the hospital and at first month follow‐up visit, respectively. RESULTS: The cardioPAT arm received 1.20 units of allogeneic RBCs per patient, whereas the control group required 2.11 units per patient, and this difference proved to be highly significant (p = 0.02). We observed a comparable 45‐day mortality rate but a lower rate of deep vein thrombosis (p = 0.04) and atrial fibrillation (p = 0.04) in the cardioPAT arm. DISCUSSION: A significant reduction in patient exposure to allogeneic RBCs was observed in the cardioPAT system arm. Complications were slightly less frequent in the cardioPAT group. The use of the cardioPAT is a safe and effective strategy to reduce allogeneic RBC transfusions in cardiac surgery.     

Transfusion of stored red blood cells adhere in the rat microvasculature

BACKGROUND: Ex vivo storage of red blood cells (RBCS) for transfusions is associated with a “storage lesion,” which decreases RBC deformability and increases RBC adhesiveness to vascular endothelium. This may impair microcirculatory flow with deleterious effects on oxygen delivery after transfusion. Previous studies have shown that human RBCs adhere to endothelial monolayers in vitro with prolonged storage and is reduced by prestorage leukoreduction (LR). The objective of this study was to determine whether duration of RBC storage and LR influence RBC adhesion in vivo in capillaries. STUDY DESIGN AND METHODS: Rat RBCs were collected and stored in CPDA‐1 under standard blood bank conditions. Three RBC products were compared: 1) fresh RBCs, less than 24 hours of storage (n = 6); 2) nonleukoreduced (NLR) RBCs stored for 7 days (n = 6); and 3) prestorage LR RBCs stored for 7 days (n = 6). RBCs were labeled with fluorescein isothiocyanate (FITC) 24 hours before transfusion and reinjected in an isovolemic manner into healthy rats. The FITC‐labeled RBCs were visualized in the extensor digitorum longus muscle using intravital video microscopy (20× magnification). The number of RBCs adherent in capillaries was counted 1 hour after transfusion in 10 random fields and the median values were compared with one‐way analysis of variance. RESULTS: Stored RBCs showed increased levels of adherence in capillaries compared to their fresh counterparts (p < 0.05). Prestorage LR decreased RBC adherence to levels equivalent to those of fresh RBCs (p < 0.05 for stored LR vs. stored NLR). CONCLUSION: Rat RBCs stored under conditions that closely mimicked clinical transfusion adhere in capillaries. The decreased RBC adherence with LR suggest a direct effect of white blood cells or their byproducts on RBC deformability and/or adhesiveness to microvascular endothelium. Further study will examine the mechanism of adherence and the impact it has on microcirculatory flow and oxygen delivery in the critically ill host.     

Variant Creutzfeldt‐Jakob disease in a transfusion recipient: coincidence or cause?

BACKGROUND: To date there have been four instances of infection transmitted through blood transfusions derived from individuals who later developed variant Creutzfeldt‐Jakob disease (vCJD). The identification of further transmission of vCJD through this route would have important implications for risk assessment and public health. STUDY DESIGN AND METHODS: Through the UK Transfusion Medicine Epidemiology Review (TMER) the fate of blood donations from individuals who develop vCJD is traced and recipients of labile components are identified. The details of recipients are cross‐checked with the register of vCJD cases held at the National CJD Surveillance Unit (NCJDSU) to identify any linkage between donors and recipients. In the reverse study, when individuals with vCJD are found to have a history of blood transfusion the donors of the transfused blood components are traced and their details cross‐checked with the vCJD register to identify any missed or unrecognized linkage between donors and recipients. CASE REPORT: A case of vCJD has been identified with a history of blood transfusion in infancy. The donors who provided the components transfused cannot be identified, but a blood donor known to have donated blood to another individual who subsequently developed vCJD could have been a donor to the index case. RESULTS: The at‐risk donor is alive 20 years after the relevant donation and continued to donate for some years, until identified as at risk, with 27 other blood components issued for use in patients, none of whom are known to have developed vCJD. CONCLUSION: Circumstantial evidence has raised the possibility that the case in this report represents a further instance of transfusion transmission of vCJD. However, detailed investigation indicates that the pattern of events may have occurred by chance and disease in this individual may have been caused by transmission of bovine spongiform encephalopathy infection, as is the presumed cause in other primary cases of vCJD.     

Prolonged anemia in an intrauterine‐transfused neonate with Rh‐hemolytic disease: no evidence for anti‐D–related suppression of erythropoiesis in vitro

BACKGROUND: Rh‐hemolytic disease may be complicated in some cases by a prolonged postnatal anemia with an extended need for postnatal red blood cell (RBC) transfusion. Besides ongoing hemolysis, marrow suppression and erythropoietin (EPO) deficiency are discussed as underlying mechanisms of this so‐called “late hyporegenerative anemia.” CASE REPORT: We present a case of a newborn with Rh‐hemolytic disease caused by anti‐D who received several intrauterine RBC transfusions. After birth, no reticulocytes or D+ RBCs were detectable in peripheral blood of the infant; thus further RBC transfusions were necessary. Administration of intravenous immunoglobulins had no obvious effect. Reticulocytes first became detectable 15 weeks after birth, when anti‐D titer had decreased to 16. A few days later, hemoglobin started to increase and no further treatment was necessary. To investigate whether anti‐D is able to cause maturation arrest of erythroid progenitors, maternal serum was added to an in vitro assay of erythropoiesis, induced from human CD34+ cells. RESULTS: In this case, no variables of hemolysis (e.g., elevated bilirubin) were observed. The EPO level was normal and a marrow sample showed increased erythropoiesis. The in vitro erythropoiesis assay revealed no influence of anti‐D on RBC proliferation and differentiation. CONCLUSION: Anemia in our patient seemed to be mainly caused by ongoing intramedullar hemolysis due to persistent high anti‐D titers. In such cases, variables for hemolysis are not necessarily found. Release of patient's own RBCs into the circulation may become sufficient when anti‐D has declined to a very low level of approximately 16.     

The cost of blood transfusion in Western Europe as estimated from six studies

BACKGROUND: Blood is a costly and scarce resource. We report on a systematic review of the literature to estimate the cost of a 2‐unit red blood cell (RBC) transfusion in Western Europe. STUDY DESIGN AND METHODS: Medline was searched for studies about the cost of RBC transfusion in Europe. Data extracted included authors, country, year of data, cost perspective, cost types, cost elements, units examined, study design, study population, and cost of a 2‐unit blood transfusion. The population‐weighted mean cost per 2 units of transfused blood was calculated. RESULTS: Six studies met inclusion and exclusion criteria and reported data from the United Kingdom, Sweden, Switzerland, Austria, and France. Methodology used to derive cost estimates differed across the studies. The population‐weighted mean cost of transfusing 2 units of blood was €877.69. CONCLUSION: The estimated cost of transfusing 2 units of RBCs in Western Europe is significant. Differences in methodology were partially diffused by aggregation of prior estimates into a population‐weighted mean. Future cost studies should follow the Cost of Blood Consensus Conference (COBCON) recommendation to apply activity‐based costing methods.     

Pulmonary effects of red blood cell transfusion in critically ill,non‐bleeding patients

The aim of the study is to evaluate the effects of red blood cell (RBC) transfusions on pulmonary parameters in critically ill, non‐bleeding patients. Retrospective chart analysis was performed on critically ill patients without overt bleeding in the intensive care unit (ICU) of a university hospital. In 83 patients in a 5‐month period, who had received at least 1 RBC unit and stayed at least 24 h in the ICU, 199 transfusions of median 2 RBCs per transfusion (n = 504) were studied. Pulmonary parameters were retrieved during the period between 24 h before the start of transfusion and 24–48 h after transfusion. Outcome was assessed. The P_aO₂/F_IO₂ dose‐dependently decreased from 250 ± 105 at baseline to 240 ± 102 mmHg at 24 h after RBC transfusion (P = 0·003), irrespective of acute lung injury at baseline and RBC storage time. The lung injury score (LIS) also increased dose‐dependently, whereas, at 48 h, oxygenation and LIS largely returned to baseline. For every seven RBCs transfused, the LIS transiently increased by 1 unit. There were no changes in haemodynamics, lung mechanics or chest radiography. The total number of RBCs given in the ICU did not directly contribute to ICU and 1‐year mortality prediction. Transfusion of RBCs decreases oxygenation thereby increasing the LIS, dose‐dependently and transiently, in a heterogeneous population of critically ill, non‐bleeding patients, independent of prior cardiorespiratory status and RBC storage time. The effects are subtle, may go unseen and unreported and may represent subclinical transfusion‐related acute lung injury. They do not adversely affect outcome, even at 1‐year follow‐up.     

Costs associated with blood transfusions in Sweden--the societal cost of autologous, allogeneic and perioperative RBC transfusion

Anaemia is characterised by an insufficient number of red blood cells (RBCs) and might occur for different reasons, e.g. surgical procedures are often with associated blood loss. Patients who suffer from anaemia have the option of treatment with blood transfusion or medical treatment. In this study, the societal cost, for the case of Sweden, of RBC transfusion using three different techniques, i.e. allogeneic, autologous and intraoperative transfusion, was estimated. The analysis was based on information from interviews with hospital staff at large Swedish hospitals and from published data. The average cost for a 2 units transfusion was found to be Swedish kronor (SEK) 6330 (702 Euro) for filtered allogeneic RBCs and SEK 5394 (598 Euro) for autologous RBCs for surgery patients. Transfusion reactions accounted for almost 35 per cent of the costs of allogeneic RBC transfusions. The administration cost was found to be much higher for autologous transfusions compared with allogeneic transfusions. The cost of intraoperative erythrocyte salvage was calculated to be SEK 2567 (285 Euro) per transfusion (>4 units).     

The societal unit cost of allogenic red blood cells and red blood cell transfusion in Canada

BACKGROUND: There is a dearth of information about the cost of allogenic red blood cells (RBCs) and RBC transfusion in Canada in the aftermath of the Canadian blood system reorganization and the introduction of various safety measures. The unit cost of allogenic RBCs and RBC transfusion in Canada in 1994 was estimated at 152.17 US dollars. The objective of this study was to determine the unit cost of allogenic RBC transfusion in Canada from a societal perspective. STUDY DESIGN AND METHODS: A cost-structure analysis using the cost information from 2001 through 2002 was used. Costs of blood collection, production, distribution, delivery (hospital transfusion service processing and patient administration), transfusion reaction management, and opportunity cost of donor's time were included in the analysis. Canadian Blood Services and Héma-Québec supplied the data for collection, production, and distribution stages. Delivery and transfusion reaction costs were collected from eight hospitals across six Canadian provinces. In-patient costs were assessed for the intensive care unit, emergency, general medicine ward, and operating room. RESULTS: The aggregate mean societal unit cost of RBCs transfused on an inpatient basis in 2002 was 264.81 US dollars (95% confidence interval [CI], 256.29 dollars-275.65 dollars). The mean cost of blood collection, production, and distribution was 202.74 US dollars (95% CI, 199.63 dollars-204.31 dollars), the mean opportunity cost of donor time was 18.21 US dollars (95% CI, 17.11 dollars-21.63 dollars), the mean cost of hospital transfusion service processing was 16.65 US dollars (95% CI, 13.50 dollars-19.79 dollars), of RBC transfusion was 26.92 US dollars (95% CI, 25.33 dollars-28.52 dollars), and of transfusion reaction management was 0.29 US dollars(95% CI, 0.22 dollars-0.36 dollars). There were substantial variations in hospital transfusion service processing and RBC transfusion costs across hospitals. CONCLUSION: The societal unit cost of RBC transfusion has doubled since 1994 to 1995. Further increases in unit costs would be expected as additional safety measures are introduced. This will have important financial implications for treating patient populations that require a high level of RBC transfusions.     

Posttransfusion recovery of stored red blood cells in very low birth weight infants using a hemoglobin balance model

BACKGROUND: A Hb balance model was used in very low birth weight (VLBW) infants to predict posttransfusion Hb levels from which we inferred allogeneic RBC recovery after transfusion of RBCs stored for varying periods of time. STUDY DESIGN AND METHODS: Premature VLBW infants receiving RBC transfusions during the 1st month of life were evaluated retrospectively for RBC survival of stored donor blood. Actual Hb levels measured in infant blood 1 and 2 days after RBC transfusions were compared to those predicted using a Hb balance model based on factors affecting blood Hb loss and gain. Transfusions were subgrouped according to whether or not infants were clinically stable at the time of RBC transfusion. Model-predicted RBC recovery was also evaluated relative to duration of RBC storage. RESULTS: Model-predicted mean (+/- SD) Hb levels 2 days after transfusion among the 30 VLBW infants receiving a total of 57 RBC transfusions were only 4 percent higher than actual values observed (15.2 +/- 1.2 g/dL vs. 14.7 +/- 1.4, respectively; p < 0.05). The infant's clinical status at the time of transfusion did not affect predicted 1- and 2-day posttransfusion RBC recovery. Model-predicted recovery of transfused RBCs was modestly, but significantly, decreased with increasing duration of donor RBC storage (i.e., 10% lower by 42 days-the maximal allowed storage period for donor blood [p < 0.01]). CONCLUSIONS: Our model-predicted RBC survival results are consistent with-but not direct evidence of-hemolysis of donor blood after RBC transfusion. Although observed post-RBC Hb levels 2 days after transfusion averaged only 4 percent less than predicted, model-predicted survival of donor RBCs at 42 days suggested a modest decrease (i.e., by 10%).     

Efficacy of red blood cell transfusion in the critically ill

This article has evaluated the published data regarding the efficacy of RBC transfusions in the critically ill. Taken together, these studies generally support conservative RBC transfusion strategies in critical care to reduce the risk of transfusion-related adverse effects. The TRICC trial has established the safety ofa restrictive transfusion strategy, suggesting that physicians could minimize exposure to allogeneic RBCs by lowering their transfusion threshold. Further research will add to the generalizability of this study and explore the possible mechanism to explain why RBC transfusions do not improve outcomes in the critically ill. Additional studies will be necessary to determine the effects of RBC storage time and the presence of allogeneic leukocytes in allogeneic RBC. The following conclusions are evident: 1. RBC transfusion does not improve tissue oxygen consumption consistently in critically ill patients, either globally or at the level of the micro-circulation. 2. RBC transfusion is not associated with improvements in clinical outcome in the critically ill and may result in worse outcomes in some patients. 3. Specific factors that identify patients who will improve from RBC transfusion are difficult to identify. 4. Lack of efficacy of RBC transfusion likely is related to storage time, increased endothelial adherence of stored RBCs, nitric oxide binding by free hemoglobin in stored blood, donor leukocytes, host inflammatory response, and reduced red cell deformability.     

Modeling red cell procurement with both double-red-cell and whole-blood collection and the impact of European travel deferral on units available for transfusion

BACKGROUND: In 1997 the FDA approved the first double-red-blood-cell (2RBC) collection device. Soon after, travel deferral for variant Creutzfeldt-Jakob disease (vCJD) risk was adopted. To show the importance of including 2RBCs in predictive models of the blood supply, an existing whole-blood (WB) model was updated to include 2RBC collection and then run to simulate the effect of vCJD deferral on total RBC availability. STUDY DESIGN AND METHODS: The model simulates donation of allogeneic WB and 2RBCs, with donors stratified into eight age and sex groups. The model was updated with 2003 donation and economic data from 16 blood centers. RESULTS: The distribution of donations by demographic group differed both within and between WB and 2RBCs. Overall, 2RBC donation made up 24 percent of transfusable RBC units, at a lower per-unit acquisition cost from both the blood bank and the societal perspectives. Component fees from hospitals would alter this interpretation. The model predicts that vCJD travel deferral led to a 3.3 percent (95% confidence interval [CI], 2.3-4.1) decrease in the total number of RBC units, which was more than offset by 2RBC collection, resulting in a 10.4 percent (95% CI, 9.8%-11.1%) net increase in RBC units. Modeled 2RBC results match operational records, whereas vCJD deferral is overestimated. CONCLUSION: Shifting to 2RBC collection led to a substantial gain in available RBCs: even with policies that adversely affect the quantity of RBCs in the supply, 2RBC collection results in a net gain. The economics of 2RBC collection are not as clear, however.     

IMMUNOHEMATOLOGY: Storage of murine red blood cells enhances alloantibody responses to an erythroid‐specific model antigen

BACKGROUND: Red blood cell (RBC) alloimmunization can be a serious complication of blood transfusion, but factors influencing the development of alloantibodies are only partially understood. Within FDA‐approved time limits, RBCs are generally transfused without regard to length of storage. However, recent studies have raised concerns that RBCs stored for more than 14 days have altered biologic properties that may affect medical outcomes. To test the hypothesis that storage time alters RBC immunogenicity, we utilized a murine model of RBC storage and alloimmunization. STUDY DESIGN AND METHODS: Blood from transgenic HOD donor mice, which express a model antigen (hen egg lysozyme [HEL]) specifically on RBCs, was filter leukoreduced and stored for 14 days under conditions similar to those used for human RBCs. Fresh or 14‐day‐stored RBCs were transfused into wild‐type recipients. The stability of the HOD antigen and posttransfusion RBC survival were analyzed by flow cytometry. RBC alloimmunization was monitored by measuring circulating anti‐HEL immunoglobulin levels. RESULTS: Transfusion of 14‐day‐stored, leukoreduced HOD RBCs resulted in 10‐ to 100‐fold higher levels of anti‐HEL alloantibodies as detected by enzyme‐linked immunosorbent assay than transfusion of freshly collected, leukoreduced RBCs. RBC expression of the HOD antigen was stable during storage. CONCLUSIONS: These findings demonstrate that HOD murine RBCs become more immunogenic with storage and generate the rationale for clinical trials to test if the same phenomenon is observed in humans. Length of storage of RBCs may represent a previously unappreciated variable in whether or not a transfusion recipient becomes alloimmunized.     

Activity‐based costs of blood transfusions in surgical patients at four hospitals

BACKGROUND: Blood utilization has long been suspected to consume more health care resources than previously reported. Incomplete accounting for blood costs has the potential to misdirect programmatic decision making by health care systems. Determining the cost of supplying patients with blood transfusions requires an in‐depth examination of the complex array of activities surrounding the decision to transfuse. STUDY DESIGN AND METHODS: To accurately determine the cost of blood in a surgical population from a health system perspective, an activity‐based costing (ABC) model was constructed. Tasks and resource consumption (materials, labor, third‐party services, capital) related to blood administration were identified prospectively at two US and two European hospitals. Process frequency (i.e., usage) data were captured retrospectively from each hospital and used to populate the ABC model. RESULTS: All major process steps, staff, and consumables to provide red blood cell (RBC) transfusions to surgical patients, including usage frequencies, and direct and indirect overhead costs contributed to per‐RBC‐unit costs between $522 and $1183 (mean, $761 ± $294). These exceed previously reported estimates and were 3.2‐ to 4.8‐fold higher than blood product acquisition costs. Annual expenditures on blood and transfusion‐related activities, limited to surgical patients, ranged from $1.62 to $6.03 million per hospital and were largely related to the transfusion rate. CONCLUSION: Applicable to various hospital practices, the ABC model confirms that blood costs have been underestimated and that they are geographically variable and identifies opportunities for cost containment. Studies to determine whether more stringent control of blood utilization improves health care utilization and quality, and further reduces costs, are warranted.     

Anemia and blood transfusion in the critically ill patient: role of erythropoietin

Critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units receive at least 1 red blood cell (RBC) unit during their stay, and the average is close to 5 RBC units. RBC transfusion is not risk free. There is little evidence that 'routine' transfusion of stored allogeneic RBCs is beneficial to critically ill patients. The efficacy of perioperative recombinant human erythropoietin (rHuEPO) has been demonstrated in a variety of elective surgical settings. Similarly, in critically ill patients with multiple organ failure, rHuEPO therapy will also stimulate erythropoiesis. In a randomized, placebo-controlled trial, therapy with rHuEPO resulted in a significant reduction in RBC transfusions. Despite receiving fewer RBC transfusions, patients in the rHuEPO group had a significantly greater increase in hematocrit. Strategies to increase the production of RBCs are complementary to other approaches to reduce blood loss in the intensive care unit, and they decrease the transfusion threshold in the management of all critically ill patients.     

Emergency department blood transfusion predicts early massive transfusion and early blood component requirement

BACKGROUND: The purpose of this study was to evaluate the ability of uncrossmatched transfusions in the emergency department (ED) to predict early (<6 hr) massive transfusion (MT) of red blood cells (RBCs) and blood components. STUDY DESIGN AND METHODS: All patients admitted to a Level 1 trauma center between July 2005 and June 2007 who received any transfusions and were transported directly from the scene of injury were included. Early MT was defined as the need for 10 U or more or RBCs in the first 6 hours. Early MT plasma was defined as 6 U or more of plasma in the first 6 hours. Early MT platelets (PLTs) were defined as two or more apheresis transfusions in the first 6 hours. Univariate and multivariate analyses were performed. RESULTS: A total of 485 patients (34%) received ED transfusions (ED RBC+) and 956 (66%) did not receive ED transfusions (ED RBC–). ED RBC+ patients were younger, were more likely to be male, and arrived with more severe injuries. Multivariate regression identified ED transfusion of uncrossmatched RBC as an independent predictor of requiring early MT of RBCs (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.36‐7.59; p = 0.001), plasma (OR, 2.7; 95% CI, 1.66‐4.39; p < 0.001), and PLTs (OR, 1.9; 95% CI, 1.08‐3.41; p = 0.025). CONCLUSION: Patients receiving uncrossmatched RBCs in the ED are more than three times more likely to receive early MT of RBCs. Additionally, patients transfused with ED RBCs are more likely to receive 6 units or more of plasma and two or more apheresis PLT transfusions. Given these findings, ED transfusion of uncrossmatched RBCs should be considered a potential trigger for activation of an institution's MT protocol.