|Year : 2016 | Volume
| Issue : 3 | Page : 34-98
|4 th ISTM Annual Conference, TRANSMEDCON 2015, Kolkata
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|Date of Web Publication||19-May-2016|
|How to cite this article:|
. 4 th ISTM Annual Conference, TRANSMEDCON 2015, Kolkata. Asian J Transfus Sci 2016;10, Suppl S1:34-98
Deferred donors: What are we missing?
Deepa Dhanabalan, P Arumugam, Rajbharath, Hamsavardhini
Background: 100% voluntary non-remunerated blood donation is the need of the hour in every country for safe blood supply and forms the foundation for future medicine (transfusion medicine). Blood donor motivational programmes are always targeted at recruiting new blood donors whereas the temporarily deferred donors are ignored. In our centre, we identified the various causes of donor deferral from December 2014 - May 2015 blood camps. 35.61% was the deferral rate with 3.16% being permanent deferrals and 96.84% temporary deferrals. Low Hemoglobin (48.06%) being the most common cause in both males and females. As temporary deferral rate (97%) was huge, we planned a prospective study from June 2015 to November 2015 to find what we are missing due to deferrals and the significance of retrieving them.
Aim: The aim of this study is to quantify the losses due to temporary deferral, to assess their hemoglobin value and platelet count using automatic cell counter, blood group (tube technique), the significance of motivating and regaining them.
Materials and Methods: About 2 ml of blood is collected in EDTA tubes from the temporarily deferred donors after getting informed consent. Hemoglobin and platelet count are determined using an automatic cell counter and blood groups using tube technique.
Results: It is an on - going study. Till now analysis of the results from June 2015 November 2015 (prospective study) shows the temporary deferral rate to be about 94.4% with low Hemoglobin being the most common cause. Using automatic cell counter, 80.35% of them had Hemoglobin value ranging from 11.5-12.5gm/dl, 90.17% had normal platelet count and 15% of them had rare blood groups (A, B, O negative and AB positive). Analysis will be concluded at the end of study.
Conclusion: Our suggestion to slightly lower the existing Hemoglobin cut off to suit the Indian scenario will reduce the deferral rate and accommodate more female donors. Considering this strategy atleast for plateletpheresis could reduce the dearth of apheresis donors and significant especially during crisis situations like natural disasters, dengue epidemics and when rare blood groups are required. Temporary deferral also reflects the health status of the community indirectly. So motivating them especially females helps in motivating whole society. This study will highlight the importance of alleviating the negative effect of deferral, proper maintenance of temporary donor deferral register, treatment of deferral cause, periodical follow up, motivating them to increase the voluntary blood donor pool and for a positive impact on public health.
Analysis of reasons for discard of whole blood and blood components in a tertiary care teaching hospital blood bank in Andhra Pradesh, South India
M Anitha, KV Sreedhar Babu
The gift of blood is the gift of life and blood donation is one of the noblest gestures a human can make when its purpose is to save lives. Much of the medical and surgical specialties depend on the steady supply of blood and there is no absolute substitute for human blood. So each unit of blood is precious and has to be utilized properly with minimal discards. The aim of this study was to analyze the reasons for discarding whole blood and blood components with an objective to manage the component preparation and rationale usage of blood and components through education and training of staff. This can help in formulating proper guidelines for donor screening, component preparation and storage.
This is a prospective and retrospective cross-sectional analytical study, conducted for a period of 2 years and 6 months (January 2013 to June 2015) in the department of Transfusion Medicine of a tertiary care referral teaching hospital in Andhra Pradesh, South India i.e. SVIMS, Tirupati. All the whole blood and blood component units collected from the eligible donors as per the guidelines of Drugs and Cosmetics Act, 1940 and Rules, 1945 and discarded due to various reasons during study period were analyzed.
A total of 506 (5.5%) whole blood units were discarded against collection of 9283 units. Out of these 232 (45.8%) were discarded because of seroreactivity for transfusion transmissible infectious diseases (TTIs). A total of 2397 (6.9%) blood components were discarded against 34824 blood components prepared during the study period. Among blood components, most common component discarded was random donor platelets and the commonest cause among discarding blood components was date expiry; especially random donor platelets due to short shelf life. Breakage/leakage was one of the main reasons for fresh frozen plasma discards.
In our study the main reasons for discarding blood and blood components except for random donor platelets was due to seroreactivity for various TTIs. A scrupulously conducted donor screening, notification and counseling will help in discarding less number of bags which are positive for different transfusion transmitted infections. Proper visual inspection and storage facilities will decrease the breakage/leakage of the fresh frozen plasma. Properly implemented blood transfusion policies will help to utilize the blood components in proper way resulting in discarding the less number of blood bags due to expiry.
A prospective study of hidden cases of beta thalessemia in voluntary blood donors at tertiary care hospital of South Gujarat
Chiragkumar Amarshibhai Unagar, Nikita J Patel, Hemali J Tailor, Prashant R Patel, Arpit C Patel
To study the prevalence of hidden cases of beta thalessemia in voluntary blood donors.
Autologus platelet concentrate therapy
Purnima Sridhar Rao, Smita R Joshi
A randomized prospective observational study was designed to assess the efficacy of APCC. The effectiveness of local injection of (APCC) in different types of patients having Orthopedic & Neurological problems. Where usually local steroid are given for reducing pain and improving function. Platelet Rich Plasma Therapy is an alternative and Holistic Medicine in additional to traditional Medical Treatments. This is one of the most popular revolutionary therapies offered by DR Nelson Kraucak. This revolutionary therapy makes use of body own cell's for recovery. The technique has proven to be very beneficial for patient suffering from shoulder, hip, spine, pelvic pain and instability, back and neck injuries, tennis elbow, ankle sprains, tendonitis and ligament sprains & planter faciatis. APCC also termed autologous platelet gel, plasma rich in growth factors (PRGF), platelet concentrate (PC), is essentially an increased concentration of autologous platelets suspended in a small amount of plasma after centrifugation. Platelets play a fundamental role in hemostasis and are a natural source of growth factors. The following growth factors can be found in the environment of a blood clot. Transforming growth factor beta (TGF-?) Platelet-derived growth factor (PDGF) Insulin-like growth factor (IGF) Vascular endothelial growth factors (VEGF) Epidermal growth factor (EGF) Fibroblast growth factor-2 (FGF-2) though the release of these growth factors can be triggered by the activation of platelets that can be initiated by a variety of substances or stimuli such as thrombin, calcium chloride, or collagen. In our case study none of these activators were added.
In coordination with the Orthopedic & Neurosurgeon for their patients APCC were prepared by us in our blood bank & issued to the patients admitted on day care basis. APCC was being utilized in the nonsurgical and surgical orthopedic settings. In the clinical or nonsurgical setting, APCC was administered in the form of an injection. We had carried out our study in almost 50 different cases as mentioned. 1. Knee Medial Meniscus Tear 2. Spine 3. Tennis elbow 4. Retro Calcaneal heel pain 5. Ankle sprains 6. Tendonitis and ligament sprains 7. Planter faciatis. 8. Endoscopic discectomy 8. Obesity 9. Skin We are aware that growth factors are involved in key stages of wound healing and regenerative processes including chemotaxis, proliferation, differentiation, and angiogenesis. The result is an APCC that contains a biologically active mixture of growth factors without the potential for an immune response. The patients were also given Tremadol 2 weeks & B12, D3 tablets for next 4 weeks in indicative cases.
It was noted that in almost all cases a single injection of APCC had noticed complete relief of pain within 3-4 weeks.
Auditing the use of blood components is necessary for all transfusion services. The main purpose of auditing blood utilization is to assess appropriate use of blood components and help to optimize their use. Different audits (prospective, concurrent or retrospective) formats may be used depending on the objectives and resources available. Adequate knowledge of various aspects of blood transfusion by all clinical staff, including nurses is essential for safe transfusion practice. In all cases providing feedback and using the resulting interventions are both necessary to optimize transfusion practice. Aims the aim of this case study is to show whether regular training programmes for nursing staff and concurrent audits of blood transfusion will help optimizing transfusion practices in our hospital.
A total of 3496 concurrent blood transfusion audits were done in various clinical departments including the emergency department of the hospital over a total period of 15 months (April 2014 to June 2015). Regular training classes on blood transfusion protocols of one hour duration were organized twice a month for nursing department over a period of 12 months (July 2014 to June 2015). The main focus of concurrent blood transfusion audits was documentation of all blood transfusion details in the patient's medical records and included: 1. Transfusion order 2. Recipient consent 3. Component name 4. Donation identification number 5. Date and time of transfusion 6. Name and signature of doctor and nurse 7. Pre and post transfusion vital signs 8. Volume transfused 9. Transfusion related adverse event 10. Total transfusion time lapsed 11. Transfusion indication During the audits individual education on blood transfusion was also provided to the nurses and other clinical staff. All documentation was monitored in the 12-24 hours following transfusion and reviewed.
Transfusion details that were not meeting the criteria were marked as non-compliance. % compliance was calculated by dividing the compliance audits per month with the total number of audits done in that month. It was found that % compliance increased gradually during this period with increasing training programmes and concurrent audits. % compliance in our audits for over a period of 15 months are summarized in below. Month/yr Compliance (%) Jun-15 98.75 May-15 98.80 Apr-15 98.90 Mar-15 99.00 Feb-15 97.50 Jan-15 99.30 Dec-14 98.60 Nov-14 97.75 Oct-14 97.50 Sep-14 95.25 Aug-14 97.25 Jul-14 95.00 Jun-14 89.25 May-14 88.93 Apr-14 91.92. After performing the concurrent audits, all transfusion staff was contacted and guided appropriately and asked to complete the lacking transfusion information.
We found that Concurrent audits combined with regular training programmes greatly helped in evaluating transfusion practices in our hospital. Also, they permitted identification of suboptimal transfusion practices.
ABO incompatible (ABOi) kidney transplantation was initially considered to be an absolute contraindication for patients with end-stage kidney disease (ESKD) due to hyperacute rejection because of ABO incompatibility. ABOi kidney transplantation has gained a renewed interest during the past years and is now being performed increasingly all over the world including India. To decrease the risk of acute-humoral rejections, patients were desensitized before transplantation. Usually these desensitization protocols included Rituximab and conventional plasmapheresis besides routine immune-suppression. At our center in 2013, a protocol for ABOi kidney transplantation based on cascade plasmapheresis (CP) was introduced. In this study we aim to assess the efficacy of CP in ABOi kidney transplant.
Desensitization protocol included routine immunosuppressive drugs, Rituximab and multiple sessions of CP. All patients received 375 mg/m2 rituximab intravenously three weeks prior to starting CP. Patients with titer of ≥16 were subjected to CP consisting of separating patients plasma as the first step and passing it through pore size based filter column as the second step. Monitoring of ABO blood group (anti A and anti B) antibody titers was done using column agglutination technology. Titers (pre and post) were performed for each procedure. CP was performed every alternate day until the anti-A or anti-B Ab titers (IgG and IgM) were lowered to desired titer of 8 or less. Post-operative conventional plasmapheresis was not performed routinely and was performed if humoral rejection was suspected or/and antibody titer rises more than 32.
29 patients (20 male and 19 female; mean recipient age 43.7 (11-61) years) were included in ABOi transplant program. Transplantation could be conducted in 28 patients as in one patient preconditioning was interrupted before transplant. 25 patients underwent preconditioning receiving rituximab and total of 76 sessions of CP. CP significantly reduced the baseline antibody titers (range 512-16) to the desired level (titer 8 or less) in all patients with the mean 3 (range1-6) procedures per patient. Three patients received only rituximab as their baseline ABO antibody titer were 8 or less. Post-operative conventional plasmapheresis was required in 5 patients. Overall patient survival was 96.4 % and graft survival was 89.2 %. Mean follow-up was 277.5 days.
ABOi kidney transplant is viable and alternative approach to ABO compatible and paired kidney transplants with comparable patient and graft survival. CP in combination with rituximab effectively depletes ABO antibodies. CP is an effective and economical modality for desensitization in these patients.
Are we following the basic rules before transfusing our patients? Audit from a tertiary hospital in South India
Daisy Henry, Sheela Durai, Premila Lee, Daisy Henry, Amal Raj, Jui Choudhuri, Joy John Mammen, Dolly Daniel
Aggregation and analysis of national data related to serious adverse effects experienced by patients undergoing transfusion forms the basis of the Haemovigilance programme of India (HVPI) started in December 2012. Documenting of bedside transfusion practice plays a crucial aspect in the evaluation of adverse effect and also to generate reliable information regarding transfusion practices followed. This audit was conducted to assess the status of the documentation of bedside transfusion procedure which can serve as indicators of good transfusion practice.
Aim: To study the conformity of health care personnel/medical and nursing personnel/medical and nursing staff in documenting bedside transfusion details in a tertiary hospital and to explore reasons for non-adherence.
This was a retrospective study conducted over one month. 168 transfusion monitoring forms were randomly selected based on the frequency of transfusion and included wards and intensive care units. The charts were reviewed systematically using a proforma for data collection and broadly looked at obtaining consent, completion of patient details, adequacy of data about the unit being transfused and monitoring information such as vitals at different time intervals and signature of the health care personnel/medical and nursing personnel./medical and nursing staff.
The overall compliance to documentation related to blood transfusion was 92.88% among our hospital staff. Of 168 forms reviewed, 90.48% had the consent form appropriately filled; 88.62% had the signature of the patient/relative and 86.32 % were revalidated for repeat transfusions. The documentation of patient details and blood group was 100%. Signature of the doctor was present in 80.95% of forms and the information most often missed was the time of completion of transfusion (71.6%).
We identified the need for a separate audit process for transfusion in the operation rooms as the procedures there were different and under the control of the anesthetist. Staff was educated about the need for consent and revalidation process in patients receiving multiple transfusions during a single episode of care. Suggestions for inclusion of new data fields are being considered and a process is in place to ensure that there is no redundancy of data collection. Documenting transfusion details is crucial in providing good and reliable medical care. It is not only needed for medico-legal purpose but also to review or look back at the details incase of any untoward incidence related to the transfusion. It forms the basis of an adverse effect work up and will significantly impact the Haemovigilance programme of India.
Implementing a digitalized blood availability information system in a public hospital in Bangladesh
Aminur Rahman, Sadika Akhter, Syed Shariful Islam, Fatema Ashraf
More than 99% maternal deaths take place in the developing countries and one-fourth of them are due to Postpartum Haemorrhage (PPH). PPH accounts for 37% of all blood transfusions in low and middle income countries. In Bangladesh, blood transfusion process is lengthy and lay people often dont know where to look for blood in emergency situations. The study aimed at testing the feasibility, acceptability and effectiveness of an innovative online blood information management application (BIMA) system in minimizing the delay for blood transfusion (BT) in a public medical college hospital in Bangladesh.
The study was conducted in Dhaka Medical College Hospital (DMCH) during January-December 2014 following a mixed method before after design. We enrolled 178 women from obstetric wards during their perinatal period those needed emergency BT before and after BIMA interventions. We took median value of time (in minutes) instead of mean for calculating average delay (as data was skewed). Qualitative key informant and in depth interviews were conducted with relevant stakeholders to understand the constraining and facilitating factors for implementing the BIMA.
On an average, the delay (between decision making to blood transfusion) reduced from 152 minutes (IQR:93) to 112 minutes (IQR:38) due to introduction of BIMA (P < 0.05). While for PPH, the delay reduced from 184 minutes (IQR:88) to 112 minutes (IQR:33) (P < 0.05). The qualitative data suggest that BIMA was beneficial for the poor patients. However, there are reports of unwillingness (and or lack of interest), fear of technology, and lack of compliance of health care providers. These might be due to influence of brokers on doctors, related staffs and patients.
BIMA was effective in reducing the delay in blood transfusion for the obstetric patients. However, the study documented major implementation challenges that need to be addressed through organizing training and other motivational programme (orientation or awareness sessions) for the providers, patients and managers.
Role of plasmapheresis in autoimmune encephalopathy
S Sreelekshmi, Shamee Shastry, Manish Raturi, B Poornima Baliga
Autoimmune encephalopathy refers to cognitive impairment due to overactive immune system and includes Acute disseminated encephalomyelopathy, Hashimoto's encephalopathy, Rasmussens encephalitis, NMDA- receptor antibody encephalitis, Limbic encephalitis. They are recognised by the association with autoantibody markers and/or clear response to immunomodulatory treatment. Cognitive impairment with tremors, seizures, stroke like events and normal thyroid hormone levels is the common scenario. In this case report we have reviewed the role of therapeutic plasma exchange in the management of Auto immune encephalopathy. It comes under Grade III ASFA (American Society for Apheresis) and AABB Indication categories, for plasmapheresis.
Case Study: A 57 year old male, diagnosed with autoimmune encephalopathy (? Hashimotos Thyroiditis), and high serum titer of thyroid peroxidase antibodies, was on corticosteroid therapy, reported with memory impairment, change in behavioral patterns and inability to do routine chores. On investigation, thyroid peroxidase antibody titer was high in serum, and thyroid function tests were normal. As the patient was having worsening of symptoms when he was on corticosteroid therapy, it was decided to start the patient on plasmapheresis. Intravenous access was secured in the right femoral vein, and with a total predicted blood volume of 3850 ml, five cycles of uneventful plasmapheresis were done with 1 to 1.5 plasma volumes of replacement fluids like fresh frozen plasma, 5% albumin, and crystalloid Ringer lactate. The patient started showing cognitive improvement after the third cycle and had significant improvement after the fifth procedure. The thyroid peroxidase antibody titer got significantly reduced after five cycles of therapeutic plasma exchange.
Patients condition improved on discharge. The thyroid peroxidase antibody titer got reduced from pre therapeutic plasma exchange level of 600IU/ml to 5 IU/ml, post plasma exchange.
We have observed that therapeutic plasma exchange/Plasmapheresis has a significant role in the management of autoimmune encephalopathy.
Therapeutic plasma exchange in postpartum haemolytic uremic syndrome: A case report
Sirat Kaur, Rajesh Kumar, Sonia, Amarjit Kaur
Adult, non-infective, haemolytic-uremic syndrome (HUS) although a rare disease in itself, has a high likelihood of occurrence in pregnancy and immediate post partum period. It is an important differential diagnosis in the evaluation of thrombotic microangiopathies. Patients with post-partum HUS display a classical triad of microangiopathic haemolytic anaemia, acute nephropathy and thrombocytopenia. We hereby present a case of post partum HUS treated with therapeutic plasma exchange (TPE).
A total of six sessions of TPE were performed daily, three sessions for consecutive days and remaining three sessions were performed on alternate days. All the procedures were carried out with Haemonetics MCS+ exchanging one plasma volume using fresh frozen plasma and saline as replacement fluid. Haemodialysis was started and four sessions were carried out on alternate days.
A 37 year old, 85 kg female, G2 P1, underwent emergency LSCS because of foetal distress at 38 weeks of pregnancy. Post surgery she developed decreasing urine output, anuria ensued. Emergency therapeutic plasma exchange was carried out within 24 hours of diagnosis. It could be found that with TPE, patient had improvement in renal function, decrease in LDH levels and increase in platelet count. Patient had sustained remission and discontinuation of haemodialysis.
HUS is a disorder with high mortality and long term morbidity, if prompt treatment is not instituted. The decision to intervene with plasma exchange should be based upon the severity of thrombocytopenia, microangiopathic haemolytic anaemia and neurological abnormalities, even if the diagnosis and nomenclature is uncertain. Improved survival after this disorder has been attributed to aggressive treatment with plasma exchange therapy.
Red cell alloimmunisation in antenatal women
Shashikant Baraku Patil, Jayashree Sharma, Chundamala Julie Jose
Universal screening of all antenatal women for alloimmunisation, including D antigen-positive pregnant ones, is mandatory but the same is not followed in developing countries such as India. Furthermore, there is limited information on immunisation rates in pregnant women (D antigen-positive and D antigen-negative) from India. We, therefore, studied the prevalence of alloantibodies among multigravida women in India.
In this prospective study, carried out to detect the prevalence of alloantibodies among multipara women in India, 752 multipara women attending antenatal clinics were typed for ABO and D antigens, Direct Antiglobulin Test and screened for alloantibodies using 3 cell screening panel followed by 11 cell identification panel in saline, enzyme and IAT phase using column agglutination technology. The medical history and detailed obstetric history of these women were reviewed and information recorded on any prior haemolytic disease of the foetus and newborn among siblings and/or blood transfusions.
The overall prevalence of alloantibodies in this study was 4.92% (clinically significant and non-significant allontibodies). Prevalence of clinically significant alloantibodies was 1.9%. Clinically significant alloantibodies included anti-D, anti-S, anti-K and anti-M. There existed highly significant statistical difference between prevalence of clinically significant alloantibodies in D antigen positive and D antigen negative women (8.82% versus 0.43% respectively). Anti-D alloantibody was the most common alloantibody (16.21% of total alloimmunisation) found in our study contributed to 78.4% of total alloimmunisations in our study.
At the same time screening for irregular red cell alloantibodies against the clinically significant blood group systems is necessary to prevent any potential complication to the fetus as well as to provide compatible blood to the mother if required. All antenatal women should be followed up in the gestational period in all their pregnancies for detection of anti-D and administration of prophylactic anti D in adequate doses as per BCSH guidelines.
Quality check of washed packed red blood cells for decreasing severe allergic transfusion reactions
Puneet Sachdeva, Hari Krishan Dhawan
Thalassemia major and other multi-transfused patients are more prone to allergic transfusion reactions to plasma proteins in packed red blood cell (PRBC) units. Some of these patients have recurrent severe allergic reactions such as anaphylaxis or severe urticarial reactions which are not prevented by pre transfusion antihistamine and steroid administration. For these patients washed PRBC transfusion is the only solution. We are providing washed PRBC to eleven such patients in our institute. Aim of this study was to assess the plasma protein levels in PRBC units after washing and its effectiveness to prevent transfusion reactions.
Forty four PRBC bags were included in the study. PRBC units were washed three times using around one litre of normal saline. Sampling was done from the satellite tube after stripping the tubes three times. Post wash protein content of the bag was done using automated biochemistry analyser (AUS 800 BECKMAN COULTER Brea, California). History of any adverse transfusion reactions with these bags was taken from the thalassemia ward staff nurse.
Out of total 44 PRBC bags mean pre wash volume was 276 ml (range 200-340 ml) and mean post wash volume was 274 ml (range 180-330 ml). Mean volume of saline used was 1001 ml (range 900 -1400 ml). Mean plasma protein levels after washing were 0.028 g/bag which were significantly less than that required by European Council Guidelines (<0.5 g/bag). No adverse transfusion reaction was reported.
Removal of plasma from red cells with normal saline helps to prevent allergic reactions to a great extent by causing removal of plasma proteins. In this study we were able to reduce plasma protein levels to less than 0.5g/bag in 100 % of bags which were washed. None of the patients developed allergic or any other adverse reaction after transfusion with washed cells. Thus red cell washing helps to a great extent in preventing severe allergic transfusion reactions making transfusion a pleasant experience for the regularly transfused patients.
Prevalence and identification of bacterial contamination in blood and its components in a tertiary care blood bank
Vijay Sawhney, Naveen Akhtar
To determine the prevalence of bacterial contamination of Blood and its components viz. Whole Blood, Packed RBCs & Platelet Units and to identify the various contaminating bacteria.
The study was done in the PG Department of Transfusion Medicine Government Medical College Jammu from April 2014 to March 2015. 5ml of blood sample was collected from the tubing of Whole Blood, Packed Red Blood Cell and Platelet Units using a needle and syringe under all aseptic conditions and dispensed in Nutrient Liquid Broth media to Microbiology Department for Culture Sterility Testing. Subcultures were done on Agar media and growth was identified using standard methods.
Of 448 (108-PRBC units, 256 WB units & 84 Platelet units) blood samples sent for culture 13 (2.9%) units were tested positive for Bacterial Contamination. Of the 13 units 3 were of Packed RBCs units, 3 were Whole Blood units and 7 were Platelet units. The contaminating bacteria were identified as Acinetobacter spp. in 6 units (1-pRBC, 2-WB, 3-Platelets), Coagulase Negative Staphylococci in 6 units (1-pRBC, 1-WB, 4-Platelets) and Citrobacter freundi in 1 unit (1 pRBC). Relative bacterial contamination of various blood components were found to be WB-3/256 (1.2%), pRBCs-3/108 (2.8%) and Platelets-7/84 (8.3%).
Identification of various bacteria causing contamination is important in the formulation and implementation of strategies for reduction and prevention of bacterial contamination of Blood Products in Blood Transfusion Centers for safety of blood. Transfusion of such units can lead to grave consequences for the recipient. Such contamination can be prevented by regular monitoring and implementation of quality Control measures, Proper blood donor selection and continuous education and training of the staff.
Prevalence of factor viii inhibitors in congenital hemophilia a patients at a tertiary care centre: A pilot study
Neha Jayant Hurkat, Jayashree Sharma, Swarupa Bhagwat, Charusmita Modi
Factor VIII (FVIII) replacement therapy is the foundation of treatment in hemophilia A and is effective unless a patient develops an alloantibody (inhibitor) against exogenous FVIII. Inhibitor development is currently the most significant treatment complication seen in patients with hemophilia and is associated with considerable morbidity and a decreased quality of life. So, the aim of this study is to evaluate the prevalence of FVIII inhibitors in Hemophilia A patients.
Study included 90 diagnosed hemophilia A patients. Activated partial thromboplastin time (APTT), factor VIII assay, and inhibitor screening (by mixing study) done on citrated plasma using the machine Sysmex CA-50 automated blood coagulation analyzer. Classical Bethesda assay done for positive inhibitor screening and the result expressed as Bethesda units (BU).
Out of 90 patients, 10 (11.11%) patients of hemophilia A were positive on inhibitor screening. On Bethesda assay, six patients were high responders (>5 BU/ml) and rest four were low responders (<5 BU/ml).
While significant progress has been made in the care of Hemophilia patients, development of inhibitors is a significant challenge in the treatment because of increased risk of bleeding. Transfusion Medicine speciality can play a significant role in Hemophilia care as these patients need to be treated with other modalities also like Prothrombin complex concentrates or recombinant Factor VII.
Blood and blood component utilization pattern in a tertiary care hospital
Parmatma Prasad Tripathi, R Kavitha, M Begum, P Amalraj, Joy Mammen
Introduction: An understanding of trends in blood and its product usage profile and current usage can help predict future trends in demand and help to put efforts to reduce use in particular areas.
Aim: To study the pattern of blood and blood component utilization in a tertiary care Hospital.
Materials and Methods: This retrospective study was conducted in Blood Bank CMCH at Department of Transfusion medicine and immunohematology over six month duration. All blood requests daily came to blood bank for blood and its components were reviewed. Data regarding patient's hospital no., demographic details, diagnosis and indication for transfusion, type of request (Routine or emergency), blood and its products transfused or returned was collected. Relevant laboratory parameters were also gathered up. Month wise utilization patterns, CT ratio, Transfusion index and Transfusion probability were analysed. Statistics related to wastage of blood and its components were also reviewed.
Results: Total 20,399 requests came to our blood bank in six months. A total of 10,364 patients utilized total 32,608 units of blood and its components. Total 14,195 units of packed red cells, 5062 units of FFP, 10,118 units of platelets, 2751 units of cryoprecipitate and 482 units of cryosupernatant were utilized. Most of the requests for blood were from the inpatients (wards). Most of the blood was requested and utilized in age group of 21-30 years. Most of the blood and its components were utilized for diagnosis neoplasm group according to ICD 10 code classification. In our study, requests for male patients were more and they also utilized more blood and components than females. Patients in the division of medicine utilized most blood. Although the division of surgery requested most of the blood, on an average, they utilized only 1/3 rd of the requested product. Among the medical specialties, Hematology utilized most of the blood and components. Overall anemia was the most common indication for red cell utilization. In surgical group Spine surgery had a maximum CT ratio. Neurosurgery and Hand Surgery had the lowest transfusion index in overall specialties. Hand Surgery and spine surgery had a lowest transfusion probability. Overall utilization rate in our study was 59.8%.
Conclusion: Regular review of blood component usage and utilization patterns act as quality indicator for quality management of blood bank.
Prevalence, profiling of seroreactive blood donors
S Usha, D Deepa, R Rajbharath
Blood safety in the context of Transfusion- Transmissible Infections involves eliciting relevant history and physical examination. It is then dependent on the detection of seroreactivity by screening tests. In spite of careful donor selection, seroreactivity is detected in small percentage of donated units. This study is aimed at describing the prevalence, profile of donors who test "reactive" during TTI screening of their donated units.
Blood donor records were analysed from January 2012 (to be continued upto October 2015) at the Department of Transfusion Medicine, The TN DR MGR Medical University, Guindy, Chennai for information on donors, who tested "reactive" during screening of their donated units for markers of Hepatitis B, Hepatitis C, HIV and Syphilis, regarding prevalence, age and gender distribution, type (voluntary/replacement) and site of donation (camp/walk-in) and past history of donation.
Preliminary results of the study from 1 st January 2012 to 12 th August 2015 reveal that out of 6445 donations, 71 were found to be seroreactive (prevalence = 1.1 %). Majority (83.1 %) of the seroreactive donors were reactive for HBsAg; co-infection was not present. All 71 seroreactive donors were males. Though the number of donors was higher in 18-24 years (55%) than in 25-44 years age group (42 %), prevalence of seroreactivity was higher in the 25-44 years (42 out of 71 i.e., 59.2 %) than in 18-24 years age group (28 out of 71 i.e., 39.43%). All 71 of them had donated voluntarily. 44 out of 71 (70 %) were first time donors. Only 1 out of 71 had donated through walk-in; rest (98.6 %) had donated at camps conducted by our blood bank.
At our blood bank, male donors outnumber female donors. This may explain the gender distribution of seroreactive donors. Walk-in donation seems to be safer than camp donations. Though all donations are voluntary, peer pressure at camp sites cannot be ruled out. Pre-donation counselling highlighting the consequences of peer pressure will address the same. Other factors need exploration. First time donors and donors in 25 - 44 years age group have to be assessed with more caution for their fitness to donate. Donors may be unaware of their health status as they may be asymptomatic. Pre-donation information with repeated emphasis on the risk factors for acquiring transfusion- transmissible infections may encourage self-deferral and discourage donation by donors at risk.
Massive blood transfusion therapy: Transfusion patterns and outcome evaluation in a tertiary hospital of Kerala
Nithya Mohanan, Susheela J Innah
Background: Massive blood loss needs prompt and appropriate administration of blood and blood products. Currently there are no predefined protocols for judicious and rational use of blood products.
• To assess current massive blood transfusion practices and evaluate ratio of blood components used with their outcomes
• To establish a massive transfusion protocol for our hospital.
Retrospective audit of massive transfusion patients from January 2012 to May 2013 at our hospital was done. Chronic medical conditions were excluded. Patterns of transfusion among various departments, cases and age were studied. Ratio of blood products transfused and clinical outcome were compared by assessing mortality and duration of hospital stay.
Total 50 cases, 9 excluded as records were incomplete. Average transfusion units used were 7.8 PRBCs, 5.7 FFP, 2.8 RDP and 3.7 Cryoprecipitate per patient. However, the individual transfusion ratio was on an average 1 PRBC: 0.77 FFP: 0.52 PLATELET: 0.49 CRYOPRECIPITATE respectively. In general, use of various blood products followed the pattern of PRBC>FFP>cryoprecipitate being transfused than platelets among most departments. Obstetric cases had maximum blood product transfusions, whereas the most rampant use of PRBC and FFP on an average was among polytrauma cases. But no strict protocols or fixed ratio transfusion practices were noted. Significant decrease in use of platelets was found among polytrauma whereas cardiac cases utilized platelets more than twice the amount of other products. Average no. of days of hospital stay (Morbidity) among the study population was 17 days, maximum for polytraumacases (34 days) and minimum with general surgical cases (6.5 Days). Transfusion ratio of various blood products shows a significant negative correlation (P < 0.01) between amount of platelet transfused and duration of hospital stay. More PRBC and FFP transfusions were also observed to prolong hospital stay. Mortality in patients after massive transfusion was only 4.8%. A positive correlation between lower levels of FFP transfusion and mortality was seen.
Analysis of transfusion patterns showed no consistent ratio of administration of blood components. A positive association between Platelet transfusion and faster recovery needs prospective evaluation. Study was retrospective, unintended biases may have occurred. Survivor bias may have occurred as well, in which surviving patients had more chances to receive increased volumes of Plasma and PRBC thus potentially leading to higher calculated ratios.
Can we have a serological algorithm for detection of D variants in Indian context? A literature review and analysis
Somnath Mukherjee, Asish Jain
The Rh blood group is highly polymorphic with significant clinical importance. The anti-D has been implicated in the hemolytic disease of the newborn and transfusion reaction. Many variants of D antigen appear due to aberrant expression of D antigen caused by mutation in RHD and RHCE genes. These D variants pose a difficulty in identification and differentiation in the blood transfusion center.
Aims: Determination of proper D antigenic status, selection of appropriate blood product, prevent inadvertent alloimmunization and appropriate consideration of RHIG prophylaxis. In India, serological approach can be considered as the molecular analysis for D variants unavailable.
Discussion: A panel of twelve monoclonal antisera (ALBAclone, Alba Bioscience, UK) had been tested on RhD discrepant samples. One antisera of this panel derived from LHM 70/45 cell line did not react with any discrepant samples. However, three antisera with LHM 76/59, ESD-1 and LHM 76/55 cell lines showed positive reactions with most of the discrepant samples. Therefore, a serological strategy both for discordant samples could be proposed. If the discordant D variant be a recipient sample or of a pregnant mother, it is advisable to test the sample with anti-D antisera of LHM 70/45 cell line. If the discordant sample is assigned to be a donor sample or even of a neonate of RhD negative mother, an initial weak D IAT testing with blend (IgM + IgG) monoclonal anti-D anti sera is suggested. If initial weak D test becomes positive, the sample should be regarded as RhD positive. If initial weak D testing is negative then the sample should be initially screened by anti-C and anti-E antisera. This screening is very helpful as most of the studies have shown presence of 'C' and 'E' antigens in many partial D, weak D variants and DEL phenotypes. If the screening reaction with both the above antisera becomes negative, it is rare possibility that the particular discordant sample would be D variant or DEL. If the screening reaction becomes positive, then further testing with anti-D antisera derived from any one of the LHM 76/59, ESD-1 and LHM 76/55 cell line should be performed to detect any possibility of partial D or weak D variants and adsorption elution test should be performed in order to rule out the DEL phenotype.
Thus a serological algorithm can be developed for further characterization of D variants by application of advanced antisera in referral blood transfusion centers in our country.
Progress of blood transfusion services in district hospital Parbhani
Mohmad Javed Ather, RM Kanakdande, Girish Chaudhari
To increase blood transfusion services with quality care to increase blood donation camps hospital data and records.
Parbhani district comprising population of above 18 lakhs. Only one govt district hospital. The blood bank of this hospital caters need of around 600 beds of hospital. Blood bank also caters need of private sector and adjoining few talukas of two district. IEC and felitation of camp organiser and doners increased blood donation movement. Now became "peoples movement".
Blood bank increased blood units from 5000 to 11000 blood units voluntary blood donation camps icreased by 90% details will be presented.
How safe is the type and screen policy in an Indian setting: Experience from a tertiary care centre in South India
JK Anupama, P Amalraj, Joy J Mammen, SC Nair, D Daniel
Pre-transfusion testing in India has evolved over time and aims at providing safe blood to patients. Current practice is that the donor units are cross-matched with the recipient sample in phases from saline to the antiglobulin phase. However, they also have an antibody screen performed as a part of routine practice. Against this background, this study was done to see if a type and screen policy with an immediate spin cross-match option could be considered for antibody screen negative patients.
Data of patients for whom cross-match requests were received in the Department of Transfusion Medicine and Immunohematology, from January' 2015 to June' 2015 were collected. All patients had had antibody screening with a 3 - cell panel from DiaCell - Asia. All cross-matches were done using tube and column techniques in duplicate, by two different technologists. The results of antibody screening and compatibility testing were collated.
During this period, a total of 20692 requests were received and cross-matches were done as per the requests. Of these, 71 were found to have Coomb's incompatibility. Of the 86 positive antibody screens, 16 were found to be compatible in Coomb's cross-match. 1 was negative on the antibody screen but incompatible in Coomb's cross-match, which was characterised as a cold auto-antibody.
This study highlights the fact that antibody screening is efficient in the detection of clinically relevant antibodies. The only discrepancy resulted from a cold auto - antibody, which was detected in the immediate spin cross-match and whose clinical significance is uncertain. The patients who had a positive antibody screen and Coomb's compatible cross-matches, probably had antibodies to low incidence antigens or had been cross-matched against antigen negative red cells. The type and screen policy seems eminently feasible and sufficiently safe in our setting, which offers alongside innate advantages of better inventory management, greater cost effectiveness and more efficient use of time & personnel.
Liver transplant in a patient with R2R2 phenotype and multiple red cell antibodies (anti-C, anti-E and anti K) at Global Health City, Chennai
Deepti Sachan, S Aswin Kumar, Dinesh Jothimani, Ravi Dara, Aseem Tiwari, Mohamed Rela
End stage liver disease (ESLD) patients undergoing liver transplant surgery are often multiply alloimmunized and pose significant challenges to the transfusion services in terms of incompatibility, detection of new red cell alloantibodies, unpredictable blood requirements etc. This may often lead to significant delays and virtually impossible to find and provide compatible red cells.
We report a case of 64 years old female from Bahrain c/o HCV related ESLD referred for liver transplant surgery. On admission, her Hb- 7.5g/dl, PC -34,400/cmm and a request received for workup and blood reservation. She had history of multiple transfusions with last one year before. One unit of A+ SDP was issued.
During workup - Blood group A Rh (D) Positive, DAT- Negative, Cold Antibodies were negative. Indirect Antiglobulin test (IAT) (Biorad) showed P1 (3+), P2 (0), P3 (3+). Antibody identification (Biorad) confirmed presence of Anti-C and Anti-K. Rh & Kell phenotype was R2R2 (C-c+E+e-K-). 110 units were cross matched over three days and 10 C- neg and K neg compatible units were reserved for future transplant. 4 days later repeat sample, showed ABO discrepancy, additional anti-e Rh antibody was detected in both saline and AHG phase with negative autocontrol and all 10 reserved units 4+ incompatible. DSTR due to SDP transfusion was suspected. The patient was started on erythropoietin and iron therapy while the search for A/O group, C neg, e-neg, K-neg units were started in our inventory. 10 Family members showed incompatible. Request were sent for R2R2 and Kell negative units to reference centre, Mumbai and major centers of various cities in India. After more than 700 units phenotyped over a period of 6 weeks, 5 compatible, R2R2 phenotype and Kell Negative units (2 in-house and 3 units shipped from Medanta -Medicity, Gurgaon) could be arranged. Intraoperative management included blood preservation techniques, cell salvage, antifibrinolytic drug and monitoring using TEG. The EBL 350 ml with pre- and post-op Hb 10.4 gm% and 9.2 gm% respectively. She received intraop 2 SDP and 3 units FFP and post-op one unit of LDPRC and doing well at 6 months follow up.
This case highlights the importance of advance immunohematology lab for timely detection of alloimmunization and transfusion reaction, phenotyping etc, proper communication between the transfusion specialists and the clinical team for proper patient blood management as well as the need for central rare donor registry program to avoid delays in providing compatible blood in such inevitable cases.
Prevalence and characterisation of platelet alloantibodies in hematology patients refractory to platelet transfusions: Experience from a tertiary care centre in South India
Ancy Susan John, Mary Purna Chacko, Dolly Daniel, NA Fouzia, Alok Srivastava
Transfusion of platelets is an important therapeutic strategy in patients with bleeding disorders with low platelet counts. Normally there is an adequate increment in platelet count after transfusion. However some chronically transfused patients fail to achieve the appropriate platelet count increment following transfusion owing to antibodies to human leucocyte antigens (HLA) and/or human platelet antigens (HPA) which mediate rapid in vivo platelet destruction. The aim of our study was to determine the prevalence of anti-HLA antibodies and platelet specific antibodies and characterize them among chronically transfused hematology patients using PAK-2LE assay.
80 Patients with hematological disorders, and a prior history of multiple transfusions (minimum of 5 cellular transfusions) were included in the study, if they did not achieve an adequate corrected count increment (CCI) within 24 hours of the present platelet transfusion. Patients with non immunological causes of platelet refractoriness (sepsis, splenomegaly, bleeding, fever and auto immune thrombocytopenia) and on drugs producing anti platelet antibodies were excluded. The test was done on 4 ml of EDTA blood sample after obtaining informed Plasma was separated and stored at - 80 degree C and was tested using the PAK - 2LE kit which is a qualitative solid phase enzyme linked immunosorbent assay (ELISA) designed to detect IgG antibodies to HLA class I antigens and to epitopes on the platelet glycoproteins IIb/IIIa, Ib/IX and Ia/IIa.
The prevalence of platelet alloantibodies in our study was 60%. Of the 48 patients who were detected to have platelet antibodies, the combination of anti-HLA and HPA antibodies together constituted the majority of 54.2%. Anti- HLA antibodies alone contributed to 31.25% and antibodies to HPA alone contributed to 14.6% of the positive results. The overall prevalence of anti-HLA antibodies was 51.25% and of anti-HPA antibodies was 41.25%. The distribution of HPA antibodies was as follows- majority of antibodies were positive for GpIIb/IIIa (47.91%) followed by GpIa/IIa (29%) and the least for GpIb/IX (23%).
We conclude that the overall prevalence of HPA antibodies in our study was greater than that reported by other groups in India and other countries. This needs to be considered, particularly in the management of patients refractory to platelet transfusions, where HLA matched platelets is current best practice.
Role of therapeutic plasma exchange in reducing abo titers in patients undergoing abo incompatible renal transplant: A prospective study
RN Makroo, Sweta Nayak, Mohit Chowdhry, Aakanksha Bhatia, Gaurav Sagar, NL Rosamma, Uday Kumar Thakur
Our study presents an analysis of the trends of ABO blood group antibody titers and the TPE (Therapeutic Plasma Exchange) procedures required pre and post ABO incompatible renal transplant.
During June 2012 to August 2015, 29 patients underwent ABO incompatible renal transplant. Blood group of the patients and donors were determined using solid phase. The ABO antibody titers were done using the tube technique. The dilution of the plasma at which 1+ reaction was observed, was the recorded titer. The titers of anti-A and anti-B antibodies (baseline titers) were determined before initiation of any immunosuppressive therapy. Details of the donors' and patients' blood group, baseline titers, titers throughout the hospital stay and number of TPE procedures done were retrieved from departmental records. A titer of ≤8 was considered acceptable for the transplant. Antibody titers were repeated after each procedure. Plasma exchange was done using the Hemonetics MCS+ cell separator (Braintree, MA, USA) using kit REF 981E (Braintree, MA, USA). Each patient was subjected to atleast 1to 1.5 plasma volume of exchange in each session with 5% albumin and 2 units of AB group FFP (Fresh Frozen Plasma) as the replacement fluid. In the post-operative period, ABO antibody titers were assessed on daily basis for a period of 14 days. The TPE procedures post-transplant was decided on the basis of a rising antibody titer with or without graft dysfunction. The clinical and laboratory parameters were noted from the patients' files.
The average number of TPE procedures required per patient was 4-5 procedures in the pre transplant and 2-3 in the post-transplant period. An average titer reduction of 1.02 serial dilutions per procedure was noted for Anti-A and 1.09 serial dilutions per procedure for Anti-B. Number of procedures required to reach the target titer (≤8) was not significantly different for Anti-A and Anti-B. The outcome of the transplant did not differ significantly by reducing titers to a level less than 8. The difference in the Anti-A and Anti-B titers at 14th day post-transplant was found to be clinically significant (p = 0.023).
We did not find any additional benefit in reducing ABO titers to levels less than 8 pretransplant. With an average of 4-5 TPE procedures pretransplant and 2-3 TPE procedures post transplants, ABO incompatible renal transplantations can be successfully accomplished. The Anti-A titers rebound to high levels more frequently than Anti-B by the 14th post-transplant day.
NAT yield and its significance in multi-transfused thalassaemia patients: A study from Eastern India
Debapriya Basu, Abhijit Mandal, Eeshita Samanta, Archana Naik, Prasun Bhattacharya, Krishnendu Mukherjee, Chikam Maity, Rathindranath Biswas, Nowroz Afroza
Background: Blood Transfusion service has very important role in saving life of patients, but it carries some inherent risks. Transmission of infections (TTI) through blood transfusion is one of the major challenges. The multi-transfused patients like chronic hemolytic anaemia, leukemia are affected greatly due to this adverse outcome. Prevalence of hepatitis B and C is very high, both in blood donor and multi-transfused patients in the eastern India. The commonly used serological screening test for HBV, HCV and HIV used in majority of blood banks by enzyme immunoassay (EIA) has a long window period. Nucleic acid testing (NAT) is a more sensitive technique to detect viral DNA or RNA where serology is negative.
Aims: To minimise the higher risk of TTIs in transfusion dependent thalassaemia patients, NAT strategy of blood components transfusion was selectively adopted as a pilot study.
Materials and Methods: We have analysed a random 4460 blood donor units' pilot samples in 10 ml EDTA tubes from March 2011 to August 2014. The non reactive samples for anti HIV (HIV1 &2), anti HCV and HBsAg by conventional EIA were tested with Individual Donor NAT (Procleix Ultrio Assay, Novartis Diagnostics, USA). EIA negative sample which were found to be reactive by initial ID NAT were tested duplicate from the reactive bag itself. The samples which were reactive in duplicate tests were screened for further discriminatory assay from the bag.
Results: Out of 4460 samples which were non reactive with ELISA, 12 were found to be initially reactive with ID NAT. Of these 12 samples repeat testing were done on 9 samples, and on the remaining 3, repeat testing could not be performed due to technical difficulties. Six out of 9 repeat samples became repeat reactive. Final discriminatory testing was done on these 6 samples of which HBV was detected in three, HCV in two and HBV, HCV co infection in one of them.
Conclusion: Overall NAT yield found in our study was 0.13% (6/4460) which is significant. In this small study we can conclude that blood screening with only conventional ELISA technique may not be adequate to assure the safety of blood transfusion especially in multi transfused patients. NAT along-with conventional ELISA may increase safety in multi transfused patients having higher risks of TTI.
Autologous marrow derived stem cells transplantation in spinal cord injury patients
Ravindra Pratap Singh, Hemang Vasavada
Transplanted bone marrow (BM) cells have been found to improve neurologic disease in central nervous system (CNS) injury models by generating neural cells or myelin-producing cells. Our study was planned to assess therapeutic efficacy of autologous bone marrow derived stem cells (BMSC) transplantation along with granulocyte-colony stimulating factor (G-CSF) administration, in phase I/II clinical trial study conducted on 16 spinal cord injury patients (study group 8; control group 8) between September 2011 to December 2012.
Eight patients with acute and chronic complete spinal cord injury (SCI) with American spinal injury association (ASIA) impairment scale (AIS) and Frankel impairment scale grade a were included in this study. The BMSC were collected through posterior superior iliac spine by multiple aspiration with Jamshedi bone marrow aspiration needle (16 gauge) and average 150 ml (range from 100 ml to 175 ml) were harvested and collected in cpda1 anticoagulated blood bag with maintaining 1:7 anticoagulation to bone marrow ratio. The entire procedure was done in operating room under aseptic condition. The collected bone marrow stem cells were processed on Sepax, Biosafe, USA and final less than 20 ml BMSC collected in close system. Final processed BMSC was transplanted by injection into the surrounding area of the spinal cord injury site through open spinal surgery. In the control group, all patients (n = 8) were treated only with conventional decompression and fusion surgery without BMSC transplantation.
The patients underwent preoperative and follow-up neurological assessment using the American spinal injury association impairment scale (AIS), electrophysiological monitoring, and magnetic resonance imaging (MRI). The mean follow- up period was 6 months after transplantation. Furthermore, the BMC transplantation and G-CSF administration were not associated with any serious adverse clinical events increasing morbidities. On follow up visit at 1 month, movements and sensations were improved and after 6 months of transplant, the AIS and frankel impairment scale grading increased (A to B or C), in our study group whereas no significant improvement observed in control group. All study group patients were completed the protocols successfully.
In our study group, good neurological recovery observed at 1 month and 6 months of follow up with satisfactory sensory and motor power improvement in 7 patients along with psychological improvement as well. One patient does not responded, probably due to major spinal cords tracts damage which were beyond regeneration of transplanted marrow cells. The control group were not shown any improvement as compared to study group.
Serological characterization of autoantibodies in autoimmune hemolytic anemia and its clinical implications: A study from atertiary care center in South India
Rajeshwari Basavanna, Biju George, Visalakshi, Ambily Nataraj, Dolly Daniel
Autoimmune hemolytic anaemia (AIHA) has a wide range of clinical presentation from mild to fulminant life threatening anaemia. Immunoglobulin class, subclass, titre, ability to activate complement, thermal amplitude and strength of direct antiglobulin test (DAT) have been implicated as factors affecting severity. This study was undertaken to analyze factors which influence the severity of AIHA in Indian population.
In this crosssectional study, all patients with evidence of haemolysis and who were also positive for polyspecific DAT were included. DAT positive patient samples were further evaluated by monospecific DAT (column agglutination technique) to identify presence of IgG, IgM, IgA class and complement. If monospecific IgG was present, further subtyping was undertaken to identify the presence IgG1 and IgG3. Correlations were drawn between the severity of AIHA and Immunoglobulin class, strength of direct antiglobulintest (DAT), IgG subtype and the titre of the latter.
Among 94 patients included in the analysis, the median age was 35.2 (Range1-77 years), with a male: female ratio of 1:1.9. Primary AIHA was identified in 54.3% and secondary AIHA in 45.7%. Spread of autoantibodies identified included, 28.7% with solitary IgG followed by complement alone in 8.5% as opposed to 62.8% of patients who had a combination of autoantibodies. Severe haemolysis was greater in patients with primary AIHA (71.2%) as compared to patients with secondary AIHA (28.7%, p < 0.001). Severe haemolysis was also seen in 89.1%, of patients who had a combination of autoantibodies as compared to 10.9% patients, with solitary IgG (p < 0.001). IgG subtyping revealed the most common subtype to be IgG1 (58.1%) followed by combination of IgG1 & IgG3 (11.6%). The remaining 30.2% were negative for IgG1or IgG3. Presence of IgG1 and IgG3 in combination, or IgG1alone showed statistically significant association with severity of haemolysis (p = 0.04 and 0.012respectively). Correlating strength of DAT revealed that severe haemolysis occurred in 80.8% patients with DAT strength of 4+ (p =0.006). This association was consistent even in the IgG subgroups where IgG1 and IgG3 were not detected however there was an association with complement fixation in this group (p = 0.04).
Identifying patients with AIHA at risk of severe haemolysis is critical for prognostication, appropriate intervention and follow up planning. This association in our study of DAT strength, IgG1 and IgG3 positivity, and complement fixation on severity of haemolysis suggest that an algorithm of following up DAT positivity, in patients with AIHA, with a monospecific DAT and IgG subtype analysis will allow for identification of this critical subgroup of patients in whom more intense clinical intervention and close follow up might be indicated.
NAT yield in blood donor samples-Matter of real concern
Blood banking in present era has seen many developments but even today the safety of blood and blood components is of great concern worldwide. Enzyme linked immunosorbent assay (ELISA)/chemiluminiscene (CLIA) relies on detection of serological markers that may not appear until upto 3 months of infection leaving window period increasing risk of transmission of infection. Nucleic Acid Testing (NAT) decreases window period by early detection. Over the past few decades, NAT has become a routine part of blood donor infectious screening in developed countries and progressively in some developing countries. NAT yield refers to samples which are seronegative but positive on NAT when repeated in duplicate and then discriminatory. Serological yield is defined as sample repeatedly positive (may be false positive) on Chemi but negative by NAT. With the implementation of NAT in countries around the world, there is growing pressure on the transfusion services in India to adopt NAT testing. India has more than 2500 licensed Blood Centres including both the private and the Government blood centres. The Transfusion Services in India are fragmented, variably regulated and the quality standards are variably implemented. This study was undertaken to assess impact of implementation of NAT testing in resources limited country like India with a population of around 1.23 billion and a high prevalence rate of HIV (0.29%), HBV (2-8%) and HCV (≈ 2%) in general population based on parameters of NAT yield and serological yield. Aims of the study: 1. To calculate NAT yield on blood samples tested.
As a cost effective measure, based on Hub and spoke model >10 blood banks across Delhi/NCR are procured for testing at single place. Sufficient care is taken to maintain confidentiality and samples/donor information are coded. Study Period-5 years.
A total of 0.2 million (approx.) donor samples to date have been tested from various centres without any lapses. Discriminated NAT exclusive reactive infectious units have been 157 (1 per 1223 units), with 128 HBV, 8 HCV, 1 HIV-1 and 1 HBV-HCV coinfections.
In this modern era, one blood unit is bifurcated to three, so transmission of TTI infection in case of NAT yield becomes 3 times. NAT combines the advantages of direct detection of the viral genetic material with sensitivity several orders of magnitude higher than that of traditional methods. Also, with the number of Regular Repeat Voluntary Donors being limited in India, there is a higher percentage of reactive samples, for which NAT testing is useful.
Rh isoimmunization due to anti-C and anti-D causing recurrent hemolytic disease
Archana Naik, Prasun Bhattacharya, Krishnendu Mukherjee
Antibodies to antigens in Rh system are well known to cause hemolytic disease of fetus and newborn (HDFN). RhD antigen is most immunogenic. In developing countrits HDFN caused by anti-D is most common, however, significance of other blood group antibodie's couldnot be ignored.
A 25 yr female was referred from antinatal clinic for antibody screning. She was 4th gravida, on her 16 th week of gestation. She had a living child and had a history of still born and a midtrimester abortion due to hydrops fetalis revealed on ultrasonography (USG). She received RhIG after second and third abortion. She had no history of blood transfusion. Her blood sample (3 ml EDTA and 5 ml clotted) was collected. Her forward, reverse blood grouping and extended phenotype were done by conventional tube technique (CTT) by using commercialy available monoclonal antibodie's and in -house pooled reagent cell's. Indirect agglutination test (IAT) was done by in-house pooled O cells by column agglutination technique (CAT) and identification was done by commercially available reagent 11 panel cells by CAT. Antibody titeration was done by CTT (serial double dilution) in antihuman globulin phase.
Her blood group was B negative and her husband's blood group was B positive. Her IAT with serum by CAT was strongly positive (3+). On antibody identification with 11 cell pannel (Ortho) the antibodie's were identified as combination of anti-D and anti- C. Extended Rh phenotype of patient was ccdee and her husband's phenotype was CCDee. The titer of anti-D and anti-C were 1024 and 8 respectively in antihuman globulin phase. The antibody specificity was reconfirmed by adsorption study done using in- house D+C- cells for adsorption of anti-D and the adsorbed serum gave the pattern of anti-C on antibody identification. Similarly anti-D was identified in the adsorbed serum after adsorpion with D-C+ cells. In our case medical termination of pregnancy was done as USG revealed hydrops fetalis.
This suggests that the patient was isoimmunized to D and C antigen due to R1 phenotype of her husband. Whenever anti-D and anti-C combination present it should be suspected as anti-G as it has specificity of both anti-D and anti-C. It was generally accepted that if titer of anti-anti-C was more than anti-D than it is anti-G. But in this case titer of anti-D was higher than anti-C, howeve presence of anti-G along with anti-D and anti-C could not be ruled out.
Acute adverse transfusion reactions encountered in a tertiary care centre of North-East India: A retrospective study
Lutika Nepram Lyngdoh, Debdutta Bhattacharyya
Transfusion of blood and blood products though life saving may entail adverse reactions which may be harmful to the recipient. It is thus important to know and understand the incidence of transfusion related adverse reactions to evaluate and take appropriate steps to mitigate future occurrences.
This study is a retrospective review of the acute transfusion reactions which were reported to the Department of Blood Bank, NEIGRIHMS during the five year period from 2010 to 2014. All the reported adverse transfusion reactions were evaluated clinically by the Blood Bank Physician. The standard transfusion reaction workup protocol of the department was followed on all the reported cases and results were recorded. This included, clerical checking, physical checking of the blood bag and its contents, pre & post transfusion checking of donor & patient blood groups, antibody screening and cross matching. Post transfusions checking of patient sample for DAT, bilirubin & urine for free hemoglobin were also performed. Culture of the donor blood in question was also performed.
Out of a total of 25660 transfusions of blood and blood products during the five year period of study, 67 (0.26%) acute transfusion reactions were reported. There were 38 male (56.7%) & 29 female (43.3%) patients who developed acute transfusion reactions. Mean age was 36 + 15 yrs (range of 1 to 80 yrs). The acute transfusion reactions observed included IHTR (n = 1, 1.49%), FNHTR (n = 30, 44.77%), Allergic (n = 19, 28.35%), non specific (n = 15, 22.38%) which included headache, etc. & bacterial contamination (n-2, 2.98%). No known cases of TACO, TRALI, anaphylactic shock etc were reported. Out of all the transfusions, whole blood transfusions constituted 1051 (4.09%) of which 7 (0.66%) adverse events were reported. There were 12275 (47.83%) Packed Red Cells transfusions of which 47 (0.38%) adverse events were associated with it, 7447 (29.02 %) FFP transfusions of which 10 (0.13%) eventful outcomes were reported, 4291 (16.72 %) platelet transfusions of which 1 (0.02%) case was eventful & 596 (2.32 %) cryoprecipitate transfusions of which 2 (0.33%) adverse reactions were reported.
Out of the 67 adverse events, the lone case of Immune Hemolytic Transfusion Reaction was seen in a case of PRBC transfusion. Out of the 30 cases of Febrile Non hemolytic Transfusion Reactions, 3 happened with whole blood transfusion followed by FFP (4 cases) and PRBC (23 cases). Out of the 19 cases of allergic reactions, 1 case was reported following transfusion of platelet concentrate, 2 cases with cryoprecipitate transfusion, 4 cases with whole blood and 9 cases with PRBC transfusion. Bacterial contamination was noted in 2 cases of PRBC transfusion. There were 12 non specific cases associated with PRBC transfusion and 3 with FFP transfusion.
1 case of Immediate Hemolytic Transfusion Reaction occurred due to transfusion of mismatch blood due to the presence of naturally occurring anti A1 antibody in the serum of an "A2B" group patient which was missed during cross matching.
In our set up, out of a total of 25660 transfusions, adverse events were seen in 0.26 % of the cases. In terms of percentage of occurrence of adverse reactions, whole blood showed a highest percentage (0.66%) followed by PRBC (0.38%), Cryo (0.33%), FFP (0.13%) & Plt concentrate (0.02%). FNHTR & allergic reactions were the most common adverse events seen which constituted 44.77% & 28.35% respectively. As adverse event like TACO, TRALI, TAGvHD, DHTR's have not been reported so far many of such events may have been missed or not recognized at the bed end and there is urgent need for a vigorous hemovigilance programme in co-ordination with clinicians. This may be enhanced with CME's on hemovigilance.
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2. Kumar P, Thapliyal R, Coshic P, Chatterjee K. Retrospective evaluation of adverse transfusion reactions following blood product transfusion from a tertiary care hospital: A preliminary step towards hemovigilance. Asian J Transfus Sci 2013;7:109-15.
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Therapeutic plasma exchange in patients with hemolytic uremic syndrome & Guillain-Barrι syndrome
Smita Ravindra Joshi, Purnima Rao, Rohini Bunge
This study was carried out to determine the effectiveness of TPE in cases of HUS & GBS. HUS is part of microangiopathic hemolytic anemia that encompasses TTP. TTP -HUS occurs more commonly in women and among women is commonly associated with pregnancy. GBS is a rare disorder in which a person's own immune system damages their nerve cells, causing muscle weakness and sometimes paralysis. Anyone can develop GBS; however, it is more common among older adults. The incidence of GBS increases with age, and people older than 50 years are at greatest risk for developing GBS. Corticosteroids were not found to be effective in such cases hence Immunomodulatory treatment has been used to hasten recovery, plasma exchange have proved equally effective.
Almost 20 cases were taken up for the study in last 2 years TPE was done with the help of Cobe-Spectra machine via femoral axis with citrate as an anticoagulant. Almost 5 lts of volume was replaced each time with fresh frozen plasma (FFP). All vital parameters were monitored during the procedure to note the adverse effect if any. IV calcium Gluconate was given when indicated. Parameters like creatinine, LDH & Platelet counts were monitored. The TPE was repeated based on values of the above mentioned parameters & clinical conditions. Mean interval between two procedures was 24 hrs. Amongst 20 cases one patient represented with TTP & Hyperthyroidism was a case of importance has been presented here.
All the above mentioned cases went home without any complications after minimum 5 cycles of TPE. But a case mentioned above we would like to present. She had Hyperthyroidism since 3 years & received Radio Active Iodine but didn't had any difference hence she was started on Oral Neomercazole. This was stopped as she had developed Neurological signs & symptoms, so she was investigated for ITP & started with steroids at one of the Hospitals in the city. Still she presented with giddiness progressive fatigue and dyspnoea on exertion and associated with petechial & purpuric rashes all over the body which persisted for 7 days & history of occasional convulsions with CT brain normal. Here she was referred to our hospital for further investigation & treatment. She had undergone plasma exchange cycle twice with miraculous recovery discharged from the hospital.
All above patients were discharged without any complication after TPE This technology proved to be a boon for better removal of Antibodies for speedy recovery of patients. Transfusion Medicine Consultants should motivate clinicians for this TPE technology in such mentioned cases than the traditional dialysis technique.
Point of care hemoglobin testing in plateletpheresis donors: Non-invasive versus invasive methods
Amit Ajay Pawar
Plateletpheresis is a procedure by which platelets are harvested from healthy volunteer donor with the help of cell separator machines (Apheresis). However, exhaustive initial screening tests required by regulatory authorities and prolonged harvesting procedure associated with few adverse effects warrant a considerable effort to motivate healthy donors for plateletpheresis. After initial medical examination, hemoglobin (Hb) of the donor is estimated by presently available invasive methods. Venous samples of only those donors whose Hb is more than 12.5 gm/dl are then screened for complete blood count and transfusion transmissible infections. There is a pressing need to substitute this initial invasive Hb test with a non invasive one in order to reduce donor discomfort and avoid further pricking the donor. With this background, we went ahead with the aim of comparing a non-invasive Hb estimation method NBM200 with the invasive methods - Hemocue and Sysmex KX-21.
500 voluntary donors who reported to the apheresis centre for platelet donation, after fulfilling laid down clinical criteria for platelet donation were included in the study. The initial Hb screening was carried out by the three methods. Hb readings obtained by the NBM200 and Hemocue were compared with the reference Hb reading obtained from the fully automated 3 part differential hematology analyser Sysmex KX-21.
Mean and standard deviation (SD) values of the Hemocue, NBM200 and Sysmex KX21 were 15.08, 14.56, 14.83 respectively and 1.148, 1.163 and 1.364 respectively. Coefficients of correlation were found to be statistically significant at <0.0001 level of confidence. The results of ANOVA on the three methods of finding Hb showed significant difference in means of three methods. Graphical representations through Bland-Altman Plots and mountain Plots also support the results. These statistical analyses reinforce the fact that Sysmex KX-21 is the most accurate reference method for Hb estimation, closely followed by Hemocue.
Pre donation hemoglobin estimation is a mandatory requirement, ensuring safety of the donors undergoing voluntary platelet donations. Rigorous pre donation screening tests before the donation can certainly demotivate the donors, thereby decreasing the platelet donor pool considerably. Introducing NBM200 for the pre donation Hb estimation could considerably reduce donor discomfort. Statistically however, significant differences were found in the values obtained by NBM200 in comparison with Hemocue and Sysmex KX-21. Sysmex KX-21 still remains the most accurate reference method for Hb estimation, while Hemocue still remains a more superior point of care method as compared to NBM200 for Hb estimation.
Acute hemolytic transfusion reaction due to negligence of appropriate bed side transfusion practices: A case report
Jaisy Mathai, Debasish Gupta, PV Sulochana, Sathyabhama, Revathy Nair
Background: Acute hemolytic transfusion reaction (AHTR) occurs due to rapid destruction of the donor red cells by host antibodies (IgG, IgM). It is usually related to ABO blood group incompatibility- the most severe of which involves group A red cells being given to a patient with group O blood. The most common cause of AHTR is clerical error where the wrong unit of blood is transfused to a patient due to negligence of appropriate transfusion practices.
Aim: A case of AHTR is reported which occured due to wrong practice of blood sample collection and non-observance of appropriate bed side transfusion practices.
A 62 year old female patient was admitted in the cardiology unit with angina and was planned for coronary angioplasty. Blood sample sent to blood centre on the day of admission was grouped as AB Rh +ve. 3 days later, red cell transfusion was planned for correction of anaemia for which another sample was sent to blood centre for crossmatch. One unit of AB Rh +ve blood was crossmatched and issued.
Transfusion of fully compatible group specific blood unit was initiated to the patient. With 3 ml of transfusion, patient exhibited chills, hypotension and shortness of breath for which transfusion was stopped and prophylactic anti-histamine and diuretic was given. Shortness of breath was attributed to the underlying pathology. Transfusion was restarted after 1 hour which resulted in severe reactions including red coloured urine. Transfusion was stopped immediately and conservative management started. Investigation revealed that pre-transfusion sample was AB Rh +ve while post transfusion sample was O Rh+ve. On inquiry, it was found that 2 patients got admitted on the same day in the cardiology unit- a male and a female (the proposita). 2 samples were collected from the male patient and were mislabelled with details of the female patient. These were the samples sent to blood bank on both occasions. Hence, the blood group discrepancy did not come to the notice of blood bank. Patient recovered with timely intervention. All hematological & coagulation parameters were monitored till discharge.
Improving bed side transfusion practice is very important to eliminate clerical and technical errors in preventing any type of transfusion mishaps. Top priority should be enforced for strict implementation of standard operating procedures in collection, labeling, transportation and receiving of blood samples in wards, casualty and operating theatres. Regular bedside training should be carried out for all staff working in these sections.
An interesting case of G6PD deficiency with severe hemolysis managed successfully with plasmapheresis
Neelesh Jain, Shilpa Bhartia, Mahesh Kumar Goenka
Glucose-6-phosphate dehydrogenase (G6PD) is a house keeping enzyme critical in the redox metabolism of all aerobic cells. G6PD deficiency is the most common human enzyme defect. Though majority remains clinically asymptomatic the risk of developing hemolytic anemia still remains. The three known trigger factors being (i) fava beans (ii) infections (iii) drugs like antimalarial, sulphonamides/sulphones, antibacterial/antibiotics/antipyretic/analgesics etc.
Case Details: Here we describe a 32 year old male patient with G6PD deficiency and viral hepatitis-E associated with severe hemolysis, acute liver and renal failure. The patient presented with fever with chills, altered sensorium, yellowish discoloration of sclera, skin & urine. On investigation he was found to have: Hemoglobin of 6.6 mg/dl, total (T) serum bilirubin was 76 mg/dl (Direct-46 mg/dl), SGOT 2240 U/L, SGPT 3360 U/L, Retic count 20%, LDH 5609 U/L, G6PD level was 3.0, Urea 98 mg/dl, Creatinine 5.2 mg/dl, PT 37sec INR 3.17. He was positive for Hepatitis-E Virus serology (IgM) also. Patient was not responding to any of the conventional medical therapy and the bilirubin kept on increasing. Considering the diagnosis of Acute fulminant hepatic failure with hepatic encephalopathy, the liver transplant was advised. As the patient was deteriorating and developed severe hemolysis, we thought of giving the trial of plasmapheresis to offload the excess bilirubin. Four cycles of plasma-exchanges were performed with the aim to remove bilirubin and minimize the risk of further organ damage. After 4 cycles of plasmapheresis, the serum bilirubin level decreased to 22 mg/dl. Consequently no trace of hemolysis was found and patient stabilized gradually without having any surgical intervention and no liver transplant was needed. His kidney's were taken care of separately.
After 4 cycles of plasmapheresis, the serum bilirubin level decreased to 22 mg/dl. Consequently no trace of hemolysis was found and patient stabilized gradually without having any surgical intervention and no liver transplant was needed. His kidney's were taken care of separately.
Conclusion: Although the hyperbilirubinemia is not a direct indication for plasma exchange therapy, but in such cases it is proved to be an effective tool in the management of patient, and we should never hesitate to advise plasmapheresis in these cases.
An analysis of donor specific antibody detection methods: Comparision of luminex donor specific antibody cross match to single antigen bead assay
Ankit Mathur, Latha Jagannathan
Patel and Terasaki first reported that the presence of recipient antibodies to antigens expressed on donor white cells was a major risk factor for immediate graft loss. The Luminex anti-HLA antibody detection assay is reportedly more sensitive and specific than either the CDC or flow cytometric crossmatches. In fact, some consider the Luminex antibody detection technique to be the new gold standard for identifying anti-HLA antibodies. In India there is no standard testing protocol followed by all transplant centers. Each center has its own testing strategy. At Bangalore, we started Luminex based Donor specific antibody tests by the end of 2009. In this retrospective study, we compared Luminex virtual crossmatch predictions with CDC XM & Luminex DSA crossmatch results. Importance of technological advances in laboratory-based testing in assessing risk of antibody-mediated rejection in renal transplantation is highlighted. Study is planned to compare Luminex Donor specific antibody cross match to Single Antigen bead Assay.
From June to December 2014 total 184 samples received for pre-transplant testing which consist of complement dependent cytotoxicity cross match (CDC XM) & Luminex donor specific antibody cross match (Luminex XM-DSA) using donor lysate along with HLA typing for ABDR. Retrospectively the samples which were CDC XM negative & Luminex XM DSA positive selected for Luminex Single Antigen Bead Assay for specificity identification. Two samples which were CDC & DSA XM negative were also testes for Single Antigen assay.
Out of 184 cases, total 9 samples found CDC XM as well as Luminex XM positive and 24 samples CDC XM negative & Luminex XM DSA positive (13 positive for class I, 9 for class II and 2 for both). These preserved sera used for Luminex Single antigen bead assay for antibody specificity identification. Out of 24 samples we found anti HLA Donor Specific Antibody in 23 cases. Only in one sample no anti HLA antibody detected though the Luminex XM DSA was positive for Class II.
On comparing Luminex XM DSA tests results with the gold standard method of antibody detection Luminex Single antigen, results found concordant. The sensitivity of Luminex DSA XM test was found 100% to detect anti- HLA donor specific antibody.
Detection of anti-HLA antibodies prior to kidney transplantation is an evolving science. Our study showed that patients with a negative AHG-CDC crossmatch can be further stratified into higher risk subgroups by testing for DSA XM & Single Antigen Test and would help in improving graft survival.
Seroprevalence and trends of transfusion transmissible infections among blood donors at a tertiary care referral teaching hospital in Southern India
Suresh Bandi, KV Sreedhar Babu
Blood transfusion is a life-saving measure in emergencies and is important for the medical treatment of every patient. Among all adverse effects of transfusion, transfusion transmitted infections (TTI) are very important. Accurate estimations on risk of TTI are needed, in order to monitor the safety of the blood supply. The objective of the present study is to analyze the seroreactivity for TTI of apparently healthy blood donors.
The study was conducted on 41,942 blood donors. All blood donors were screened for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) by using the appropriate enzyme-linked immunosorbent assay and reactive donors were retested using a standard immunochromatographic technique. Malarial antigen testing was carried by rapid diagnostic device, which was based on immunochromatographic technique. The rapid plasma reagin (RPR) test was used for estimation of syphilis infection.
A total of 41,942 blood donors were screened during the study period, of which 40,718 (97.1%) were males and 1,224 (2.9%) were females. Among all donors 25,993 (62%) were voluntary and 15,949 (38%) were replacement donors A gradual increasing trend in voluntary donor population from 19.5% in 2009 to 77.4% in 2014 was observed in the present study. The abrupt rise after 2009 was due to broadened definition of voluntary blood donors by national AIDS control organization (NACO). The overall seroprevalence of TTI were 3.5% among these HIV, HBV and HCV were 0.7%, 2.3% and 0.4% respectively; for malaria and syphilis, the seroprevalence was estimated to be 0.02% and 0.05% respectively. In the present study, decreasing trend for all the markers was observed during study period and it was declined from 4.5% to 2.5% from year 2009-2014. But it was not statistically significant (p = 0.224).
The risk of TTI remains despite of serological testing because of donors' window period. Steps should be under taken to prevent these transmissions by careful selection of potential blood donors through a health history questionnaire and create opportunities for self-deferral.
Alliance of blood group along with coronary artery disease in patients with coronary artery bypass graft surgery
Ashadul Islam, Sonia Shormin Miah
Blood played a vital premise in different population. The frequency of blood group in Bangladesh is parallel with that form of India, Pakistan and other South Asian countries. This study has conducted to determine the frequency of blood group in patients with coronary artery disease evaluated in a tertiary level hospital in Bangladesh. This is designed to investigate the distribution of ABO blood group and its association with the risk of various diseases. It is focused to determine the most regular blood groups for the high incidence of coronary arterial disease in the blood group carriers without any association with other co morbidity like smoking, obesity, diabetes mellitus, high triglyceride etc. To establish a possible correlation with ABO blood group among the coronary artery disease (CAD) in well documented patients and in patients awaiting for coronary artery bypass graft (CABG) surgery.
A cross sectional study was made in a tertiary level hospital (National Institute of Cardiovascular Disease) from March'14 to September'14. Total 52 patients were preferred to establish the relationship of ABO blood groups with coronary artery disease.
This study is consisted with 52 patients. Among them 38 (78.08%) were male and 14 (26.92%) were female. Mean age 47.21 8.00 and 46.74 11.98 years respectively. Furthermore, blood group O was (34.62%), group B was (26.92%) and group A was (25.00%). This result also demonstrates that the prevalence of coronary artery disease in blood group O is higher than all other blood groups and it is male predominant.
Thus in conclusion reveals that the O phenotype have a positive association which substantially increased a risk for coronary arterial disease. Though the entire disease occurs due to thrombotic occlusion at the site of a ruptured or erosive atherosclerotic plug which is the main cause of death in adults. This learning may also alarm the patients who are of group O. At present, the mechanisms underlying this observation are unknown. Therefore, more work will be needed. Moreover, the prevalence of blood group O shows a well documented correlation with advancing of the entire disease process. Though group B is higher in Bangladeshi population but the risks reveals more in group O patients. This also advocated that coronary artery disease risks are allied with group O phenotype that seems to be a independent of conventional cardiovascular risk factors therefore assumed in this observation and can be extrapolated in Bangladeshi population.
Study and management of anemia in blood donors rejected due to low hemoglobin
Abhay Ghanshyam Jhaveri, Hemanti Nirav Buch, Mayuri Rameshchandra Patel, Tanvi Govindbhai Patel
The requirement for safe blood is increasing with time and so is the need of voluntary, healthy donors. Among the donor deferral reasons, anemia is the commonest cause. We tried:
· To classify anemia in blood donors
· To give treatment for nutritional anemia
· To counsel the donors having hemoglobinopathies.
Demographic details of donors were obtained. Relevant medical questionnaire was asked and physical examination was done.
Following investigations were carried out on all the samples:
· Peripheral smears examination
On the basis of results and observations of above-mentioned investigations, following investigations were done:
· Serum iron and TIBC
· Vitamin B12.
Donors with IDA were given oral 66 mg elemental iron and 1.5 mg folic acid daily. They were followed up monthly. CBC was repeated on each visit. The treatment was continued for three months in males and six months for females after hemoglobin level reached maximum level. Donors who had hemoglobinopathy were counseled to prevent vertical transmission of the same. Donors having vitamin B12 deficiency were advised oral or inject-able vitamin B12.
Total 562 donors were rejected due to low Hb on the basis of estimation by Copper sulphate method. Some investigations were not possible due to defect in sample quality and/or quantity in 4 samples. Out of these donors, 68 donors had Hb ≥12.5g/dl, so they were excluded from further study. Nutritional anemias were commonest (79%). Amongst nutritional anemia, iron deficiency anemia was most common, present in 63.88% followed by dimorphic and megaloblastic anemia present in 7.55%. Highest number of donors had Hb ≥ 10.1 g/dl. Young donors (age group of 18-30 years) had highest rejection (49.35%). 51.84% were females while males were 48.16%. 58.37% donors were vegetarian while 31.63% were non-vegetarians. After oral iron supplement (in iron deficiency anemia) the mean hemoglobin increased from 10.98 g/dl on the initial visit to 13.99 g/dl on fifth monthly visit. 40% of these donors returned to regular donor pool after successful treatment.
Nutritional anemias are commonest as in general population. They are more common in young group, females and in vegetarians. By studying the cases of anemia, we can provide treatment in case of nutritional anemias to improve their health status and bring them back in donor pool. We can prevent vertical transmission of hemoglobinopathies like β thalassemia and Sickle cell disease.
ABO blood groups and its correlation with inherited thrombophilia in patients with venous thromboembolism
Ujjwal Dimri, T Chatterjee, RS Mallhi
Venous Thromboembolism (VTE) is a known situation of considerable mortality and morbidity. In India VTE occurs in 14.9% to as high as 54% of hospitalized patients, and has an estimated incidence of 17.6 VTE episodes per 10000 admissions. The development of VTE is due to convergence of multiple acquired and genetic risk factors. In this study we have comprehensively analyzed the effect of ABO blood groups and inherited thrombophilia factors (namely Protein C (PC), Protein S (PS), Antithrombin III (AT III), Activated Protein C Resistance (APCR) and Homocysteine (Hsy)) on unprovoked VTE patients, in comparison with normal healthy population.
In this case control study, 150 consenting consecutive patients in age group 18 - 60 years, with confirmed first episode of VTE without identifiable acquired risk factors and not on oral anticoagulant, formed the cases. 150 consenting age and sex matched healthy volunteer blood donors formed the control population. The controls and patient blood samples were ABO phenotyped using DiaMed ID gel card method and their AT III, PC, PS, Hsy and APCR levels were done using standard kits on STA Compact Coagulation autoanalyzer.
Non O blood group was significantly more frequent among cases than controls (77.3% v/s 62.7%, respectively; p < 0.05). Non O group cases had higher odds of VTE (OR = 2.03, CI: 1.22-3.37, p < 0.05) than O group controls. The highest odds for VTE were conferred by AB (OR = 3.95, 95% CI: 1.69-9.27, p < 0.05) and B blood group (OR = 1.85, 95% CI: 1.04-3.28, p < 0.05). Among cases, 40% (n = 60) were positive for at least one marker of thrombophilia in comparison to 16% (n = 24) of controls, and had significantly higher odds (OR = 3.5, 95% CI: 2.03-6.04; p < 0.05) of VTE. Positivity for more than one thrombophilia markers had even higher odds (OR = 5.25, 95% CI: 1.69-16.34; p < 0.05) of VTE. Deficiency of PS (n = 25, 16.7%) was the most common thrombophilia marker amongst cases. highest odds of VTE among cases were conferred by elevated H levels (OR = 4.35, 95% CI: 1.42-13.36; p < 0.05). Combination of non O group with positivity for thrombophilia markers among cases had much higher odds (OR = 5.67, 95% CI: 2.76-11.65; p < 0.05) of VTE in comparison to O group controls without positivity for thrombophilia markers. Highest odds of VTE were associated with non O group in cases with Hsy (OR = 10.8, 95% CI: 2.27-51.5; p = 0.001), followed by APCR (OR = 6.39, 95% CI: 1.65-24.65; p = 0.007), PC (OR = 4.91, 95% CI: 1.87-12.89; p = 0.001) & PS (OR = 4.39, 95% CI: 1.81-10.65; p = 0.001).
The study results show that individually both Non O blood group and positivity for factors of inherited thrombophilia impart higher odds of VTE. These odds are further increased when both are combined. This awareness could assist physicians in identifying those individuals which are at a higher risk of VTE and tailor-made the thromboprophylaxis accordingly.
Platelet concentrate without swirling phenomena in a blood center inventory
Naveen Agnihotri, Ajju Agnihotri, Lokesh Pal
Platelets stored in blood bank undergo progressive transformation in their morphology from thin discs to spheres leading to a decreased in-vivo survival capacity and function. Swirling phenomenon is a non-invasive and inexpensive way of checking the morphological quality of the stored platelets. All blood units should be inspected for swirling before they are released for patient transfusion however data on discard due to poor or no swirling of platelet units is conspicuous by its absence. We thus planned to (a) prospectively (over 22 months) look for platelet units in our inventory which did not demonstrate a swirling phenomenon (b) study the pattern of PC issue to our hospital inpatients to understand the possible impact of poor quality PC unit release.
(a) Only 450 mL whole blood donations were used for the platelet preparation. Two observers - a senior technician and a blood bank physician, independently noted the swirling phenomenon of the platelet units from day 1 to day 5 of the shelf life. Swirling was graded as 0, 1 and 2, with 0 as no swirling and 2 as good swirling. Any swirling not categorizing either as 0 or 2 was graded as 1. Day of shelf life and red cell contamination (if any) was noted; platelet count, pH, and bacterial culture were done on all the platelet units with grade 0 swirling. These were compared with appropriate controls (b) Number of units issued per patient per issue episode was studied for a 12 month period during the study.
(a) Out of 2614 platelets prepared, 102 (3.9%) platelets were found to have grade 0 swirling. Loss of swirling was more evident as units neared their shelf life expiry - 20.6% in first two days, 44.3% in next two days and 35% on the last day of storage. Two-third of these units failed to meet minimum quality criteria on platelet counts (p < 0.0001 as compared to controls). (b) Patients less than 12 years of age were issued 1.5 platelet units per issue episode as compared to 3.4 or more units in more aged patients.
Nearly 4% of the platelet inventory is unfit for transfusion. Lack of data in the available literature and our study findings suggest that swirling phenomenon should be checked in the stored platelet units rather than at the time of issue. Pediatric patients who receive 1-2 units per issue may be affected the most if poor swirling is missed and unit is issued.
Report on errors in pretransfusion testing from a tertiary care centre: A step towards transfusion safety
Meena Sidhu, Renu Bala, Naveen Akhter
Errors in the process of pretransfusion testing for blood transfusion can occur at any stage from collection of sample to the administration of blood component. Errors made at any step in these processes may assign wrong blood to the patient which can have serious consequences to the recipient. Present study was taken to analyze the errors that threaten the patients' transfusion safety and actual harm/serious adverse events that occurred to the patients due to these errors.
The prospective study was carried out in the Department Of Transfusion Medicine, Shri Maharaja Gulab Singh Hospital, Government Medical College Jammu from January 2014 to December 2014 for a period of one year. Errors were defined as any deviation from established policies and standard operating procedures. Near miss event is defined as those errors which did not reach the patient. Location and time of occurrence of events/errors were also noted. During the one year study period, staff was explained that error collection will be nonpunitive and the main aim is to determine the weaknesses in the whole chain of pretransfusion testing and strengthening the transfusion safety.
A total of 32,672 requisitions for transfusion of blood and blood components were received for typing and cross matching. Of these 26,683 products were issued to various clinical departments. A total of 2229 errors were detected over a period of one year with the median of 182 per month and mean 185.3 of per month i.e 6/day. Near miss events constituted 53% of the errors and actual harmful events due to errors occurred in 0.26% patients. Sample labeling errors were 2.4%, inappropriate request for blood components 2% and information on requisition form not matching with that on sample 1.5% of all the requisitions received, were the most frequent errors in clinical services. In transfusion services the most common event was accepting sample in error with the frequency of 0.5% of all requisitions. Frequency of Actual harmful events in present study was 4.4 per 10.000 transfusions. ABO incompatible hemolytic reactions were most frequent harmful event with the frequency of 2.2/10,000 transfusions.
Present data suggests errors are much more frequent than actual events. Thus, implementing error reporting in transfusion services will help in determining the problematic areas and making effective policies to deal with them, thus, improving the transfusion safety. Sample labeling, inappropriate request and sample received in error were the most frequent high risk errors.
Effect of storage and leucoreduction on Potassium in whole blood and packed red cell units
Sirat Kaur, Amarjit Kaur
The development of blood storage systems has allowed donation and transfusion to be separated in time and space. Preservation and long term storage of RBCs is needed to ensure a readily available, safe blood supply for transfusion medicine and has greatly revolutionised the practice of surgery and medicine. During storage, RBCs undergo numerous pathological changes, collectively referred to as RBC "storage lesions" which affect the quality, function and in-vivo survival of transfused RBCs.
Aim: To evaluate in vitro changes in supernatant plasma Potassium levels in four types of stored red cell units for 28 days.
The types and number stored blood bags which were studied are as follows:
• Single CPDA bags - 17
• Triple CPD-SAGM bags - 44
• Quadruple CPD-SAGM bags- 15
• Integral CPD-SAGM bags with integral Leukoreduction filter- 14.
These blood units were tested for supernatant plasma potassium starting from day 0 (day of collection), day 1 (following processing to pRC units, except for single bags), days 7, 14, 21 and 28.
There was an increase in mean plasma potassium levels in all four groups for 28 days and it was found to be significant (p < 0.001).
For CPDA single bags, the highest mean potassium was found on day 28 and the rise was maximum between day 21 to 28 (p < 0.001).
For Triple CPD-SAGM bags, the highest mean potassium was found on day 21, followed by day 28. However the difference between the two is not statistically significant and could be due to sampling error (p < 0.05). For Quadruple CPD-SAGM bags, the highest mean potassium was found on day 28 and the rise was maximum between day 7 to 14.
For Integral Bags, highest mean potassium was found on day 28 and the rise was maximum between day 1 to 7 of storage. The change in potassium concentration following processing from day 0 to 1 was not significant. Significant mean difference (P < 0.001) was found between potassium levels of leucoreduced Integral bags and Triple Bags from days 1 to 21 with mean for Triple Bags being greater than Integral. No significant difference was found on day 28.
Conclusion: Significant rise is found in potassium with storage of blood and packed red cell units. Transfusing a high potassium load assumes importance in cases of sick neonates, renal failure and when hyperkalemia already exists. Prestorage lecoreduction results in relatively lesser increase in potassium and improves quality of stored pRC units. Storage time adversely affects potassium levels of all the red cell units.
Clinically significant IgM anti-Cw: A rare case report
Nishant Saini, Tanvi Sood, Ravneet Kaur Bedi, Kshitija Mittal, Rakesh Kumar, Paramjit Kaur, Gagandeep Kaur
Anti-C Willis antibody (anti-Cw) was first described in 1946 and is often naturally occurring. Most of the cases reported in the literature describe anti-Cw of IgG type which can lead to mild to moderate haemolytic disease of foetus and newborn and mild to severe immediate or delayed haemolytic transfusion reactions. We report a case of anti-Cw of IgM type with broad thermal amplitude which can be clinically significant in a transfusion recipient.
A 23 year old unbooked, primigravida, Rh 'D' negative female presented in labour in the Obstetrics and Gynaecology department of our hospital. Her blood sample was sent to our department for indirect antiglobulin test (IAT).
Patient blood group was B Rh D negative and her husband's blood group was B Rh D positive. IAT was positive (strength +3) by gel technique. using Further, anti-Cw antibody was identified on antibody screen and identification. Anti-Cw showed wide thermal amplitude by tube technique (room temperature +1, 4C +2 and 37C+1). Antibody was IgM type as antibody screen after DTT treatment using proper controls was negative. Both wife and husband were negative for Cw antigen. There was no history of blood transfusion in the patient. For other Rh antigens, the patient's red cells typed as C+ c- E+ e- and her husband'sas C+ c+ E+ e+. Antibody titresby tube technique were negative in 1:2, however by gel technique they were 1:8. The patient delivered a term baby soon after reaching the hospital. No antenatal records were available. The baby's haemoglobin was 19.2 gm/dl and serum bilirubin of cord sample was 5.6 mg/dl. Baby's blood group was B Rh D positive and direct antiglobulin test (DAT) was negative using polyspecific antihumanglobulin. Newborn's red cells were negative for Cw antigen.
Anti-Cw can be clinically significant and lead to haemolytic transfusion reactions. This case highlights the importance of creating awareness amongst the physicians regarding the occurrence of this antibody. Such patients should be issued an alert card for future transfusions. Moreover, screening cells should incorporate Cw positive cells for this antibody identification.
Review of 242 transfusion episodes in 40 patients of thalassemia and sickle cell disease with emphasis on auto/alloimmunization and selection of blood units by extended phenotype cross match
Background: Transfusions are the primary therapy for thalassemia and sickle cell disease but have significant complications and expose the patients to a variety of risks. Continuous blood transfusion can cause alloimmunization against RBC antigens and complicate further treatment in these patients; Alloimmunization to red cell antigens is one of the most important immunological transfusion reaction and results in ineffective transfusion. However, few data are available on the frequency of RBC alloimmunisation in the Indian population with history of chronic transfusions. Extended phenotype matched blood may help in decreasing the rate of alloimmunization and effectiveness of transfusion.
Aim of the Study: The purpose of this study is to evaluate the role of transfusion medicine services in thalassemia and sickle cell patients and significance of extended Rh and Kell phenotype matched blood to prevent alloimmunization.
Materials and Methods: Reviewed all the red cell transfusions given to clinically diagnosed patients of thalassemia major/intermedia (29), sickle cell anemia/disease patients (11) between Aug 2011 to Aug 2015 Total 40 patients and 240 blood transfusion work up were reviewed. ABO Rh and Kell grouping, Direct and Indirect Coomb's test, Antibody screening for Auto/Allo antibodies, Anti body identification by 3 cell panel, 11 cell panel and select cells was done in all the cases. Rh extended and Kell along with ABO typing done for the donors for each transfusion. All the tests were performed by column agglutination method.
Results: Allo antibodies like Anti -c, E, e, C, D (Rh system), Kell, Xga, Duffyand Kidd were identified in both thalassemia and sickle cell patients 10/40 (4%). Both auto and allo antibodies were present in 4 patients 4/40 (1%). Only auto antibodies were present in one thalassemia intermedia patient. Multiple allo antibodies were detected in 5 patients of sickle cell disease. ABO group discrepancy was detected in 5/40 cases (12.5%). Total 707 units were crossmatched and only 400 compatible units (1.76 CT ratio) were issed after Rh extended phenotyping in thalassemia patients and 11 units issued out of 74 cross matches (CT ratio 6.7) in Sickle cell patients.
Conclusion: Rh and Kell extended phenotype matched blood helped in preventing delayed haemolytic reactions in alloimmunized cases. RBC allo and auto antibodies were associated with previous transfusions without antibody screening and extended phenotype cross matching. Rh and Kell extended Phenotyping also helped in preventing further alloimmunization.
Promoting voluntary blood donation amongst hospital employees
Nitin Agarwal, Prashant Pandey
Replacement donors comprise of relatives and friends of patients who require transfusion of blood and blood components. However professional donors utilize this opportunity by donating under the guise of friends or relatives of the patient, a circumstance that cannot be verified by the blood bank staff. The emphasis has now rightly moved from merely depending on replacement blood donors to voluntary blood donations. Moreover, many of the patients coming to our hospital are international patients having only one or two attendants with them and find it hard to replace the blood required. Therefore a need was felt to promote voluntary blood donation amongst the staff of our hospital and to motivate everyone to be a regular voluntary donors. A meeting was held with the hospital management and some incentives were decided for the employees to enhance our voluntary blood donor registry.
It was decided by the management that every employee who donates whole blood or apheresis once will get one day leave along with all the incentives of a regular voluntary blood donor (like certificate of appreciation, Infectious markers tests report, blood grouping reports, privilege card valid for one year). If an employee donates for 4 or more times, he will be eligible for a complete health check up package either for himself or a family member. He would also be tested for anti -HBs titer and vaccination if titer would be low. The health package could be availed by whole family if the number of donation crosses 10 times or more at our hospital.
There were only 63 donations by the hospital employees in whole year preceding the introduction of incentive scheme in the hospital. In first four months of this announcement, we have already crossed the 50 donations and expect to triple this mark by the end of year. Not only there was an increase in whole blood donors but the number of voluntary donors for platelet apheresis required for many a patients (both national and international) also increased in last 4 months.
Though this project is still in early days but it can be seen that non monetary incentives like paid time off work and health screening tests can be used to motivate potential blood donors.
Efficacy of platelet concentrates prepared by random donor buffy coat and single donor apheresis in acute leukemia and chemotherapy induced pancytopenia
Aikaj Jindal, Amarjit Kaur, Rajesh Kumar, Jagdev Singh Sekhon
Since discovery of platelets, there has been continuous and accelerated progress in understanding of platelet functions and their utilization. In Oncology, platelet transfusions are indicated for prophylactically and/or therapeutically. Despite our improving knowledge about the beneficial effect of platelet concentrates, there has been limited data that can predict their therapeutic efficacy quantitatively. The need for this study arose to fill this void, to assess the therapeutic efficacy of leuko-reduced platelet concentrates made by buffy coats and single donor apheresis in thrombocytopenic patients of Acute Leukemia and Chemotherapy Induced Pancytopenia.
Aims: To study the post transfusion therapeutic efficacy of Buffy Coat Random Donor Platelet Concentrates (RDP) and Single Donor Apheresis Platelet concentrates (SDP) in patients of Acute Leukemia and Chemotherapy Induced Pancytopenia.
Thrombocytopenic patients from oncology ward were included as per the inclusion criteria. Platelet count of the platelet concentrates to be transfused was done prior to transfusion. Post transfusion efficacy of platelets in the patients (in vivo efficacy) was assessed by Corrected Count Increment (CCI) [units: plateletsm 2/΅L x 1011, hereafterimplied for the sake of clarity]and Percentage Recovery (PR) at 1 hour and 24 hours. If the CCI at 1 hour and 24 hours is <7500 platelets m2/΅L and <4500 platelets m2/΅L and PPR at 1 hour and 24 hours <30% and <20% respectively, it indicates platelet refractoriness. Data was analyzed usingStudent t-test onSPSSVersion 21.0.
Out of 61 patients, who had comparable pre-transfusion platelet count; 48 received RDP and 13 received SDP. In patients receiving RDP, the mean platelet increment at 1 hour and 24 hours was 22784.8 1166.2x 1011platelets and 16835.4 8859.9x 1011platelets, respectively. TheMeanCCI at 1 Hour and 24 hours was 10727.1 5495.3 and 7915.1 4201.1 respectively. The MeanPR at 1 hour and 24 hours was 24.0 12.2 % and 17.7 9.3 % respectively. In patients receiving SDP, the mean platelet increment at 1 hour and 24 hours was 48619.0 17214.8 x 1011 platelets and 41952.4 16758.5x 1011 platelets respectively. TheMeanCCI at 1 hour and 24 hours was 18104.5 6375.5 and 15602.6 6229.1 respectively. The Mean PR at 1 hour and 24 hours was 48.4 17.2 % and 41.7 16.9 % respectively. Platelet refractoriness was seen in 15 (24.5%) of cases out of which 13 (86.6%) were seen in patients receiving RDP and 2 (13.3 %) in patients receiving SDP. Statistically significant (p = 0.001) higher platelet increment, CCI and PR was observed with SDP than RDP and less refractorinesswas seen withSDPtransfusion.
Transfusing SDP is more efficient method to increase platelet count in oncologic thrombocytopenic patients andisassociated with longer in vivo survival of platelets.
Fresh frozen plasma utilization audit in nims, a tertiary care centre in correlation with evidence based guidelines
Background: Blood and its components should be used appropriately, particularly plasma products to minimize existing ill practices.
Aim: Audit of the institute's Fresh Frozen Plasma (FFP) usage with the specific aim of assessing the appropriate use, based on clinical indications and laboratory parameters available in FFP requisition forms submitted.
Materials and Methods: Transfusion services requisition forms of 660 consecutive patients who received 1509 units of FFP in our hospital from Jan 2015 to May 2015 were retrospectively analyzed for Provisional clinical diagnosis, Indication for FFP, Specialty, age and gender of the patient, Number of units transfused and, Haematological and coagulation lab parameters provided.
Results: FFP transfusions which were in Inadequate dosage and for un-indicated reason as per the NHMRC, BCSH and ASBT guidelines were labeled as inappropriate use. Clinical use of FFP for medical conditions was highest seen in Acute Leukemia with disseminated intravascular coagulation, 92 transfusion episodes/660 (14%). Cardiac diseases, chronic renal disease and Carcinoma solid organ with anemia/DIC (3%, 5% and 4% respectively). Clinical use of FFP for surgical conditions was highest for cardio thoracic surgery, CABG-20%. Sepsis with MODS in DIC contributed for 5% usage.
Appropriate use (16%) of FFP with INR value and proper dosage was observed in Chronic liver disease, Sepsis with MODS and DIC, factor deficiencies. Clinically Appropriate use (16%) of FFP with proper dosage was observed in Massive transfusions in CABG and CAD, Valve surgeries. Inappropriate FFP transfusions (33%) with improper dosage were observed in, Neurosurgical and general surgicalprocedures. No information available in 35% of FFP requisitions from Emergency department CABG, Post op CABG.
Conclusion: Regular audit of blood utilization and discard rate serve as an important tool for accomplishment of the quality goals. Periodic reinforcement about proper use of blood products in hospital blood transfusion committees should be done.
Blood donation: Donor`S perspective
Gita Negi, Swati Sharma, Dushyant Singh Gaur, Meena Harsh
There is a need to strengthen blood donor management in order to reduce the demand supply gap. Efforts are needed in this direction at all levels including educating and motivating more individuals to be involved in voluntary blood donation and converting them to retention donors. In order to develop rational and evidence based systems to address blood shortage, we need to assess the current donor services and improve them to encourage more future donations.
A study was planned to observe the current blood donation practice in order to assess the blood donation experience and reasons and barriers for blood donation.
Donors were monitored for their perceptions and satisfaction levels regarding the donation experience through a predesigned questionnaire.
It was found that the motivating factors included altruism, need to help a friend or relative or sometimes even the small gift that was being handed out. Most donors had heard about blood donation from relatives in need or from news. Factors that influenced blood donation experience were found to be the attitude of the person at the reception, phlebotomy and counselling areas, staff professionalism and appreciation for the act of blood donation. They also reported that the infrastructure including reception, donation and refreshment area and lighting etc also play an important role in the overall experience. 99% donors reported a good experience. Many of them (84%) said they wanted to be regular blood donors. Limitations of the study were small sample size and it was time intensive.
It was concluded that donor satisfaction affects donor retention and such studies help to improve quality of Blood donation services.
Prevalence of Rh D variants in coastal Karnataka and their serological characterization
S Sreelekshmi, Shamee Shastry, Manish Raturi, B Poornima Baliga
D antigen is the most immunogenic because of the ability to cause transfusion reactions and HDFN. Rh discrepancies may arise when an individual has a variant of D antigen. D variants express a significantly reduced amount of D antigen per red blood cell and are usually identified by Indirect Antiglobulin Test (IAT). D antigen discrepancies need to be resolved to assign the correct antigen status and to administer the appropriate blood products. Our study aims at finding the prevalence of RhD variants in coastal Karnataka, and to further characterize them with extended phenotyping.
The study was from February 2015 to July 2015 at our department. Donors and patients' blood grouping samples during the study period were included. Rh blood group typing of all samples were done by column agglutination technique. Samples with 4+/3+ reaction were considered Rh positive. Clear negative samples and samples with reaction strength of ≤ 2+/ mixed field, were further tested for Rh D typing using Anti D (IgG) in antiglobulin phase. The samples showing agglutination at AHG phase were considered Variant D. Further classification of variant D was done using the commercially available kit (BioRad) for Partial D and were categorized accordingly.
Total number of subjects from Feb-July 2015, were 29893 (21732 patients and 8161 donors). There were, 2091 Rh negative subjects (7.1%), 1463 patients, and 628 donors. Samples showing Rh negative result (2091) and <2+/MF reaction (30) were tested with anti D IgG in IAT phase. 30 samples were thus categorized as variant D that is 0.1% of the 29893 study subjects. Among them 12 samples were tested with partial D kit. 7 samples (3 donors and 4 patients) were categorized as weak D type 1&2 (58% of the phenotyped samples). 5 samples of patients (41% of the phenotyped samples) were categorized as DIII. 5 patient samples reacted with all panels- (DIII). 7 samples (3 donors & 4 patients), showed negative reaction with LDM1 (IgM) panel- suggestive of weak D type 1 & 2, in view of previous studies.
The prevalence of Variant D was found to be 0.1% that is 30 out of the total 29893 subjects. Partial D phenotyping is helpful in categorizing D variants, and for the appropriate administration of blood components. Further study with molecular methods will prove beneficial in absolute categorization of RhD variants.
Postdonation counselling of HBSAg seroreactive donors
Sindhuja Kondareddy, R Arun, DS Jothibai
Introduction: Hepatitis B viral infection (HBV) is a major health problem worldwide1. In spite of the mandatory screening of the donated blood for Hepatitis B surface antigen (HBsAg), introduced in 1972, HBV still remains the most common transfusion transmitted infection in India.
Aim and Objectives: To evaluate the current HBsAg sero prevalence in the blood donors at the department of Transfusion Medicine attached to a tertiary care teaching hospital in South India, to study the demographic pattern of the sero-reactive donors and to undertake post donation counceling.
This is both a retrospective and a prospective study undertaken after the introduction of chemiluminiscence technique for the screening of HBsAg from March 2015. The sero reactive donors tested for a period of two months (March & April) were included in the study. Demographic details of donors' who were reactive for HBsAg were noted; an attempt was made to contact the donors through phone calls for counselling.
Out of a total number of 1472 donors, serum was reactive for HBsAg in 26 (1.76%) donors which includes two female donors (7.69%). All the sero reactive donors belong to the age group of 18-34 years. About 4 donors (15.4%) were repeat donors donating for the 5 th time; the pervious donations were elsewhere. Seven (27%) of the seroreactive donors' who were around Tirupati were called and counseled in person. After repeat testing for all of them, the reactivity persisted except one. They were informed about the positive test. They were educated about the spontaneous clearance of the infections in the majorityand the possible complications if it persisted. They were also advised to have follow-up. They were thankful for the counseling.
Post donation counseling has been recognised as one of the strategies to reduce TTI including Hepatitis B virus. The donors should be notified about the sero reactive status. If not, it may predispose to the risk of repeat donations, particularly by the voluntary donors. This study was conducted to increase the donors awareness regarding transfusion transmitted infections and to prevent future donations.
Quality control assesment of blood components in a basic transfusion medicine laboratory
Koppukonda Ravi Babu, P Satya Narayana, Aparna Varma
Background: Quality control management of blood components is to ensure that blood components prepared should meet requirement for quality, safety, identity, potency and purity. For legal requirement and continuously improve the system. Transfusion medicine quality control laboratory can be established at low cost with basic equipment. Issues involved in quality control of blood components are good premises, calibrated equipment, material, trained personnel, standard operating procedures and documentation.
Aim: Quality control of the blood and blood components in a basic transfusion medicine laboratory in comparison with standard quality control parameters of AABB, DGHS guidelines.
Materials and Methods: Blood and blood components collected from 2009 to till date quality control parameters like haemoglobin, haematocrit were measured by cyanmethhaemoglobin and wintrobe's method. WBC, RBC and platelet count by Neubar cell counter, pH meter and coagulometer for the adequacy of factor VIII, Vwf and fibrinogen. All these were performed for every 1% blood components prepared.
Results: Total blood units collected from 2009 to 2015 July were 3,776 blood units. Blood components prepared were whole blood -2655 units, packed cells- 411, platelets-115, FFP -266 units. Quality Control Parameters ranged from Hb-11.3 gm/dl to 20.5 gm/dl, Hct -36.1 to 57%, platelets-1.8 to 3.87 lakhs, WBC -4200 to 11600. Platelet counts ranged from 0.9 X 1010 to 5.3 X 1010.PH ranged from 6.82-7.4.
Conclusion: Quality control of blood components can be maintained with basic equipment and minimum technical skills. 1% of component shall be tested for Quality Control out of which 75% shall match the acceptable ranges. Internal Quality Control monitors quality of single Blood Bank, necessary for daily monitoring of precision and accuracy. External Quality Control is necessary for Comparison of performance of many Blood Banks mandatory for long term accuracy & performance of the analytical method.
New approach to blood component separation: Top-and-bottom whole blood separation
Jyoti Pranavbhai Bhatt, Nishith A Vachhani, Falguni Jani, Sanjiv Nandani
Rajkot voluntary blood bank & research centre currently collects whole blood using top & top quadruple bags for preparation of blood components. New type of top & bottom bags were analyzed and compared during this study with regards to product quality.
Whole blood collected in Top & Top and Top & Bottom bags were centrifuged in cryofuge at 57 x 106 and 74 x 106 accumulated centrifugal effect (ACE) respectively. Blood components were separated using automated cell extractor system. Post separation analysis of blood components (Hb, HCT, cell counts, indices etc.) Was done using three part automated blood cell counter. Quality control data were evaluated and compared to estimate yield and quality of final blood components obtained with the two systems.
Compared two different blood bag systems, the whole blood units collected with Top & Bottom bags yielded greater red blood cell concentration with low WBC count (0.8 x 109/΅l) and platelet count (0.25 x 1010/bag). No any clinically significant difference found in term of volume of red cell concentrate product and hematocrit. Increased platelet count (8.69 x 109/bag) is achieved with less quantity of platelet concentrate (58 ml/bag) with significantly better leucoreduction (76%) in comparison with Top & Top bags. The volume of plasma is larger (213 ml) than Top & Top bags.
From these in-vitro data, the study concludes that the Top & Bottom bags produce components of higher quality than routine blood bags system. Regular use of this bag system could result in an important quality improvement in blood components manufacturing. Newer and latest technologies must be implemented in blood banking.
Phenotype frequencies of antigens of clinically significant blood group systems in blood donor population from Nagaland
Swati Sanjay Kulkarni, Bhavika Choudhary, Tina Khamo, K Ghosh, K Vasantha
As India is a vast country with several distinct population groups, there is an obvious need for phenotype frequencies to be determined in different parts of the country. Few studies reporting frequencies of antigens of clinically important blood group system are available mainly from north and western part of India. The current study was performed with an aim to have an estimate of phenotypes frequency of clinically important blood group system antigens in blood donors from Nagaland as no such studies have been reported from this part of India. Knowledge about the frequency of red blood cell-antigen phenotypes in a population will be helpful in the creation of a donor data bank for the preparation of indigenous cell panels and for providing antigen-negative compatible blood to patients with multiple alloantibodies.
Blood samples from 255 blood donors from Kohima, Nagaland (mainly Anagmi, Ao and Chakesang tribes) were tested for ABO, Rh, Kell, Kidd, Duffy and MNS blood group system antigens by standard tube technique using commercial antisera.
The ABO blood group distribution was as follows: A-26.6%, B-18.5%, AB-4.7%, O-50.2%. Out of 255 donors tested only five were RhD negative blood group (1.96%). Among the most probable Rh phenotypes, 48.23% were R1R1, 16.9% R1r, and 23.52% R1R2. The incidence of R2R2 (3.9%) was higher and rr lower than that reported in other parts of India. All donors belonged to kk phenotype. The incidence of Fya+b- was 68.2%, Fya-b+ 13.4%, Fya+b+ 18.4%, Jka+b- 38%, Jka-b+ 23.5% and Jka+b+ was 38.5%. In the MNS system, 29.7% donors were typed as M+N+, 51.46% as M+N-, and 18.82% as M-N+. S+s+ phenotype was found in 11.7% of donors, S+s- in 4.6%, and S-s+ was the most common (3.68%).
This is the first study reporting extended antigen typing for various blood groups in blood donors from Nagaland and provides with a donor database of blood group antigen frequency in this north east part of India. There is varied distribution of clinically important blood group antigens from other Indian population reported. In situations where clinically significant antibodies are identified in patient′s serum, antigen-negative donor units for such cases can be easily retrieved from the local donor database in blood transfusion center.
Donation with multiple transfer blood bags for component preparation increases the undercollection
Ketan Garg, DS Rawat
Use of cumbersome blood bags with multiple transfer bags creates a fear in the donor and a hindrance in the smooth process of blood collection. The aim of this study was to assess the undercollection in the different types of component blood bags.
The study was conducted from April 2015 to August 2015 in the department of blood bank in Safdarjung Hospital, New Delhi. Undercollection was taken as less than 10% of the total volume to be collected. The number of undercollections were noted and compared among different blood bags. Statistical analysis was done using chi square test. P value of less the 0.05 was considered significant.
Out of the total 12758 donations, 4132 (32.38%) components were made. The various components bags comprised of 1000 (24.2%) leucodepleted leucofilter bags, 954 (23.08%) leucoreduced quadruple bags, 1506 (36.44%) triple bags, 672 (16.26%) double bags. Out of the total of 4132 components, 168 undercollections were reported, comprising of 69/1000 (6.9%) leucodepleted leucofilter bags, 34/954 (3.56%) leucoreduced quadruple bags, 48/1506 (3.18%) triple bags, and 17/672 (2.52%) double bags, which had to be discarded. A significant difference was found in the undercollection in leucofilter bags as compared to other bags which thus decreased the output and increased the cost.
Advancement in the blood donation in the form of leucodepleted leucofilter bags claims to decrease the contamination and leucocyte content of the packed cells but carries the disadvantages of increased undercollection, cumbersome to handle, fearful to the blood donor, and costly. In the world of nanotechnology, multiple blood bags are cumbersome. A more precise and easy to attach and detach component bags to the main blood bag system will enable an easy blood donation process and thereby increasing the output.
Analysis of packed cells prepared by different methods
Ketan Garg, Disha Arora, Rekha Tirkey, DS Rawat
Removal of leucocytes from packed cells has been shown to minimize Febrile nonhemolytic transfusion reactions, HLA alloimmunization, and prevention of transmission of leukotropic viruses such as EBV and CMV. The aim of this study was to analyse the leucocyte content and hematological values in the packed cells made by different methods.
The study was conducted from April 2015 to August 2015 in the department of blood bank in Safdarjung Hospital, New Delhi. The leucocyte content and hematological values in packed cells made by different methods were assessed and compared with each other. Three methods used for preparing packed cells in the study are leucofiltration (in leucoreduced top bottom bags with inline filter), only buffy coat removal (in top bottom quadruple bags), centrifugation and separation without buffy coat removal (in triple and double bags). Statistical analysis was done using chi square test. P value of less the 0.05 was considered significant.
Out of the total 12758 donations, 4132 (32.38%) packed cells were made. The leucocyte content and hematological values in leucofiltered packed cells, leucoreduced buffy coat removal packed and simple packed cells were 0.1, 1.0, 10.8 (*10^3) TLC, 7.21, 4.67, 8.7 (*10^6) RBC, 65.7, 51.5, 59.8 Hematocrit, 0.1, 2, 294 (*10^3) platelets. The significantly lower number of leucocytes by leucofilters prompted the increased use of leucodepleted leucofiltered blood bags for preventing the adverse reactions although no adverse reaction were reported with any of the packed cells used in the study.
Leucofilters have been very effective in the removal of leucocytes and have led to the preparation of almost leucocyte free packed cells and thus decreasing the risk of various side effects of multiple blood transfusion.
Tradeoff of specificity for sensitivity: Time to review pretransfusion testing policies
Karishma Ashwin Doshi, Shamee Shastry, KP Cheirmaraj, Poornima Baliga
Newer techniques of pretransfusion testing have been adopted for the benefit of being faster and providing objectivity for interpretation of test results. In adherence to the guidelines laid by the American Association of Blood Banking, pretransfusion testing of all all patient samples should be performed using polyspecific anti-human globulin (anti-IgG + C3d). This was established in view of certain complement activating clinically significant antibodies which might be missed if monospecific antihuman globulin (AHG) was used. At our centre we aimed to compare the crossmatch results of 1000 samples randomly done over a period of 4 months using both polyspecific and monospecific AHG.
Over a period of 4 months the compatibility tests 1000 tests were performed using Autovue by Johnson and Johnson. A minimum of 1 milliliter of packed, washed donor red cells and corresponding patient serum samples were loaded following barcoding of all samples with unique identification numbers. All donor red cells were taken from tubing segments after stripping thrice and sealing off a 4-5 cm long segment. All patient samples with incompatible results were further screened using 3 panel reagent cells. Results were categorized under true negative (compatible results); true positive (incompatible crossmatch and positive antibody screening result); false positive (incompatible crossmatch and negative result in antibody screening); false negative (test failed to detect the antibody).
Polyspecific AHG:- The sensitivity and specificity of Polyspecific AHG were 83.33% and 97.08% respectivelty. The negative predictive value was 99.89% and the positive predictive value was 14.72%. The accuracy of the test procedure was 97%. Monospecific AHG:- The sensitivity and specificity of Monospecific AHG were 83.33% and 99.79% respectivelty. The negative predictive value was 99.89% and the positive predictive value was 71.43%. The accuracy of the test procedure was 99.89%. The concordance in results by the two techniques is 97.3%. Mc Nemar's test was applied to the paired data of the test results and the difference in results was statistically significant with a p-value <0.001.
During the study we observed a high rate of false positivity with polyspecific AHG which not only led to unfruitful steps of antibody screening but was also responsible for delay in issue of a life saving resource. We suggest a review of existing standards be made after more extensive research which may save resouces significantly.
Grey zone reactive sample retesting: Does it enhance the scope of blood safety?
Arumugam Pothipillai, S Usha, S Hamsavardhini, R Rajbharath
The ultimate goal of advancements in TTI screening methodology is to minimize window period donations. Advanced technologies like NAT are available at few centres only; a large majority of the blood transfusion services in our country is reliant on Enzyme-linked Immunosorbent Assay (ELISA) in which results are reported as "reactive "and "non-reactive" based on a cut- off absorbance. Samples are considered to be "grey zone" reactive when their absorbance values are less than but fall within 10% of the cut-off value. The aim of this study is to quantify the blood safety achieved by retesting of "grey zone" reactive samples obtained during TTI screening of donor samples for markers of HIV, Hepatitis B and Hepatitis C by ELISA.
Results of the TTI screening for markers of HIV, Hepatitis B and Hepatitis C by ELISA, performed on the donor samples, were analysed during the study period from January 2012 to August 2015 at the Department of Transfusion Medicine, The Tamil Nadu DR.M.G.R Medical University, Guindy, Chennai. Both "reactive" and "grey zone" reactive samples in the initial ELISA testing had been subjected to duplicate testing by ELISA and consensus results (2 or 3 test results) were accepted.
During the study period (January 2012 to August 2015), TTI screening for the three viral markers was done on all 6585 donor samples. 71 of the 6585 (1.1 %) samples were confirmed as "reactive" for one of the three viral markers; co-infection was not detected.13 of the 6585 (0.2 %) samples had absorbance values in the "grey zone" in initial testing. Upon retesting of "grey zone" reactive samples, 2 out of 13 (15.38%) samples (i.e., both "grey zone" reactive samples for HCV) were found to be "reactive" and the remaining 11 "grey zone" reactive samples were found to be "non-reactive".
As per the results of this three years' study, the potential occurrence of transfusion-transmissible HCV infection was able to be prevented on two occasions by retesting of "grey zone" reactive samples. Analysis of more number of donor samples over a much longer period would probably yield more results. Until we adopt advanced methods like NAT, relying on "grey zone" reactive sample retesting in ELISA will serve to enhance blood safety.
Should we reconsider platelet content criteria for single donor platelets in West Bengal?
Rizwan Javed, Sabita Basu
Quality Control is an integral part of a modern blood banking. DGHS and AABB set the minimum platelet content of Single donor platelets (SDP) as 3 x 1011. However there are many reports of lower platelet counts among donors in West bengal.
Need of the Study: Achieving the requisite standard in platelet content is often untenable in our region. We undertook this study to find the relation between ethnic bengali donors and low SDP platelet content.
We retrospectively analyzed all SDP donations from 1 st January'2015 to 31st July' 2015. All the procedures were done on MCS+ (Haemonetics, USA). All qualified SDP donors who were residents of West bengal and had bengali mother tongue were put in "Category-A" while the rest were labelled as "Category B". Age, sex, repeat donation were noted. Pre-procedure platelet counts and SDP platelet content were obtained from Coulter Ac Tdiff2 (Beckman Coulter).
A total of 311 donors were screened, out of which 252 procedures were performed. We included only 182 SDP donations for which quality control data was available. Category-A had 78 donors, where as Category-B comprised of 104. The mean pre-donation platelet count for Category-A and Category-B was 189 x 103/cm and 243 x 103/cm respectively. The mean SDP platelet content was 2.7 x 1011 and 3.1 x 1011 respectively. The requisite SDP platelet content was achieved in 29.5% and 87.5% of Category-A and Category-B donors respectively. The difference in the platelet content was statistically analysed.
SDP derived from Category-A donors have a lower platelet content than Category-B. Therefore, many of our SDP fail to meet the minumum cut-off as mandated by DGHS and AABB. Hence, SDP platelet criteria for eastern India needs to be reconsidered.
Analysis of blood donors deferral at a tertiary care hospital in Delhi
Ketan Garg, Disha Arora, Sachin Bajaj, Rekha Tirkey,
Blood donor deferrals lead to a potential loss of blood pool and simultaneously puts a lot of pressure on the patients relatives to arrange blood somehow. The undue pressure may promote blood touts but ensures blood safety. The aim of this study was to find the incidence of donor deferral and to know the reasons for deferral of the blood donors.
A retrospective study is carried out in the department of blood bank in a tertiary care hospital from January 2014 to June 2015. All blood donors during the study period who were deferred for any reason were analysed. A list was prepared and comparison of the reasons were done among voluntary and replacement donors and males and females.
Out of the total of 47164 donors who had come for blood donation, 5507 (11.68%) were deferred. Out of the total deferred, a deferral rate of 11.15% among replacement donors (RD) and 24.03% among voluntary donors (VD) was found. Most common reason for deferral were low haemoglobin (21.5%) and low weight (19.8%), and other reasons were fresh prick marks, history of jaundice, increased Blood pressure, skin infections etc. The common reasons for donor deferral among males has been low weight (12.61%), history of recent prolonged jaundice (12%), allergy/skin infection (9.94%), self inflicted cuts/fresh prick marks (9.47%) whereas among females it was low haemoglobin (57.33%).
Donor deferral leads to a significant loss of blood donor pool but it is equally important, so as to prevent any harm to the patient as well as donor from blood donation. Deferral criteria may be altered according to the regional population but further studies are required to corroborate the same.
Acute transfusion reactions occurring in a tertiary care hospital
Acute transfusion reactions (ATRs) are defined as any adverse event that occurs within 24 hours of transfusion of blood and blood components. These untoward effects vary from being relatively mild to severe. So rapid recognition and management of transfusion reaction can be life saving. The aim of study is to analyze the incidence and spectrum of adverse effects of blood transfusion and to initiate measures to improve overall transfusion safety for patient care.
This was a prospective one year study, from 1st January 2014 to 31st December 2014. The ATRs related to the administration of blood component in the patient were recorded, analyzed and classified on the basis of their clinical features and laboratory tests. Transfusion reactions occurring during or within 24 hours of transfusion were evaluated and classified according to the standard and recognized definitions defined by American Association of Blood Banks.
During the study period, 48060 blood and blood components were issued. A total of 123 (0.26%) transfusion reactions were reported from various department. The most frequent were Febrile non hemolytic transfusion reactions (FNHTRs) 52 (42.27%), followed by Allergic 36 (29.26%) isolated hypotension 3 (2.43%), 2 (1.62%) were acute hemolytic transfusion reactions and 30 (24.39%) were unclassified and labeled as non specific.
Blood transfusion is a vital therapeutic procedure with a potential risk to already critical patients. So a strict vigilance has to be kept and each transfusion has to be monitored carefully with prompt recognition and treatment of ATRs. A rational use of these products considering their deleterious effects can decrease transfusion related morbidity and mortality in the critically ill patients.
Rh null: A rare blood group phenotype
Swati Sanjay Kulkarni, Seema Jadhav, K Ghosh, K Vasantha
Rh null phenotype is a rare blood group characterized by the lack of expression of all Rh antigens (D, C, c, E and e) on the red cells. This phenotype has frequency of about one in six million individuals and most often results from consanguineous marriage. These subjects readily form alloantibodies against several Rh antigens if exposed to transfusion or pregnancy and are risk of adverse transfusion reaction. The antibody reacts with all red cells except Rh null cells. We report here two cases referred to us to identify and resolve problems for incompatible crossmatching.
Case 1: Blood sample of 25 year old antenatal women (20 weeks gestation) was referred for non availability of compatible blood for transfusion to her fetus. She had bad obstetric history of three abortions and two intrauterine deaths after first living child. Case 2: 27 year old female with first living child (Rh negative), second child died at one and half months age and after that she had three IUFD. Patient after her last IUFD required blood for correction of anemia and was referred to our Institute for problems in crossmatching. ABO and Rh grouping, Rh phenotyping, DAT, antibody screening and identification were performed as per standard procedure. The blood group phenotype identified was confirmed by serological and flowcytometric methods.
The blood group of two women was found to be B negative and AB negative respectively. In both cases, DAT was negative and their Rh phenotyping with anti-C, c, D, E and e showed a very rare phenotype i.e absence of all Rh antigens (C, c, D, E and e) on the red cells - Rh null. Absorption elution test on patients red cells with suitable anti-C, anti-c, anti-D, anti-E, and anti-e did not reveal the presence of any Rh antigens. Serum showed the presence of high titre antibody (anti-total Rh) and when tested with reagent red cell panel was positive with all common Rh phenotypes. Based on the above serological studies it was interpreted that both women belonged to very rare Rh null blood group and the phenotype was also confirmed by flowcytometric techniques. Their parents were not consanguineously related.
We report here two cases of very rare Rh null phenotype in Indian population. Both women are counseled to be donors and are now registered in our rare blood group registry.
Factors predicting allogenic blood exposure in cardiac surgical patients
Karishma Ashwin Doshi, Shamee Shastry, Vasudev Pai, Nitin T Patil
Cardiac surgical patients are an especially at risk group for receiving blood products either intra-operatively or post-operatively since volumes varying from 1-2L remain extracorporeally in the cardiopulmonary bypass circuit. Nearly 20% of all blood transfusions are associated with cardiac surgeries implying them to be major consumers. We set forth with the aim to analyze the effect of several preoperative and intraoperative variables and their effect on the risk of receiving allogenic blood products.
Data of 348 patients who underwent elective cardiac surgery on pump from January 2013 to December 2014 was collected. Variables analyzed were age, gender, height, weight, body surface area; preoperative parameters of hemoglobin, hematocrit, PT, aPTT, INR, urea, creatinine, serum bilirubin-total and direct, albumin, globulin; echo findings of left ventricular dysfunction, regional wall motion abnormalities, pulmonary artery hypertension, ejection fraction; history of previous cardiac surgery, diabetes, chronic obstructive pulmonary disease, endocarditis, rheumatic heart disease, redo surgeries, simple or complex surgery, treatment history of warfarin or clopidogrel; intraoperative variables of cross clamp time, bypass time, minimum and maximum activated clotting time and bypass temperature. Univariable data analysis of all the variables was done and the variables significantly associated with the outcome were put through multivariable logistic regression.
Study population consisted of 230 men, 118 women. With the mean height 159.5 cm (SD = 9.63), weight 59.2 kg (SD = 12), hemoglobin 12.6 gm% (SD = 1.63) and ejection fraction 56.56% (SD = 10.6). Of all the variables height (p < 0.001), weight (p < 0.001), preoperative hemoglobin (p < 0.001), ejection fraction (p = 0.03), gender (p = 0.003) and history of warfarin (p = 0.002) were found to significantly affect the outcome of receiving packed red cells.
Several studies have shown different variables to be significant with a consensus on hemoglobin, gender and weight. Clinician judgment seems to be a variable with significant weightage governing the decision to transfuse or not despite guidelines for preoperative, intraoperative and postoperative cut off values of hematocrit. We eventually intend to develop a simple scoring tool based on the significant variables on an ongoing larger population. At the providing end of transfusion services it would only be apt for every institution to review past data and to develop predictive tools rather than to develop a rather restrictive maximum surgical blood ordering schedule.
Profile of adverse transfusion reactions in a tertiary care hospital and evaluation of the reporting system with respect to the transfusion setting
JK Anupama, P Amalraj, D Daniel, Joy J Mammen
Transfusion is an important part of the health-care system, without which most of the emergency and critical-care conditions are difficult to handle. There is always some risk involved in transfusion which results in adverse reactions. The success of a good transfusion practice greatly depends on the reporting of such adverse reactions, so that proper measures can be taken to identify the root-cause. Our aim is to study the profile of transfusion reactions reported in our hospital and to evaluate the current reaction reporting system.
All the reactions reported to our blood bank from June'2014- May'2015 were analysed. The reports were broadly classified into four settings-ICU, Wards, Theatre and Casualty. They were analysed for several parameters including the legibility of the report, presence of employment number of the clinician and adequacy in the reporting of signs.
Of the 139 reports studied, most of the reports were from the transfusions that occurred in the wards (59.7%) followed by operating rooms (20.8%), ICUs (12.2%) and casualty (7.9%). Overall when all components were considered, the most common reaction reported was allergic/anaphylactoid reactions (47.5%), followed by FNHTR (27.3%). When analysed by component transfused, FNHTRs accounted for most of the reactions (43.2%), where Red-cell-concentrates were used. However, with the plasma-containing-products including whole blood, allergic reactions seemed to be the most common type (69.2%). Legibility was a concern in 39.5% of forms reviewed and the easy identification of the reporting clinician was not possible in 58.3% of reports.
The most frequent reaction among patients receiving plasma containing products was allergic. This is similar to that reported from other large centers in the country. When red cell concentrates were considered, we found that FNHTRs dominated. Anecdotal reports seem to suggest that there is under-reporting of reactions, especially when managed successfully at the bedside and transfusion is completed. Much effort is required in the blood bank towards acquiring and collating data when forms are illegible and the identity of the reporting physician is unclear. An important limitation of the current reporting form is that most of the times the pre-transfusion vitals are not recorded leading to variations in the reporting of FNHTRs. This retrospective study helped us to identify some lacunae in the system of reporting. A revised form that avoids redundant data-entry and provides options to select from, with required guidance is being piloted. New modalities (SMS, Tele-reporting) have been added to improve the ease of reporting on the clinicians, leaving the onus on the blood bank to follow-up the event.
Acute transfusion reactions in a tertiary care hospital in North Eastern India
Laikangbam Dayalaxmi, A Meina Singh, A Barindra Sharma, Salam Robindro
Acute transfusion reaction (ATR) is defined as adverse events during or within 24 hours of blood transfusion. There is wide variability of different ATRs in their frequencies and severity. Most of the severe ATRs such as Acute Hemolytic Transfusion Reaction (AHTR) are uncommon and least severe ones are common and often preventable. With a view of patient safety as paramount in transfusion practice, the present work is aimed to study acute transfusion reactions in recipients of RIMS Hospital with respect to the frequency, types, and related variables.
A prospective study, conducted in the Department of IHBT, RIMS, Imphal, during the period from January 2014 to July 2015. Work-up of transfusion reactions reported in 31 patients, were conducted as per departmental standard operating procedure (SOP). After clerical check, the necessary laboratory investigations were performed and a possible diagnosis was made. The data collected were analysed and conclusions were drawn.
Out of a total of 22,244 blood and blood components issued, 34.22% were transfused in Medicine wards, 17.28% in Obstetrics & Gynaecology, 13.15% in Casualty, 11.25% in Radiotherapy and 8.49% in Surgery. Among the issued units, 38 (0.18%) were whole blood (WB), 17,302 (77.78%) PRBC, 2176 (9.78%) Platelet concentrate and 2728 (12.26%) FFP. A total of 31 (0.14%) recipients developed ATRs during transfusion. Gender-wise, 10 (32.26%) were males and 21 (67.74%) females. Thirty (96.77%) cases of ATRs were associated with PRBC transfusion, one case with WB and none with other components. Among the indications of transfusion, anemia was in 21 cases (67.74%), intraoperative bleeding in 7 cases (22.58%) and one each (3.22%) in cases of haematemesis & melaena, massive haemoptysis, splenic injury and haemoperitoneum. Among the type of ATRs, the most frequent type was FNHTR-17 (54.84%) followed by Allergic - 12 (38.70%), AHTR - 1 (3.23%) and TACO-1 (3.23%). Majority (61.29%) of the patients had ATR transfusions during night time (6 PM to 6 AM). All patients recovered well.
The frequency of ATRs was found to be 0.14% (1 in 718 recipients) of all blood and blood components transfused, being more in female patients. Majority of the ATRs involved red cell transfusion. FNHTR was the most frequent ATR followed by allergic reaction. Only one case of severe AHTR was reported. All recovered well. More reactions occurred in blood administration during night time and thus, routine transfusions should be avoided at night. Measures to minimize the ATRs and for safe blood transfusion need to be advocated.
Effect of timing of irradiation on quality of red cells stored in SAGM
Rajesh R Chandran, Dolly Daniel, Joy John Mammen, Sukesh C Nair
Gamma-irradiation of red cell concentrates reduces the risk of graft-versus-host disease in immunocompromised transfusion recipients. However, gamma-irradiation also produces reactive oxygen species that cause lipid peroxidation and membrane damage. This reduces RBC function and viability, which may diminish post-transfusion recovery and lead to adverse post transfusion outcomes. Guidelines vary in defining the period up to which red cells can be irradiated before transfusion as well as duration of post irradiation storage. The present study is designed to monitor the changes of the extracellular potassium concentration, supernatant haemoglobin and haemolysis in red blood cells (RBC) stored in SAG-M (saline adenine glucose-mannitol), in order to estimate the right time for their prophylactic irradiation and the right span of post-irradiation storage. This study was done to assess whether the difference in timing of irradiation affects quality of stored red cells.
Thirty units of Red blood cells stored in SAG-M additive solution were irradiated at different periods of their storage and the changes following irradiation were monitored at weekly intervals. These units were serially monitored for plasma potassium, hemoglobin and supernatant hemoglobin. Generalized Estimating Equations (GEE) method was used to test the difference between the two irradiation groups, age group and overall time effect. Wilcoxon signed rank test was used to test the difference in the pre and post day of irradiation.
There was significant increase in potassium value over time (p = 0.000) with storage. Statistically significant difference was seen between non-irradiated and irradiated groups for increase in potassium (p = 0.000), which is unrelated to the day of irradiation (p = 0.000). Increased supernatant hemoglobin level was seen irrespective of whether the units were irradiated or not (p = 0.001) and statistically significant increase was noted on units irradiated on day 35 (p = 0.004). Hemolysis increased significantly over time (p = 0.002) and between irradiated and non-irradiated groups (p = 0.056). However increased hemolysis was significant only in units irradiated on day 35 of storage (p = 0.007).
Timing of irradiation is an important parameter deciding the quality of transfused red cells and the post -irradiation storage period does not contribute to any further decline in quality.
The successful management of postsurgical atypical haemolytic-uraemic syndrome with plasma exchange therapy: A case series study
Neelesh Jain, Joydeep Chakrabortty, Suresh Ramasubham
HUS is defined by the triad of mechanical, non-immune hemolytic anemia with fragmented erythrocytes, thrombocytopenia and renal impairment. Atypical HUS (aHUS) defines non Shiga-toxin-HUS which is further classified as a primary aHUS due to a disorder in complement alternative pathway regulation and a secondary aHUS due to Streptococcus pneumoniae ther causes. Here we describe the three cases of post surgical atypical HUS, managed successfully with multiple plasma exchanges through "COBE spectra" cell separator.
Case Details: The first case was a 36 yr old multiparous lady underwent a total abdominal hysterectomy for endometriosis. 24 hours after the surgery she became oligouric, anemic (HB-7.4), thrombocytopenic (PLT-48000) with petechiae and rashes all over the body, admitted in medical intensive care unit (ICU). Her serum creatinine (3.4), LDH (1044) were increased. Patient was managed successfully with 5 cycles of plasma exchange. After that she stabilized and recovered gradually. The second case was a 49 yrs old female underwent a whipple procedure for adenocarcinoma pancreas, after 48 hours of surgery she developed anemia (Hb 6.8), thrombocytopenia (PLT-68000) and renal failure with creatinine of 2.7, LDH went up to 920. Considering the diagnosis of aHUS, she was planned to undergo plasmapheresis, after 6 procedures of plasma exchange on daily basis she started improving and became stabilized gradually. The last but not the least was case of a 41 yr old multiparous lady underwent a ovarian cystectomy, after 24 hours of surgery she developed anemia (hb 8.0), thrombocytopenia (PLT-88000) without any rashes and renal failure with creatinine of 3.3, LDH went up to 1100. Patient was managed in the line of aHUS with 5 cycles of plasma exchange on alternate days successfully. The common findings in all three cases were low serum C3 complement level and DCT negativity. Stool culture and PCR for Shiga-toxins was negative. Thrombotoc thrombocytopenic purpura (TTP) was ruled out as serum ADAMTS 13 activity was with in normal range in all three cases.
The post surgical aHUS is one of the dreaded complications, but timely diagnosis and management with plasma exchanges can definitely save the patient's life successfully without much complications.
Conclusion: the post surgical aHUS is one of the dreaded complications, but timely diagnosis and management with plasma exchanges can definitely save the patient's life successfully without much complications.
A survey of knowledge and practices of transfusion medicine among post intern doctors in Army Hospital Colombo Sri Lanka
Samantha Kumarage, Lanka Gunasekara
Knowledge of blood transfusion is one of the key elements of efficient blood management of the patients. Insufficient knowledge drastically affects the function of the blood bank as well as patients out come. This continues to be observed at the blood bank end on daily basis. Our aim was to access the fundamental knowledge of transfusion medicine among post intern doctors.
A descriptive cross sectional research conducted by using self answered questionnaire. The subjects were 57 post intern doctors (PID) with varying years of experience in various specialties. 45 questions were formulated considering six main areas of transfusion practice. Anonymity and confidentiality were assumed. Data were analyzed using SPSS software and results were expressed as Mean SD.
Study revealed that overall average score is 26% for correct answers. Lowest knowledge score was 23.50% in interpretation of the lab result section. The knowledge differences between various specialties were not statistically significant.
This study revealed that most of the PIDs have inadequate knowledge of transfusion medicine. Island wide survey must be conducted to collect more data to implement national level remedy. Two weeks training of blood banking as most of the PIDs requested in the survey can be lunched as an immediate solution.
Significance of follow up of HCV antibody reactive blood donors by quantitative molecular method in a tertiary care hospital in North-East India
Robindro Salam, A Meina Singh, A Barindra Sharma, Laikangbam Dayalaxmi
Transfusion-transmitted infections (TTI) remain a major global public health problem particularly in developing countries. Hepatitis C virus affects around 130 million worldwide and in India, around 15 million people are affected, causing chronic hepatitis in approximately 85% of the cases. The seroprevalence rate of TTI in blood donors reflects indirectly about the situation of the viruses in the state. The aims of this study are to analyse HCV reactivity among the blood donors and compare the significance between antibody ELISA and molecular methods for HCV RNA in blood safety.
A prospective study, conducted in the department of IHBT, RIMS, Imphal, from August 2013 to May 2015, in which 22,095 blood donors screened for TTI as a part of the routine screening process. HCV antibodies were screened by 3rd generation ELISA (Erba Lisa Hepatitis C, NACO approved) test as per departmental standard operating procedure (SOP). Those HCV antibodies reactive blood donors were recalled for counselling and laboratory investigation by RT-PCR for quantitative HCV RNA (Real Time PCR - Taqman Technology). The RT-PCR were referred to and performed by a third party accreditated laboratory outside the state. The results are compared, interpreted and analyzed.
Of the total number of 22,095 blood donors screened, 258 (1.16%) donors were HCV seropositive by ELISA test. These donors were recalled for counselling and further investigations. Only 38 (14.72%) HCV seropositive donors participated in the quantitative RT-PCR test for HCV RNA. All were apparently healthy looking. Only 4 (10.53%) were negative for HCV RNA and 34 (89.47%) donors were confirmed positive with the HCV viral copies ranging from 6188 to 41938871 IU/ml. The donors with both ELISA and RT-PCR reactive were interpreted as having current HCV infection, whereas ELISA reactive but viral RNA negative donors as having no current HCV infection and may be due to persistent HCV IgG antibodies.
The high RT-PCR positivity of ELISA reactive blood donors is significant and there is possibility of missing something in the donor screening procedure. It is suggested that the donors with negative PCR may be recalled again for a repeat HCV Ab test so that the donor, if non-reactive may be allowed to donate blood. Further, health policy makers may include all viral TTI reactive blood donors to molecular tests for further genotyping and appropriate treatment. This will help enormously in the case finding and control of HCV infection.
Role of therapeutic plasmapheresis in neuromyelitis optica: A 2-year study at an apex neurosciences institute in India
Sundar Periyavan, A Batra
Neuromyelitis optica (NMO) (Devic's disease) is an autoimmune demyelinating disease preferentially targeting the optic nerves and spinal cord. The attacks are poorly controlled by steroids and evolve in stepwise neurological impairments. Therapeutic plasmapheresis (TPP) is an effective adjunct therapy in severe NMO attacks (ASFA category 2). We intend to study the role of therapeutic plasmapheresis in patients with NMO.
A prospective study was done at transfusion medicine centre, National Institute of Mental Health and Neuroscience (NIMHANS), Bengaluru, South India, during the 2 years period (July 2013 to June 2015). There were 43 cases of NMO; 7 males and 36 females (M:F ratio 1:4). Age ranged from 16 to 64 years. TPP was done with intermittent cell separator. All patients underwent alternate day TPP for 5 times (acute) and of these 10 patients are undergoing, additional maintenance TPP, once sitting a month. Plasma pheresed ranged from half to one third volumes. Peripheral venous access was achieved in 95% of patients (n = 41) and rest was done with central line. 58% (n = 25) of patients had been transfused fresh frozen plasma (FFP) against Albumin (42% (n = 18)) as replacement fluid.
Definite clinical improvement (esp. in terms of delayed spinal attack) was observed in 93% of patients (n = 40) at the end of acute TPP.
TPP is a safe and efficient add-on therapy in NMO, esp. in steroid-resistant cases. Although the volumes of plasma pheresed during both acute and maintenance therapy were less than recommended volumes, majority of patients had positive clinical outcome in terms of disease remission. Further large prospective therapeutic trials are required to assess the response definitively.
Study of hepatitis-B core antibody detection in healthy blood donors at a tertiary care hospital in Western part of Rajasthan
Dev Raj Arya, NL Mahawar, Archana Singh, Sunita Arya, Arun Bharti
Screening of blood donors for infectious disease markers is done to make it as safe as possible. Though sensitive screening assays for detection of hepatitis B virus surface antigen (HBsAg) are available, occasional cases of post-transfusion hepatitis B virus infection (PTH) still occur. The present study was done to detect Hepatitis B core antibody (anti-HBc) positivity in healthy blood donors. All the core antibody positive samples were further tested for HBV-DNA by NAT testing. This study was conducted in the Department of Transfusion Medicine at S.P. Medical College & Associate Group of Hospitals, Bikaner, Rajasthan only for research purpose.
Randomly selected 900 serum samples collected from healthy blood donors at AG Hospitals, Bikaner during the year 2012 were tested for the presence of anti-HBc antibody in addition to the mandatory markers. All samples positive for anti-HBc antibody and equal number of negative samples (control) were tested for HBV-DNA by NAT testing.
Out of the 900 samples tested, 77 (8.5%) were found positive for anti-HBc antibody and 8 (0.88%) were positive for HBsAg. Out of the 77 samples positive for core antibody, 23 (29.8%) were positive for HBV-DNA. Out of the 8 samples positive for HBsAg, 5 (62.5%) were positive for HBV-DNA. None of the 76 samples negative for core antibody (control) was found positive for HBV-DNA.
Positivity of Anti-HBc antibody (8.5%) is very high as compared to positivity for HBsAg (1.22%). Detection of Anti-HBc antibody definitely has role in increasing blood safety but HBV-DNA positivity in core antibody positive samples was only 29.8%. On review of the data we are of opinion that more studies are required in different geographical areas of our country to assess the utility of core antibody and HBV-DNA (NAT testing) as Hepatits B marker to increase the blood safety.
Red cell alloimmunisation in oncology patients: A study from Eastern India
Supriya Dhar, Sabita Basu
Red cell alloimmunisation is an important complication in multi-transfused patients with haematologic and surgical malignancies. Antibody screening with identification is necessary to ensure transfusion safety. Data on the prevalence of alloimmunisation in oncology patients is limited. This was a retrospective analysis undertaken to assess the alloantibody prevalence and determine the antibody specificity.
Aim: To assess red cell alloimmunisation in multitransfused haematology- oncology patients.
Materials and Methods: Retrospective analysis of antibody screening data was done for haematopoietic stem cell transplant (HSCT) patients as well as surgical oncology patients, from April 2013 to May 2014. This included the antibody screening done prior to surgery, antibody screening prior to HSCT and any antibody screening performed for these patients at cross match. Antibody screening was done using the three cell panel (surgiscreen) and if positive, further identification performed using the 11 cell panel (Resolve Panel A). If the antibody screen (three cell panel) was positive, an autocontrol was performed using reverse diluent (Ortho Biovue System) card. Patients with autoantibodies were excluded from this study.
Our overall red cell alloimmunisation rate was 2.5%. Alloimmunisation rate among HSCT transplant patients was 1.6% as compared to the 2.4% in patients with solid organ malignancies.
Keeping in view the low alloimmunisation rate, the justification of repeating antibody screening 72 hours post transfusion in this category of patients needs to be re-assessed.
Partial phenotyping in voluntary blood donors of Gujarat state
Kruti Kiritkumar Patel, Nidhi Bhatnagar, Maitrey Gajjar, Tarak Patel, Mamta Shah, Megha Shah
Partial phenotyping of voluntary blood donors has vital role in transfusion practice, population genetic study and in resolving legal issues. The Rh blood group is one of the most complex and highly immunogenic blood group known in humans. The Kell system, discovered in 1946, is the third most potent system at triggering haemolytic transfusion reactions and consists of 25 highly immunogenic antigens. Knowledge of Rh & Kell phenotypes in given population is relevant for better planning and management of blood bank; the main goal is to find compatible blood for patients needing multiple blood transfusions. The aim of this study is to evaluate the frequency of Rh & Kell phenotype of voluntary donors in Gujarat state.
The present study was conducted by taking 5670 samples from random voluntary blood donors coming in blood donation camp. Written consent was taken for donor phenotyping. The antigen typing of donors was performed by Qwalys-3 (manufacturer: Diagast) by using electromagnetic technology on Duolys plates.
Out of 5670 donors, the most common Rh antigen observed in the study population was e (99.07%) followed by D (95.40%), C (88.77%), c (55.89%) and E (17.88%). The frequency of the Kell antigen (K) was 1.78 %.
The antigen frequencies among blood donors from Gujarat were compared with those published for other Indian populations. The frequency of D antigen in our study (95.4%) and north Indian donors (93.6) was significantly higher than in the Caucasians (85%) and lower than in the Chinese (99%). The frequencies of C, c and E antigens were dissimilar to other ethnic groups while the 'e' antigen was present in high frequency in our study as also in the other ethnic groups. Kell antigen (K) was found in only 101 (1.78 %) donors out of 5670. Frequency of Kell antigen in Caucasian and Black populations is 9% & 2% respectively. The most common Kell phenotype was K-k+, not just in Indians (96.5%) but also in Caucasians (91%), Blacks (98%) and Chinese (100%). Conclusion: Phenotype and probable genotype showed wide range of variations in different races and religion. Reliable population based frequency data of Rh & Kell antigens has vital role in population genetic study, in resolving medico legal issues and in transfusion practice.
Study of red cell exchange procedure on twenty one patients in a tertiary care hospital, Tamil Nadu, India
Joshua Daniel Jeyakumar, Prakash
Red cell exchange (RCE) is a medical procedure which involves removal of abnormal red cells from blood of a patient and replacing it by normal donor red cells either manually or using an automated cell separator. Though it is most commonly employed in removing sickle cells in patients with sickle cell disease with complications, it is also useful to reduce the disease burden in severe cases of Babesiosis More Details, malaria and certain types of overdose or poisoning. RCE is helpful in to reduce iron overload due to top up transfusion in thalassemia major. RCE can be life saving if employed early in ABO mismatch transfusions.
To study the efficacy of this procedure in various clinical conditions and to understand the challenges and complications associated with the procedure.
This study analyzed 21 cases of RCE performed on 18 cases of sickle cell disease, 2 case of severe falciparum malaria and 1 case of nitrobenzene poisoning. All these procedures were performed with through spectra optia apheresis system - terumo bct. Almost all of those RCE done on SCD were for avascular necrosis of head of femur and admitted for hip replacement surgery. Two RCE were performed on patients infested with falciparum malaria with high parasitemic index (>10%), and one on nitrobenzene poisoning.
RCE is very effective in reducing sickle cell percentage in patients with homozygous sickle cell disease prior to hemiarthroplasty also helpful to prevent sickling complications during prolonged anesthesia. The effectiveness of this therapy in malaria with high parasitic index is doubtful though literature documents clear benefits in patients with high parasitic index. RCE is found to be effective in nitrobenzene poisoning as adjuvant therapy.
Red cell exchange transfusions remain an effective but possibly underutilized therapy in India. Only very few centers are practicing red cell exchange in India due to inadequate awareness, technical expertise, lack of equipments and facilities to identify the clinical conditions per se etc.
Quality management of outdoor blood donation camps: A novel approach
Rakesh BV Dhanya, Rajat Agarwal, Arpit Vaish, Amit Sedai, Lalith Parmar, Ritesh Sharma
Background: Retention of non-remunerative voluntary blood donors is the cornerstone of blood safety. Outdoor blood donation drives contributes the majority of all voluntarily donated blood. Implementing a system which ensures delivery of quality, promotes best practice and contributes to process enhancement is important to continued success of such drives. In-spite of the obvious importance, quality management of outdoor blood donation camps has not been thoroughly explored.
Aim: Our aim was to set-up a systematic approach of quality management and assurance in outdoor blood donation camps.
The study covers 301 blood donation drives held in Karnataka (primarily in Bangalore) between 1 Sep 2013 and 1 Sep 2015 organized by Sankalp India Foundation. It involved the participation of more than 15 blood bank teams. 23892 units of blood were collected in these drives. The participating blood banks agreed to follow common standards which were based upon the Drugs and Cosmetics Act, the NACO guidelines and the WHO guidelines. Common definitions for non-compliance to the process to be followed for blood collection were agreed upon and the classification of adverse reactions/events was accepted as per the ISBTI working party on hemo-vigilance. A software system was setup to capture data associated with each drive. This included non-compliance, adverse events, deferral rate and the % of component preparation. A scoring system (with a max score of 10) was defined to rate the drive on each of these parameters and generate a total score.
The implementation of this quality management system allowed each blood donation camp to be bench-marked rationally. It allowed immediate identification of causes of concern and enabled continued performance improvement. It further allowed comparing performance over time paving way for scientifically informed review of the delivery of service to the donors. Informed decision on selection of blood banks and volunteers for future blood donation camps was also possible. It was seen that an average score of 7.429 was obtained over the 301 camps with an average of 3.63% adverse events, 1.5 instances of non-compliance, 23.67% deferrals. 79.93% units were eligible for component preparation.
We were able to establish and implement a rigorous performance assessment system and set-up effective quality management of outdoor blood donation camps. In particular the need for a consensus on donor deferral, stricter implementation of adverse event management protocol and ensuring greater compliance to norms by all teams was clear. Our experience paves the way for better quality assurance for voluntary blood donation.
Is voluntary blood donor calling a challenge?
Deepak Kumar, Rashmi Sood, Sushma Rani, Asha Bora, Vineeta Gupta
The first records of the voluntary blood donation initiative in India can be traced back to 1942, during the time of World War II when the first blood bank was established in Kolkata, West Bengal. A decade passed by till Mrs. Leela Moolgaokar initiated voluntary blood donation drives in Mumbai, 1954 onwards. She was inspired by the blood need of her injured son. In 1971, Prof. J.G. Jolly the founder President of the Indian Society of Blood Transfusion and Immunohematology took the movement to further heights and the Society under his stewardship declared October 1 as National Voluntary Blood. In India, the ratio of usage of blood components to whole blood is 15:75, while globally it is 90:10.
Study was carried out in Department of Transfusion Medicine, Saket City Hospital since July 2013 to July 2015. Voluntary blood donations are very useful to our society.
Results: Our blood bank has prepared in house & outside voluntary panel. Since July 2013 to July 2015, 434 voluntary donors were arranged for blood donation with negative and positive group. Response was good but difficult to call because the donor had different types of queries includes: Number of donor's called-620. Number of Blood donors coming for donation-434. Number of Blood donors not coming to blood bank on calling-186. Reason for non-compliance on first call towards blood donation, No. of Donors with this response, % of Donors with this response, No & % of Blood Donors coming for blood donation out of these non-complaint one second call
· Donated few days back - 67 (36%), 0 (0%)
· Out of station - 41 (22%), 8 (1.84%)
· Will come within 2 to 3 days - 24 (13%), 10 (2.30%)
· Phone not reachable - 15 (8.06%), 2 (0.46%)
· Not Feeling well - 14 (7.52%), 1 (0.23%)
· Will talk to patient relative then consider donation - 8 (4.30%), 3 (0.69%)
· Call disconnected, once he/she knows calling for blood - 7 (3.76%), 0 (0%)
· Call you later - 4 (2.15%), 1 (0.23%)
· In house or outside patient - 3 (1.61%), 1 (0.23%)
· Arrangement of transportation - 1 (0.53%), 2 (046%)
· Associated with other voluntary blood bank - 1 (0.53%), 0 (0%).
Positive blood donors came easily for blood donation but negative blood donors were not willing to come immediately. While making call to blood donor, first we need to motivated them, once they get motivated then convenience them for repeat donation. Effective voluntary donor calling gives best result to retain blood donors. In last 2 years, 434 voluntary donors have been enrolled out of which 318 donorswere positive blood group and 116 of negative. Number of repeat donor's average is 6 to 7 every month since 1.5 year.
Visual inspection: An important parameter in the quality control of blood components
R Raj Bharath, P Arumugam
One of the important parameters in quality control of blood components is visual inspection of the blood bags. Many abnormal conditions occurring in the blood bags such as hemolysis, clots, lipemia, icterus, particulate matter and bacterial contamination can be identified by having a proper visual inspection. Blood components and blood products should also be visually inspected for proper labeling, collection and expiry date. Blood components that do not meet visual inspection criteria as prescribed by quality control standards must not be issued for transfusion. We report various instances in blood bank where visual inspection of blood components helped in averting a major adverse event.
This study was carried out at each phases such as blood collection, component separation, storage, issue of blood and also in case of an adverse transfusion reaction at the blood bank for the past three years. Blood bags which did not fulfill the quality standards were either quarantined or discarded and the probable reasons were analysed.
The most common aberration at the time of phlebotomy procedure was excess blood volume collection which was a predisposing factor for clots in bags. Lipemic or icteric plasma was the common cause for discarding of fresh frozen plasma during or after component separation. When stored blood components were analysed for their entire storage period, hemolysis was a predominant cause in red cell concentrate which on testing were above the normal standards. Rare instances of white particulate matter or aggregates in whole blood and red cell concentrate were other reasons for discarding of blood bags. Absence of swirling in certain platelet concentrates and RBC contamination was a main reason for discard of platelets. There were two cases of Macroaggregates in the thawed plasma which on histopathologic examination revealed eosinophilic acellular material. During issue of blood components improper labeling concerning the details of the bag was a common error. There were few cases when the bag was returned back to blood bank for no blood flow which later was found to be clots obstructing the lumen of the blood infusion set. Clots were smaller in size which was missed by the staff while issuing the blood component.
Visual inspection is an easy but effective way of improving the quality standards of blood components in a blood bank. Our experiences emphasize that proper and meticulous visual inspection at various phases in blood bank helped in preventing possible adverse events.
Screening of red cell antibodies in normal healthy blood donors in a hospital in North India
Archana Solanki, Tulika Chandra
Provision of safe blood for transfusion does not only imply thorough testing for infectious markers, but also protection from haemolytic transfusion reactions resulting from alloimmunization against red cell antigens. The development of red cell antibodies can significantly complicate transfusion therapy and results in difficulties in cross-matching of blood. Most literature on red cell alloimmunization is limited to multi-transfused individuals, with very few studies on the general blood donor population. This study was aimed at assessing the frequency and type of unexpected red cell antibodies in the general donor population at a multispecialty hospital in North India. The purpose of this study was to determine prevalence and identification of unexpected red cell antibodies in healthy blood donors. To assess the further need of additional red cell antigen typing (other than ABO and Rh) on blood donors.
Blood donor samples for antibody screening were tested from January 2014 to June 2015. During study period a total of 76,803 healthy donors (71902 males and 4901 females) were screened for the presence of red cell antibodies. Initially antibody screening of all blood donors was performed as routine by using commercially available single vial of 2 pooled donors (Diagast, qwalys, hema-screen, erythrocyte magnetised technology). Positive sera were further investigated to identify their specificity by commercially available red cell panels (Diagast, qwalys, hema-ident, erythrocyte magnetised technology).
The prevalence of unexpected red cell antibodies was 0.38%. Antibodies against the MNS system were most common, followed by Rh system. Among the MNS blood group system the most common alloantibody identified being anti-M (20.5%) followed by anti-N (11%). In the Rh blood group system the most common antibody was anti-D (5.2%) followed by anti-E (4.4%).
Alloimmunization to red cell antigens is still a current problem in our transfusion practice. Since clinically significant antibodies are detected in our blood donor population, antibody screening and if required, identification of that antibody is the need as well as challenge for the blood transfusion services. This strategy is another step forward to improve the safety of blood transfusion with optimal blood grouping.
ABO and Rh association to transfusion transmitted infections among healthy blood donors in Jamnagar, Gujarat, India
Sumit Vallabhdas Bharadva, Jitendra Vachhani
This study aims at investigating the seroprevalence and correlation between ABO & Rh groups and transfusion transmitted infections namely: HIV. Hepatitis B, Hepatitis C and Syphilis duration from January, 2013 March, 2015.
A Retrospective study was conducted at Dept of IHBT, G.G. Hospital Jamnagar, Gujarat, India. The serum samples of the donors were tested for the most common transfusion transmitted infections namely; Hepatitis B, Hepatitis C, HIV, Syphilis by Third generation ELISA kit for Hepatitis B and Hepatitis C, Fourth generation sandwich ELISA HIV and RPR tests for syphilis. Blood grouping of the donors was done through standard tube agglutination technique which included forward and reverse grouping. The results thus obtained were put for chi square analysis in order to determine statistical significance.
In total, 42274 serum samples were collected from January 2013 to March2015. Out of them 317 were positive for Hepatitis B, Hepatitis C, HIV, and Syphilis. The seroprevalence of HBV, HCV, HIV and Syphilis was 0.57%, 0.05%, 0.10% and 0.05% respectively. Hepatitis C infection were significantly associated with blood group of donors (P < 0.05). Percentage of Hepatitis C was found to be higher in donors with blood group A. There was no significant association found between HIV, HBV and Syphilis with blood group of donors.
Prevalence of Transfusion Transmitted Infections among blood donors of G G Hospital is relatively low as compared with different regions of India. From the study it was concluded that Blood group type of an individual has got some association with Hepatitis C infection.
Utility of combining molecular and serological techniques in individuals with Rh discrepancies
Amal Raj, Rajeshwari, JJ Mammen, Dolly Daniel
The Rh blood group system is a complex blood group system and is underscored by the RhD, is considered the most immunogenic of all antigens. Serological detection of RhD antigen is one of the important test done in the immunohaemotology laboratory. Considering greater risk of alloimmunisation, it is imperative to identify the presence of RhD antigen. Although most individuals may test as Rh positive/negative, variant forms of D genotypes are implicated for the occurrence of weak or partial D forms. The role of combined serological and molecular techniques in resolving Rh discrepancies.
A retrospective study, was conducted on subjects whose blood was Rh typed between years 2012-2015 at our centre. Our routine protocol included duplicate testing on 2 platforms. In subjects with discrepant results combination of serological tests and molecular typing was performed. These serological platforms are tube method, microtitre plate, CAT method in Diamed (DVI+/DV1-) and Ortho cards. Molecular typing done by PCR SSP kit for weak D and partial D type, when discrepancy could not be resolved by serology.
Out of a total of 2,44,000 subjects who were Rh typed over a span of 3 years, 0.2% (38) of subjects were noted to have Rh discrepant results. Of the 38 patients with Rh discrepancy, in 65.7% (25) of subjects combination of serological platforms were able to resolve the discrepant results. However in 34% (13) of patients molecular typing was indicated. The group of patients who underwent molecular typing fell into three categories. In first group, 8 subjects had wide range of strength of reaction (0 to 3+) on serological platforms. In these subjects both partial and weak testing was done and it revealed to have 1 subject with partial D (DAR 4.2) and 7 subjects with wild type RhD positive. Second category included 3 individuals, who appeared to be DV1 positive based on the serological tests. Only one subject was identified to have partial D (DFR) and remaining two being wild type. The last category included 2 individuals with suspected weak D. Subjects had weak positive reaction and positive reaction with AHG respectively. These patients were noted to be wild type and partial D (type 15) respectively.
The Rh antigen by virtue of its high level of immunogenicity, requires accurate identification. This study highlights the importance of using a combination of multiple serological platforms and reagents along with molecular typing, which ensures resolution of RhD discrepancy thus impacting both on transfusion practice and quality of clinical care.
Hemovigilance: A step towards managing safe blood transfusion at G.G. Hospital, Jamnagar
Spruha Kashyap Dholakia, Sumit Bharadava, Jitendra Vachhani
Hemovigilanceis defined as set of surveillance procedures covering the whole transfusion chain from collection of blood and its components to follow up of its recipients intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence and recurrence. This study aims at establishing hemovigilance and creating awareness among clinicians for rational use of blood and its components.
To study overall requirement of blood and its components over a period of one year at G.G. Hospital, Jamnagar from August-2014 to July-2015, for a period of one year. Requisition form send by clinicians from different wards and analysed for their requirements and retrospective analysis was made.
Through this audit the data regarding overall requirement of blood in a tertiary care hospital was obtained. It was also useful for quality validation of blood products issued from blood bank.
Hemovigilsnce is extremely necessary to manage blood demands at tertiary care hospital and to enhance transfusion safety and avoid irrational use of blood and its products.
External quality assessment scheme in blood bank viral transfusion transmitted infection screening: Experience from a Tertiary Care Center
Antonio Paul, Amal Raj, Priya Abraham, Rajesh Kannangai, Dolly Daniel, Sukesh C Nair, JJ Mammen
Participation in external quality assessment scheme (EQAS) or an inter-laboratory comparison (ILC) is integral to assuring accuracy in blood bank testing for transfusion transmissible viruses. Among the reasons that are cited for non-participation are the lack of awareness about its significance, difficulty in performing the required tests, lack of easy access to characterized material be tested, substitution of kit controls for EQAS, lack of regulatory requirement and the associated expense. We describe results from an ILC between Department of Clinical Virology and blood bank over the last 12 years within our institution to ensure quality in viral TTI screening in the blood bank.
Once a month, a coded panel of 10 plasma samples that are variably positive for Hepatitis B surface antigen, Hepatitis C Virus (antibody) or HIV 1/2 antibody and characterized by the Department of Clinical Virology are provided to the blood bank in a blinded manner. These samples are included along with the routine analysis of blood donor samples. The results are tabulated and submitted to the Department of Clinical Virology that performs the evaluation of the results and communicates it to the blood bank in a confidential manner.
Comparison of blood bank results with virology lab results showed that 98.75%, 97.42%, 99.51% concordance for HBsAg, HCV and HIV respectively. In all instances (100%), the lack of concordance was due to increased false positives detected by the blood bank screening system.
The results show that the highly sensitive kits used in the blood bank led to lack of concordance. We describe a method to perform an ILC utilizing the resources available within institutions thus overcoming expense and availability issues and thereby providing confidence in the blood banks testing system. It is also perhaps time for regulatory bodies to consider making this a mandatory requirement.
Frequency of alloantibody in multi-transfused thalassemia major patients and factors affecting alloimmunization
Kruti Kiritkumar Patel, Nidhi Bhatnagar, Maitery Gajjar, Megha Shah, Sangita Shah, Hardik Raval
The recommended treatment for beta thalassemia major is blood transfusions at regular intervals to maintain desired hematocrit. Due to multiple transfusions, some patients develop alloantibody (usually IgG) against the antigens of transfused RCCs (Red cell concentrates). These can result in acute or delayed haemolytic transfusion reaction and difficulty in finding compatible blood units in subsequent cross-match. The purpose of this study was to determine the frequency of development of RBC alloantibodies, specificity of these antibodies and factors influencing on alloimmunization among multi-transfused thalassemia major patients.
Total 185 paediatric patients with thalassemia major who had received regular transfusion in Civil Hospital Ahmedabad, Gujarat, India, during 2014-15, are evaluated for antibody screening by Qwalys-3 (Electromagnetic technology, manufacturer: Diagast). Antibody screening was performed by 3-cell panel followed by antibody identification using 11- cell panel by column agglutination technique(manufacturer: Biorad).
15 patients developed alloantibodies against RBC Antigen. Out of total alloimmunized patients, 9 patients were female and 6 patients were male. Majority of alloantibodies were directed against antigen in the Rh and Kell blood group system.
Frequency of red cell alloimmunization was 8.11% in this study. Alloantibodies were found mainly against Rh and Kell blood group system. In our study alloimmunized patients did not revealed any evidence of haemolytic transfusion reaction. The frequency of Antibody positivity depends on immunogenicity of Antigen. Females patients are showing more frequency of alloimmunization. Effect of leuckodepleted blood is still debatable. Routine pretransfusion matching of blood, other than ABO and RhD antigen is recommended to find out alloimmunization in multi transfused patients. Along with this, Patients extended red cell phenotyping is recommended before starting first transfusion for determining antigen matching in case of future development of alloimmunization.
Comparison between Luminex crossmatch and single antigen bead assay in detecting donor specific anti HLA antibodies
Shanthi Ravi Kumar, Mary P Chacko, Dolly Daniel
Background: Pre-renal transplant work up has evolved tremendously in recent times from dependence on the complement dependent Cytotoxicity (CDC) crossmatch to the use of highly sensitive platforms such as the Luminex crossmatch (LumXm)and the Luminex single antigen bead (SAB) assay to aid in detecting donor specific antibodies. While in the LumXm donor lysate and patient serum are used with micro beads coated with either class I or class II HLA antigens, in the SAB assay patient serum is tested with a panel of beads, each one conjugated with a single recombinant HLA molecule (class I or class II).
Aim: To compare the LumXm using donor lysate and SAB assay in detecting donor specific anti-HLA antibodies.
This study conducted over a one year period included 61 patients awaiting renal transplant for whom both a LumXm using donor lysate and SAB assay had been performed for donor specific antibodies.
The 61 patients included in our study were divided into 4 groups. The first group included 18 patients who showed concordant results on both platforms - 1 patient was positive for both Class I and Class II and 17 were negative for both classes. The second group included 9 patients who showed positivity on the SAB, but were negative on LumXm. Of these 7/9 were positive for Class I donor specific antibodies and 2/9 for Class II. Third group had 18 patients on the LumXm however showed negative result on the SAB. These 18 patients had MFI ranging from 1010 to 5041 with a mean of 2,443 MFI. In this group 5 had Class I donor specific antibodies and all 18 had Class II antibodies. The last group consisted of another 16 patients positive on LumXm and on SAB, however the antibodies identified on the SAB were not donor specific.
A concordance of 30% (18/61) was observed between the two platforms. The efficacy of picking up donor specific antibodies by SAB assay in 9 of 61 patients can be possibly explained by its greater sensitivity and specificity. 34/61 patients showed positivity on LumXm but negative for donor specific antibodies on SAB. Considering the intensity of MFI of this group it raises the question whether all alleles of our ethnic population are represented on the beads. Therefore it is prudent to use a combination of platforms and have an algorithm which includes different formats to ensure detection of all donor specific antibodies.
Analysis of wastage of blood and blood components in a Tertiary Care Center at Bhubaneswar, Odisha
Rachita Behera, Suman Sudha Routray, Girija N Kanungo, Bibudhendu Pati
Blood transfusion is an integral and indispensable part of health care system. Human blood has no substitute. This emphasizes judicious use of blood and its component with minimal wastage. By analyzing the data and the reason for the discards, the blood transfusion services can take remedial measures to minimize the number of discarded units.
This retrospective study was carried out in the blood bank of IMS and SUM Hospital, Bhubaneswar. A total of 19709 donors donated blood during the period from 1st January 2013 to 31st July 2015. The donors record, transfusion transmitted infections (TTI) testing record, component preparation record & discard record during the said period were analyzed.
A total of 334 units of WB & PRBC were discarded. Out of these 277 (82.93%) (WB 94; PRBC 183) were discarded because of TTI positivity. Among this HBsAg positive 202 (60.47%), HIV positive 59 (17.6%), HCV positive 15 (4.49%), Syphilis reactive 1 (0.29%). Hemolysis occurred in 22 (6.5%), Leakage during centrifugation 12 (3.59%), Irregular antibody 10 (2.99%), Low collection 10 (2.99%), Outdated 3 (0.89%). In the 19709 donor units, percentage of overall TTI positivity was 1.40% (HBsAg 1.02%, HIV 0.29%, HCV 0.07%, Syphilis 0.005%, MP 0%), Hemolysis was 0.11%, Leakage during centrifugation 0.06%, Irregular antibody 0.05%, Low collection 0.05%, Outdated 0.01%. A total of 12392 RDP were prepared out of which 440 units were discarded. The most common cause of discard was outdating 257 (58.40%) followed by TTI positivity 183 (41.59%). Out of 12392 FFP prepared 222 units were condemned. Amongst these 183 (82.42%) were TTI positive and 39 (17.56%) had leakage during thawing, most likely due to mechanical damage to frozen bags during retrieval from ultra low freezer.
A properly conducted donor interview, correct response to donor questionnaire will help in reducing the number of discarded blood and components units due to TTI positivity. Similarly, properly implemented blood transfusion policies and inventory management in blood bank would prevent blood wastage due to outdating. Careful handling of FFP units stored in deep freezers would prevent leakage during thawing. This will not only minimize wastage of man power but also optimize material and financial resources of blood bank.
Targeted yield and post harvest platelet count in SDP donors at a Tertiary Care Centre in Odisha
Suman Sudha Routray, Rachita Behera, Girija N Kanungo, Bibudhendu Pati
The quality of SDP in terms of yield influences the platelet recovery in the recipient and allows prolonging intervals between transfusions. Various donor factors such as predonation platelet count, BMI, age, haematocrit may affect platelet yield. The aim of the study was to assess the effect of automated plateletpheresis on platelet count of healthy donors subjected to various yields and effects on donors.
A retrospective study was performed in 300 healthy, first time plateletpheresis donors in the Transfusion Medicine Department, IMS and SUM Hospital, Bhubaneswar between July 2014 to July 2015. Donor demographic and laboratory data were analyzed prior to performing plateletpheresis. The plateletpheresis procedures were performed using TRIMA ACCEL programmed at different yields depending on donor's pre-donation platelet counts and BMI. TBV calculated based on BMI and Nadler's Formula. To assess the pre and post-donation platelet count, whole blood samples were collected in EDTA vials just before and within 30 minutes after the procedure. A relationship between yield of platelets and post donation donor platelet count was studied using Pearson correlation test.
The age of donors ranged from 18 to 54 years (mean 25.79 years), weight ranging from 55 to 101 kg (mean 73.56 kg) and height from 149 to 195 cm (mean 169.23 cm). Pre donation platelet count ranged from 155 to 450 (x109/L) with 79 donors (26.33%) having platelet counts between 150 to 200 (x109/L), 198 donors (66%) in the range of 200 to 300 (x109/L) and only 23 donors (7.67%) between 300 to 450 (x109/L). A significant decrease in the post donation platelet count (P < 0.05) was observed following plateletpheresis with total mean reduction of 54.100 0.381 (x109/L) at 3.0 x 1011/unit yield (60 donors); 69.657 3.396 at 4.0 x 1011/unit yield (111 donors); 73.592 7.981 (x109/L) at 4.5 x 1011/unit yield (49 donors); 80.313 0.803 (x109/L) at 5 x 1011/unit yield (80 donors). A positive correlation was observed between platelet yields and post donation drop in platelet count in SDP donors.
Despite a significant drop in platelet count following plateletpheresis, none of the donors had post donation count below 100 x 109/L. Nevertheless, more prospective studies on this aspect are required to ensure donor safety with a targeted higher yield. This will help develop protocol in cost effective SDP supply to patients requiring multiple transfusion.
Significance of antibody significance of antibody screening and identification in Pretransfusion testing: A retrospective study
Background: Genetic disparity of red cell Antigen between donor and recipient is responsible for RBC alloimmunisation. Though red cell transfusion is a lifesaving therapy in most of the patients, risk of alloimmunisation is always a concern for patients receiving multiple transfusion. Pregnancy also carries the risk of alloimmunisation. Very few studies on alloimmunisation are done on the general Indian Hospital patients. Aim The study was aimed at assuming the frequency and type of unexpected red cell antibodies in both patients going to receive transfusion and antenatal cases at a multi-specialty tertiary care hospital in Bangalore.
Methods: It is a retrospective study. Antibody screening was carried out in 1912 patients including inpatients and antenatal mothers from January to December 2014. All positive cases were subjected to antibody identification. In patients receiving transfusion antigen negative red cells were cross matched and given. Antenatal cases were followed up every month with antibody titre till the time of delivery.
Results: It is a retrospective study in which evaluation of 1912 cases (870:45.5% males and 1042:54.5% females) done. Antibody screening was positive in 19 patients (0.99%). In the serum samples of 37 patients only autoantibodies were identified, 4 cases revealed autoantibody along with underlying alloantibody. The total alloimmunisation rate was 0.99%, alloimmunisation in antenatal females was 0.15%. Among the antenatal females anti D was the most common (4 cases) Anti E and Anti K one each.
Interpretation and Conclusion: Since clinically significant antibodies are frequently detected in our patient population, antibody screening and identification is mandatory to ensure safe transfusion practice. Since antibody against Rh, Kell and Le group antigens are more common and clinically significant, provision of Rh and Kell matched cells may be of protective value. Clinically significant unexpected antibodies are capable of causing hemolytic transfusion reactions secondary to accelerated destruction of a significant proportion of transfused red blood cells. Therefore, screening for unexpected antibodies should be part of all pretransfusion testing, with antibody identification in the event of a positive result. Antenatal detection of the non-anti-D causes of HDN requires Red cell antibody screening. If RCAS is positive, the following steps are to be taken. Antibody Identification should be done to identify the antibody. The spouse has to be screened for the presence of offending antigen and the pediatrician has to be alerted about delivery of a potentially sensitized infant. The blood bank should find a suitable antigen-negative donor for transfusion to baby and mother.
A study on the blood transfusion practice in the ectopic pregnancy management
M Sri Devi, P Arumugam
Background: An ectopic pregnancy is a life threatening clinical condition. It is the leading cause for the pregnancy related deaths in the first trimester of pregnancy. The management options available are surgical, medical and expectant management. The surgical management is indicated in the hemodynamically unstable patients (due to ruptured ectopic and resultant hemoperitoneum). Medical management is preferred to hemodynamically stable patients on an out- patient basis and with good patient compliance for follow ups.
Aim: To study the transfusion practice in the management of the ectopic pregnancy.
Materials and Methods: The ectopic pregnancy cases of our hospital, with their cases records and the blood requests were accessed for the clinical and blood transfusion details for six months period (August 2014 January 2015).
Results: Total ectopic cases-29, medically treated cases-5, surgically treated cases-23, and one case with failed medical treatment, was subsequently treated surgically. Whole blood -24 units, red cell-43 units, plasma-10 units were the blood usage pattern for the all cases under study. Red cells of 26 units transfused for anemia in medically managed cases (1 case each with hemoglobin 7-8 gms% and 8-10 gms%, 4 cases in >10 gms%). There were no other co-morbid medical conditions. No side effects due to Injection Methotrexate noted during the management.
Conclusion: The stringent criteria are used to select cases for the medical management of Ectopic pregnancy. This mode of treatment reduces the morbidity due to anesthesia and surgical management for the uncomplicated ectopic. The recovery period is faster. The blood transfusion is known for its immune and non-immune complication. The use of the same if restricted/followed as per the transfusion guidelines for anemia management to such medically managed cases without any co-morbid illness, would prevent the cases from the hazards of transfusion and improve the blood inventory.
Study of seropositive cases of transfusion transmitted diseases
Gopal Krushna Ray, Smita Mahapatra, Binay Bhushan Sahoo
In the process of life saving by blood transfusion, there is always risk of transmisson of transfusion transmitted diseases. The organisms causing mainly are Hepatitis B virus, Hepatitis C virus, Human Immunedeficiency virus, Cytomegalo virus, Syphilis, Malaria. This study is aimed to determine the prevalence and trend of seropositive cases on yearly basis.
This study was aimed to determined the prevelance of sero-positive cases in blood donors in our hospital SCB MCH, Cuttack from January 2010 to July 2015. All voluntary and replacement donors were screened for mainly five disease. 5 ml blood was taken in a test tube and then cenrifuged for obtaining serum, then tested for HBsAg, HCV Antibody, HIV Ab by ELISA & Syphylis and Malaria by rapid kit test (card).
It was a retrospective study on total 100701 donors. Majority of donors were male 94627 (93.96%), and also voluntary donors 76308 (75.7%). There was gradual increase in seropositive cases from 0.3% in 2010 to 1.2% in Jan-July 2015. Out of total 1,00,701 donors there were 528 (1.2%) seropositive cases constituting 24 numbers of HIV, 403 numbers of HBsAg, 95 numberss of HCV, 4 numbers of VDRL & 2 numbers of MP.
Most of the seropositive cases were male 506 (95.8%), as most of the voluntary donors were male. The number of voluntary female donor was less (6074, 6.04%), due to lackof education, awareness, information and so also there is more rejection due to anemia, low weight, malnutrition. Though in our study the prevalence of seropositive cases was low 0.5% in comparison to other studies, may be due to more numbers of voluntary donors, proper medical history and examination but there is increase in trend of seropositive cases from 2010 to 2015 as more sensitive and specific test methods are being followed.
ABO blood group discrepancies: How frequent and what is the way forward? A study carried out at a Tertiary Care Medical Centre in South India
Ashish Dhoot, Jui Choudhuri, Amal Raj, Dolly Daniel, Joy John Mammen
Accurate ABO blood grouping forms the basis of safe transfusion practice. Discrepancies, identified on the basis of mismatch between the forward and reverse blood grouping can be a major challenge in an immuno-haematology laboratory. They can occur due to underlying clinical conditions, ABO subgroups or other causes. Discrepancies are categorized into 4 groups: Type 1 due to weak or missing antibodies, Type 2 for weak or absent antigens, Type 3 are commonly due to rouleaux formation and Type 4 has other miscellaneous causes.
Aims: To analyse ABO blood group discrepancies along with the associated clinical condition and resolve them using molecular method.
In our institute every blood grouping (patients and donors) is done in duplicate using two different platforms. Blood groups like Bombay group and A2 subgroup are identified using lectins such as Anti-H and Anti-A1 respectively. A retrospective study was done between September 2014 and August 2015 in which all patient and donor results showing ABO discrepancies consistent on all platforms were analysed, along with the clinical condition to resolve them. Unresolved groups were further identified using molecular grouping (BAGene of BAG Health Care).
Of a total of 1,06,278 blood groupings (69% corresponds to patients and 31% for donors) carried out during the study period, 35 (0.033%) discrepancies were encountered. Of these 26 (0.024%) were among the patient population and 9 (0.008%) among donors. 57% (29) were type 1 discrepancies, 29% (10) type 2 and 14% (5) were type 4. We observed no type 3 discrepancies in our study group. Auto immune haemolytic anaemia with cold autoagglutinins was the most frequently associated clinical cause and responsible for 38% (10) cases, with haematological malignancies following the trend. Molecular ABO grouping was done for 5 among the patients which could be accurately resolved and were transfused with group specific unit. The remaining 21 patients were transfused with O blood group red cells as per routine protocol and further molecular typing is awaited.
Forward and reverse grouping together not only form a check in itself but also help to pick up discrepancies. Resolving discrepancies is absolutely crucial to label patients and donors correctly and cannot be ignored in view of our constant effort at improving transfusion practices and safety. Against this background, though molecular blood grouping is expensive for routine practice it can be incorporated in tertiary centres to resolve such discrepancies.
Reference lab of IH in Karnataka: One year experience at rotary TTK Blood Bank
Samrat Thapa, Ankit Mathur, Darshan Adulkar
During nascent stage of Transfusion medicine, a generation of medical men had grown up believing that blood transfusion is one of the simplest forms of therapy. But, with the advancement in technology and core study of Transfusion Medicine, we have been able to figure out slightest deviation from expected result in Immunohematology lab and explain it clinically. Significant number of cases are reported daily for incompatible testing , discrepant blood group and post-transfusion reaction; indicating the need of a Reference Lab which can solve the issues faced by a conventional immunohematology lab. Immunohematology Reference Laboratories provide an exchange of information and consultation on red cell antibodies, discrepancies in blood typing and blood compatibility testing. Rotary Bangalore TTK Blood Bank, Bangalore receives discrepant samples from various blood banks & hospitals to perform Advanced Immunohematology tests.
The IH lab receives discrepant samples from various hospitals/blood banks of South India for investigation/testing of Irregular Antibody, ABO typing discrepancies, Positive DAT, Compatibility etc. Testings were performed by both tube technique as well as Column Agglutination Technique. All groupings and IAT were performed in Autovue while 3 cell panels as well as 11 cell panel were done both in Tube and Biovue. The advanced techniques like adsorption-elution & auto/allo-adsorption were also performed as per the requirement.
Of the total 102 samples received in the lab from Sept 2014 to Aug 2015. Out of 102, 18 cases were requested for Resolution of ABO Typing Discrepancy while remaining others were all requested for Antibody screening and Identification. Out of 84 samples for ABID, it was found that Anti-D was most frequently detected antibody with 27 Anti-D cases reported. Anti-M, with 07 cases reported made it to the second place. Anti-c, with 06 cases, was third most reported antibody followed by Anti-E (05), Anti-Leb (05), Anti-Lea (03), Anti-P1 (02), Anti-K (02). Similarly each of Anti-S, -N as well as -Fya were detected once taking the count of allo-antibodies to 60. Whereas there were 13 cases of autoantibody reported out of 84 samples for ABID.
The study concludes that 71.4% of cases were reported for allo-antibody while 15.47% cases were reported for auto-antibody. Similarly, 2.38% cases were of antibody with high frequency antigen and those cases where no clinically significant antibody was detected covered 10.71%. It is also seen that a Reference lab is mostly getting samples for ABID which covers 82.35% followed by samples for resolution of blood grouping discrepancy i.e. 17.65%.
Proficiency testing: External samples for internal assessment
Ravishankar Jeyaraj, Pothipillai Arumugam
The primary objective of proficiency testing is to provide laboratories with an information and support to demonstrate and improve the quality of their analytical measurement. ISO/IEC 17025 has prescribed the requirements for maintenance of quality system in Testing and Calibration laboratories. The Department of Transfusion Medicine, The Tamilnadu Dr. MGR Medical University is participating in EQAS programme from the year 2011. The samples are received from CMC EQAS by the Department of Hematology and Transfusion Medicine, Christian Medical College, Vellore which is a NABL Accredited Proficiency Testing provider (PTP-ID: P-0004). The aim of the study is to evaluate the performance of our blood bank in EQAS tests over the past 4 years from 2012-2015.
We regularly participate in Immunohematology program of EQAS which includes ABO grouping, Rh typing, crossmatching, Direct & Indirect antiglobulin testing, antibody screening and antibody identification. Test samples are received thrice a year in 8/9 tubes with patients red cell suspension and plasma, three donors red cell suspension and plasma (sometimes a separate sample for antibody identification). All tests were run as regular test samples by laboratory technicians and results were documented in the prescribed format. According to the Proficiency scoring for Immunohematology (CLIA Subpart 1-Sec. 493.959), a testing lab must obtain 100% of challenges correct in ABO grouping, D typing and compatibility testing. 80% of the challenges should be reported correctly in unexpected antibody detection and antibody identification. All test results along with the marks calculation sheet received from 2012 to 2015 were analyzed and documented.
A total of 11 test samples were received during this study period. Full marks were obtained (450/450 or 550/550) in 9 of the 11 tests. Marks were reduced twice during this period. Once, it was due to error in filling the report form (DAT result was not filled even though the test was performed) which resulted in reduction of marks. In another instance, it was due to missing the antibody identification due to aged reagent cell panel.
Regular participation in proficiency testing programs has helped our blood bank to be more effective in maintaining quality of service. The efficiency of the standard operating procedure and compliance of the personnel to the SOPs are accurately assessed by EQAS program. Thus it also helps in continuous assessment of laboratory practices and personnel.
A case report of anti P1 alloantibody positivity
The carbohydrate blood group antigens that are most relevant in the Transfusion Medicine is found in the P human blood group system. The immune response to these antigens classically produce low titred IgM antibodies and are rarely of clinical significance; however, rare acute hemolytic transfusion reactions have been described. In contrast, the unusual individuals with the P1k, P2k, and p phenotypes have naturally occurring high-titered IgM antibodies with specificity either for the P antigen (ie, anti-P) or for all the antigens in the P blood group system (ie, anti-P1PPk). These antibodies are clinically relevant in that they can cause severe hemolytic transfusion reactions. An unusual syndrome of recurrent spontaneous abortions has also been associated with these antibodies, In addition, the syndrome of paroxysmal cold hemoglobinuria is caused by Donath-Landsteiner antibodies which are cold reacting, complement-fixing IgG antibodies with anti-P specifi city that cause immune-mediated hemolysis in vivo.
A 52 year old female referred to Medical College Hospital for anemia correction following fibroid induced menorrhagia. She was a multiparous lady with 2 full term normal deliveries without any complications. There was no history of transfusion/immunoglobulin intake. No family history of any autoimmune/hereditary disorders. Her physical examination revealed moderate pallor with bilateral pitting pedal oedema. Abdominal examination showed the presence of a mass consistent with fibroid. Lab investigations confirmed anemia with peripheral smear showing microcytic hypochromic cells. Decided to go for transfusion. As a preliminary step, blood grouping was done. She was typed as having B+ve blood group. But when cross matching was done it showed incompatibility. So gone for antibody screening. It showed the presence of an alloantibody with wide thermal amplitude more reactive at colder temperature.
An antibody identification test was done which showed a pattern consistent with anti P1 antibody. As per serial titration test antibody titer was high.
So P1 negative blood was identified among donors by random crossmatching with patients serum & compatible one issued. After transfusion her anemia improved.
Evaluation of fresh frozen plasma use in a Tertiary Care Hospital in Punjab
Jasmeet Singh, Amarjit Kaur, Rajesh Kumar, Sonia Gupta
To determine patterns of usage of fresh frozen plasma (FFP) in a tertiary care hospital and optimizing usage to address concerns about transfusion-transmitted infections (TTI) and overcoming shortage of blood components.
A retrospective study of fresh frozen plasma (FFP) usage was carried out in a tertiary care hospital in North India to determine usage patterns with the aim of optimizing usage of blood and blood components.
A total of 749 units were issued to 141 patients during the study period, of which 68 units (9%) were returned to unused, and were wasted. Among 141 patients, 93 (66%) had appropriate FFP transfusions (247 units) according to British Council for Standardization in Haematology (BCSH) criteria for indications that primarily included chronic liver disease and prolonged bleeding with abnormal coagulation profile.
34% of total fresh frozen plasma (FFP) requests were inappropriate as per British Council for Standardization in Haematology (BCSH) criteria. Regular auditing of blood component use and appropriate physician training through regular CMEs and lectures is needed to rationalize the use of blood components.
Audit of Irradiated blood components usage in Surat's Hospitals
Hetal Prashant Randeri, Rinku Shukla, Snehalata Gupte
Background: Surat city has about 50 lakhs population and about 5000 big and small hospitals among which 24 receive irradiated blood from Surat Raktadan Kendra & Research Centre as only this centre has the Blood Irradiator in South Gujarat. It is a compact, portable, self- shielded type of a Co-60 Gamma Irradiator. Irradiated blood/blood components are in use for immunocompromised patients and first degree family members of patients to prevent transfusion associated Graft Versus Host Disease (TA-GVHD).
Aim: Transfusion audit of Irradiated blood components in different indications.
Materials and Methods: The minimum dose of irradiation achieved in the irradiated field is 25 Gy. The details of irradiated blood/blood components supply for different category of patients were analyzed using data from the requisition and blood components issued which were entered in Microsoft excel.
Result: During the period of Feb-2014 to July-2015, 51,559 blood units were collected and 4,479 (8.68%) unit of random donor platelet (RDP) and 47,561 (92.2%) red cell concentrate (RCC) were prepared. 2727 (4.3%) units of RDP and 44,312 (71%) unit of RCC were issued among which 183 (6.71%) RDP, 223 (0.50%) RCC were irradiated. We received 268 demands for irradiated product from 24 hospitals and 19 other centers. The maximum usage of irradiated components was 62 for Acute Myeloid Leukemia (AML), 27 for Thalassemia, 25 for Acute Lymphoid Leukemia (ALL) patients and many other cases.
Conclusion: On the basis of the present audit it is concluded there is a grossly inappropriate usage of irradiated blood components prescribed in Surat hence training of proper use of irradiated blood components in the city is necessary.
Red cell transfusion practices in critically ill patients
Gagandeep Kaur, Rakesh Kumar, Satinder Gomber, Paramjit Kaur
Anaemia is a common problem in critically ill patients. Nearly two third of patients have haemoglobin levels below 10 g/dl at the time of admission in intensive care unit (ICU). The cause of anaemia is multifactorial. The aims of this study were to determine the incidence of red blood cell transfusion among patients admitted in the intensive care unit and to ascertain the relationship of red blood cell transfusion to clinical outcomes.
This was a prospective observational study conducted over a period of 18 months in a tertiary care hospital. The subjects enrolled in the study were assessed for relevant clinical history. The blood product details and laboratory parameters were correlated with clinical outcomes. These patients were followed for either 30 days or until hospital discharge or death if these occurred before day 30. The subjects requiring RBC transfusion were then being followed up in the Blood bank for various laboratory parameters. Clinical parameters and clinical outcome were noted from case file.
Out of total of 46 patients who were included in the study, 25 (54%) patients received transfusion which included 32 (69.6%) males and 14 (30.4%) females. The age group of patients admitted in the ICU was 20 to 88 years with mean age of 49.3517.93 years. The mean age of patients in the transfused group was 45.4816.76 years. The main indication of admission to ICU was post operative in 24 patients (52.2%), 6 patients (13.0%) of active bleeding and 5 patients (10.9%) of trauma. The mean Hb at the time of admission to hospital in the transfused group was 10.811.56 g/dl. The mean pre-transfusion haemoglobin was 7.61.16 g/dl and the mean post transfusion haemoglobin was 9.061.19 g/dl respectively. The mean pre-transfusion and the post-transfusion lactate levels were 1.641.09 mmol/L and 1.300.62 mmol/L respectively. The mean duration of stay in the ICU, Post ICU stay and total hospital stay was 16.3010.71 days, 9.203.23 days and 20.308.89 days respectively. The mean duration of ICU stay in the transfused group was 19.6010.57 days. Out of 25 transfused patients, 6 (24.0%) patients expired.
Restrictive transfusion policy can be followed in the critically ill patients.
Are the health consious people motivated and inclined towards voluntary blood donation? An awareness survey among the gymnasium going public
Debasish Gupta, Usha Kandaswamy, Jaisy Mathai, PV Sulochana, S Sathyabhama
Voluntary blood donors are considered to be the safest donors in context to safety and quality of blood as they usually lead a healthy life style and follow low-risk practices. Many people, both young and old, in the country now believe in keeping fit and healthy and they go to gymnasium or practice yoga. These people can be easily categorized as safe blood donors and need to be motivated for enrolling them as regular voluntary blood donor. However, the attitude and knowledge of these people towards blood donation and associated good health are not documented.
This study was undertaken to assess the awareness and inclination of gym going healthy people towards blood donation. This study was undertaken to assess the awareness and inclination of gym going healthy people towards blood donation.
27 gymnasiums were randomly selected in the city and rural area of Trivandrum. The owners of these gyms were approached to obtain their consent for participating in this study. A detail questionnaire was prepared to be distributed to the willing members of the gym through the owner/manager. The questions were framed according to two categories: Those who have donated blood and those who have never donated blood. The participation by the people going to gym was entirely voluntary. Confidentiality of the information was assured to the participants.
Out of 2000 leaflets of questionnaire distributed to 27 gyms, only 1006 members (50.3%) responded. Among the respondents, 495 (49.2 %) had donated blood (range 1-8 donations) while 511 (50.8 %) have never donated blood. Amongst those who have donated blood, 59% donated only once. Humanitarian factor for blood donation accounted for 16.4% while good health due to blood donation was reported by 7.2% of the donor group. Amongst the non-donated group, a lot of misconception still persists in their mind towards blood donation. Fear of becoming weak (34.2%), not interested in blood donation (32.5%), restriction of activities and exercise after blood donation (26.1%), losing weight (23.6%), fear psychosis towards blood donation (21.6%), fear of contracting infections (13.9%), no idea about blood donation (13.6%), were the major responses from this group.
Gymnasium going people are the best candidates for safe and quality blood as they lead healthy life and are from low-risk population. However, some sort of misconception towards blood donation still persists among the mindset of these people which need to be removed by more awareness programmes and counseling.
Study of adverse events in healthy blood donors with post donation follow up
Ankit Mathur, Latha Jagannathan
Though blood donation considered being a safe procedure, at times it can lead to mild to severe adverse reactions. The aim of the present study is to analyses the frequency and type of adverse events in blood donors and to access the practice which will help to decrease their occurrence and motivate them to be a repeat donor.
A prospective single-center study was conducted from July 2013 to June 2015 in our hospital on 44,275 healthy donors. Blood was collected from donors as per guidelines of drugs and cosmetic act. Attention was prioritized to the donor all type adverse events. Such episodes were managed actively. Such donors contact numbers were kept and were asked to be repeated donor. After 6 months they were asked telephonically about their willingness of blood donation.
We recorded a total number of 44,275 whole blood donations during the study period comprising of 30,108 blood bank donations and 14,167 camp side collections. Males constituted 41,036 and females were 3,239 in number. Overall 1,067 (2.41%) adverse events were reported in 44,275 donations. The majority events were mild like vasovagal attack seen in 554 (51%) cases followed by hematoma in 384 (36%) cases, vomiting in 58 (5.4%) cases, nerve injury in 277 (26%) cases, thrombophlebitis in 20 (1.9%) cases, hyperventilation in 05 (0.52%) and rigor in 05 (0.52%) cases. Major syncopal adverse reactions were very rare, seen in 03 (0.31%) of all donations, none of whom required hospitalization. In 703 cases, who were donating for the first time, adverse events were noticed, where as only 364 multiple donors complained of any adverse events. All 1067 donor were followed to see chance of donation after facing an adverse reaction. Around 261 (24%) donor donated irrespective of adverse event with in 6 month post donation. 454 (42.5%) donor agreed to donate in recent future when motivated over phone. Rest others couldnt be contacted.
Blood donation is a noble cause for saving precious life. It is considered as safe procedure. Adverse reactions are around 1 to 3% worldwide (ours is 2.41%). This can be further reduced with appropriate donor selection, proper counseling predonation, accompanying donor during procedure at post donation phase. These actions reduce donor reactions, reduce severity of reaction and help the donors to be repeated donors in spite of having adverse reactions. Our present study shows voluntary blood donation is safe and turnover of adverse reaction victims can be excellent if they get proper care.
Study of adverse events in healthy blood donors with post donation follow up
Dibyajyoti Sahoo, Smita Mahapatra
Though blood donation considered being a safe procedure, at times it can lead to mild to severe adverse reactions. The aim of the present study is to analyses the frequency and type of adverse events in blood donors and to access the practice which will help to decrease their occurrence and motivate them to be a repeat donor.
A prospective single-center study was conducted from July 2013 to June 2015 in our hospital on 44,275 healthy donors. Blood was collected from donors as per guidelines of drugs and cosmetic act. Attention was prioritized to the donor all type adverse events. Such episodes were managed actively. Such donors contact numbers were kept and were asked to be repeated donor. After 6 months they were asked telephonically about their willingness of blood donation.
We recorded a total number of 44,275 whole blood donations during the study period comprising of 30,108 blood bank donations and 14,167 camp side collections. Males constituted 41,036 and females were 3,239 in number. Overall 1,067 (2.41%) adverse events were reported in 44,275 donations. The majority events were mild like vasovagal attack seen in 554 (51%) cases followed by hematoma in 384 (36%) cases, vomiting in 58 (5.4%) cases, nerve injury in 277 (26%) cases, thrombophlebitis in 20 (1.9%) cases, hyperventilation in 05 (0.52%) and rigor in 05 (0.52%) cases. Major syncopal adverse reactions were very rare, seen in 03 (0.31%) of all donations, none of whom required hospitalization. In 703 cases, who were donating for the first time, adverse events were noticed, where as only 364 multiple donors complained of any adverse events. All 1067 donor were followed to see chance of donation after facing an adverse reaction. Around 261 (24%) donor donated irrespective of adverse event with in 6 month post donation. 454 (42.5%) donor agreed to donate in recent future when motivated over phone. Rest others couldnt be contacted.
Blood donation is a noble cause for saving precious life. It is considered as safe procedure. Adverse reactions are around 1 to 3% worldwide (ours is 2.41%). This can be further reduced with appropriate donor selection, proper counseling predonation, accompanying donor during procedure at post donation phase. These actions reduce donor reactions, reduce severity of reaction and help the donors to be repeated donors in spite of having adverse reactions. Our present study shows voluntary blood donation is safe and turnover of adverse reaction victims can be excellent if they get proper care.
Para-Bombay blood group: A case report
Darshan Gangaram Adulkar, Ankit Mathur
The H antigen is the precursor for the formation of A and B antigens and its absence is termed as H antigen deficient phenotype 1. It results in, Bombay or Para-Bombay blood group in an individual. Para-Bombay phenotype is characterized by the deficiency of H, A and B antigens on the red cells. These persons inherit hh/Sese or hh/SeSe genes. Though they lack H antigen on RBCs, it is present in secretions and hence these patients are referred to as "Para-Bombay secretors" or "red blood cell (RBC) H negative secretors," in distinction to "Bombay phenotype" which refers to individuals whose RBCs and secretions lack the H antigen. The reported prevalence of Bombay and Para-Bombay phenotype in Indians is reportedly 1/10,000. However, since anti-H is not routinely used in blood grouping, many cases may remain undetected. We report the first case of Para- Bombay phenotype detected at our institute.
The blood sample of a 34-year-old healthy male blood donor was referred to us, as a suspicion of Weak Sub group of "A" had been raised elsewhere. Blood grouping was done according to departmental SOPs using conventional tube technique (CTT). In forward typing, no agglutination was observed with A and B antisera, very weak agglutination with AB antisera (ortho clinical diagnostics), but strong agglutination was noticed with D antiserum (Group O). On repeating forward typing using different antisera (immucor), weak agglutination was seen with A antisera. In reverse typing, there was agglutination with B cells and no agglutination in tubes A and O cells (Group A) resulting in discrepancy between forward and reverse grouping. Saliva testing was done to confirm presence of secretory H and A antigens.
Further testing confirmed that the individual's blood group was Para-Bombay A (Para-AH), which is a rare entity. The Para-Bombay phenotype is very rare. Only a few cases of Para-Bombay were reported in India till now. This entity is characterized by the absence of H, A and B antigens on the red cells but their presence in saliva and secretions of gastrointestinal and genitourinary tracts.
In case of blood group discrepancy, always use two different set of antisera for confirmation. Without the use of anti-H Lectin or antisera, the Para-Bombay phenotype would have remained unidentified and grouped as O. Para-Bombay AH should be considered as 'A' Blood group for all practical purposes.
A study of knowledge, attitude and practices regarding voluntary blood donation among MBBS students in Ludhiana, India
Gurkiran Kaur, Amarjit Kaur, Rajesh Kumar
Knowledge, attitude and practice surveys have been used in many areas to understand factors that influence blood donation and as the basis for communication and donor mobilization strategies. Voluntary blood donation is the safest and ideal source of good quality blood. Voluntary blood donation among medical students will also inspire the people and other working staff making the voluntary blood donation a successful mission.
A validated and pretested questionnaire on knowledge, attitude and practice on blood donation were assessed among 157 medical students from Dayanand Medical College and hospital and their responses were further analyzed and compiled.
Students level of knowledge by scoring scale. Data were presented in percentages. Results showed that knowledge on blood donation among respondents was 52.8%. Majority of participants (85.9%) had never donated blood in which 62.2% of non donors were females. Among these non donors (22.2%) had a negative attitude about blood donation like, it can cause anemia (26.6%), can lead weakness (53.3%) and some (20%) fear the donation process. 87.6% of non donor expressed willingness to donate if they were asked to donate blood. About 3% of non donors do not know the importance of blood donation. Among all, 14.0% students who have donated earlier, 86.4% were males and 13.6% were females. 45.4% have donated once and 22.7% were regular donors. 31.8% had experienced discomfort after final donation.
The present study recommends that even medical student community needs to be educated about blood donation process, the importance of voluntary blood donation, health benefits and myths. Awareness and motivation of blood donors of blood donation on regular basis and addressing problem faced strengthen the recruitment and retention of blood donation to donate on regular basis with which the aim of 100% voluntary donation can be achieved.
Blood issue in emergency: Appraisal of institutional protocol at a Tertiary Health Care Hospital
Devi Prasad Acharya, Aseem Tiwari, Ravi C Dara, Dinesh Arora, Geet Aggarwal, Gunjan Bharadwaj
In emergency, risk is weighed between transfusing uncross-matched blood against the risk of "delaying" transfusion until compatibility testing is complete. At our centre, protocol has three categories based on time (5, 15 and 30 minutes respectively) within which the red cell component should be made available. Guiding principle was that O negative RBCs are issued if ABO group is not known and there is insufficient time for compatibility tests. If group is known, group specific blood was preferred. If sufficient time is available, RBC with all compatibility tests (grouping, antibody screen and immediate-spin cross-match) completed was issued. Compatibility tests were completed for all RBCs issued where tests could not be completed. Any unfavourable result was communicated to physician. Here we evaluated effectiveness of institutional emergency protocol.
Data were collected prospectively from February to May 2015. Institutional protocol had three categories; Category I (life-saving) - RBCs issued within 5 minutes, Category II (immediate) - RBCs issued between 5-15 minutes and Category III (urgent) - RBCs issued within 15-30 minutes. Recipient demographics, diagnosis, TAT, management and outcome were assessed.
64 cases (51 male and 13 female; mean age 45.5 years) received RBCs. Among 23 patients in Category I, 10 received O negative while 13 received group-specific RBCs. In Category II, from 37 patients 6 received O negative, 14 received group-specific and 17 received compatible RBCs. In group III, out of 4 patients 3 received compatible and one received O negative RBCs. 72 RBCs were issued to patients in Category I (38 in initial emergency + 34 during rest of the hospital stay). In Category II 215 (129 + 86) and in Category III 15 (9 + 6) RBCs were issued. Most common cause was gastro-intestinal haemorrhage (n = 26, 40%) followed by trauma (n = 15, 23%). Outcome in terms of death was 22. TAT of three categories was 4.13, 10.56 and 27.50 minutes respectively. No incompatibility was detected in cases where the compatibility tests were completed later.
Analysis proved that RBCs were being issued within the expected TAT. System was quite efficient since O negative units were conserved by issuing group-specific RBCs, especially in Category I. The reason could be that 37 patients had historical blood group record, which reiterates the importance of doing "group and screen" at time of admission to the hospital.
Error management in transfusion services: A two year study at a tertiary care hospital
Krishnamoorthy Radhakrishnan, A Ashwin, VK Panicker
Blood banking and cell therapy are considered the next generation medicine and such process should be error free. Though processess are in place to ensure a safe blood transfusion, zero risk is not guaranteed. Pre-analytical, analytical or post-analytical errors are prone to occur. Surveillance of the entire transfusion chain is the prerogative of a hemovigilance program. To estimate & determine the causes for occurrence of errors in transfusion services and suggest remedial action with the aim of improving transfusion safety.
This study was carried out in the Department of Transfusion Medicine, Sri Ramachandra Medical College & Research Institute, Chennai over a two year period (August 2013 to July 2015). Whenever an error was identified, immediate remedial action was taken. Root cause analysis (RCA) was done and corrective and preventive action (CAPA) taken.
During the study period, a total of 84,162 samples were processed for pre-transfusion testing. Percentage occurrence of errors was 0.001% (n = 8). Wrong blood in tube (WBIT) due to patient mis-identification was reported in one case. In 2 instances, the cord blood sample of the live newborn was received under the mother's identifiers. Wrong blood group was released due to transcription error in 2 cases. Technical error was ruled out. Wrong expiry date on the blood product was noted in 2 cases. In one instance, as there were two patients by the same name in a particular ward, the blood products were swapped mistakenly while issue from the blood bank. Reasons cited for the human error were either lack of awareness or increased work load due to shortage of staff. In all the above instances, serious hazards were averted due to timely identification and intervention.
Patient identification during sample collection and at the time of transfusion is prudent. Two identifiers - patient's name & unique hospital number should be used for identification. Sample tubes should be labelled appropriately at the bed side of the patient. Bar coding of samples and automation will minimize transcription errors. Staff education and training plays a crucial role in transfusion safety. Clerical checks should be carried out at the time of issue of blood products and before starting transfusion at the bedside. Reporting of errors (pre-analytical, analytical, post-analytical) should be made mandatory under the hemovigilance program to improve transfusion safety.
Transfusion syphilis elimination
NR Ramesh Kumar, S Shanmugam
A safe method for preventing transfusion syphilis by comparing Non-Treponemal test vs Treponemal tests. In India as per Drugs & Cosmetic Act the Mandatory tests for syphilis is VRRL/RPR (non-treponemal) before transfusion. This study aimed to compare the non-Treponemal test (RPR) vs Treponemal tests (ELISA).
A total of 4,560 voluntary blood donors samples were tested for syphilis by RPR (IMMUTREP) and by ELISA (Trepolisa 3.0 - 3rd generation ELISA kit to detect IgM, IgG and IgA treponemal antibodies).
Among the total 4560 blood donor tested for syphilis by ELISA 75 (1.6%) donor's were repeatable reactive and 52 (1.1%) donor's were initial reactive by RPR method. All the ELISA positive sample was confirmed by TPHA method. Of the 75 reactive by ELISA method only 54 (72.0%) was reactive by RPR method, again retested for the 21 negative samples by same RPR reagent and found that 4 sample were reactive.
In the 52 reactive samples by RPR method we found only 47 (90.4 %) was reactive by ELISA method.
We found that 17 (22.7%) donor's sample were false negative and 5 (9.6%) donor samples were false positive by RPR method. We found that 4 sample initially negative by RPR was due to improper rotation & timing. If we perform ELISA method for syphilis it will be easy to keep the print out of the ELISA reading, where as for RPR it is not possible. We consider that Enzyme Immunoassays having better sensitivity and specificity and preferred choice for screening and confirmation of blood for Syphilis in a blood center.
So we conclude that ELISA can be considered as a suitable test for screening of syphilis and should be made mandatory to prevent Transfusion Syphilis.
Acute pancreatitis with TTP/HUS treated with therapeutic plasma exchange and haemodialysis
Bhargav Shakarabhai Prajapati, Nidhi Bhatnagar, Maitrey Gajjar, Tarak Patel, Kamini Gupta, Hardik Raval
Haemolytic uremic syndrome is a disorder in which acute kidney injury (AKI) with non-immune haemolytic anaemia and thrombocytopenia occurs and is most commonly seen in children. Pancreatitis as a cause of thrombotic thrombocytopenic purpura/haemolytic uremic syndrome (TTP/HUS) has only been described in a few case reports.
Here we describe the case of a 30 years old male patient, who was admitted with a diagnosis of acute pancreatitis (AP) and developed deterioration of renal function, despite fluid resuscitation.
The clinical features, radiological findings and laboratory investigations were in favour of diagnosis of AP with TTP/HUS. Therapeutic plasma exchanges along with haemodialysis were started on alternate days. Renal failure was part of TTP/HUS in this patient with diagnosis of AP.
The exact mechanism causing this condition is not clear. Early initiation of therapeutic plasma exchange has a major impact on survival and long term renal function improvement.
Comparison of dry and wet thawing methods for fresh frozen plasma
S Sanooja Pinki, Susheela J Innah
The thawing of fresh frozen plasma has traditionally been done using a water bath (wet plasma thawing system). The potential contamination risk of water bath had always been a point of concern. The main source of contamination is the water used in the water baths. A study using plasmatherm (dry thawing system) to reduce contamination of FFP and product quality is investigated for. Dry and wet thawing methods when compared will give an insight into their merits and demerits and there by improving quality of service to the patient.
• To evaluate the quality of FFP by assessing PT, APTT, factor VIII and fibrinogen in two methods
• To compare other aspects of these 2 thawing systems; like the ease of use, accessibility and maintenance.
This is a prospective cohort study for 3 months. All FFP taken up for this study were prepared by PRP method within 6-8 hours of collection of the whole blood. In order to preserve the coagulation factors, FFPs were snap frozen at -80C for 24 hours and later stored in -40C. For standardization, QC was done at the time of preparation from all 60 FFPs. Factors assessed were PT, APTT, Fibrinogen and Factor VIII in ACL TOP 300 IL coagulation analyzer.
Equipments used for thawing are Barkey Plasmatherm and Plasma thawing bath by REMI. 30 FFPs thawed in plasmatherm (45C for 15 minutes) and another 30 were thawed in water bath (37C for 20 minutes). Immediately after thawing, QC of the same FFPs were done again. QC will be compared after obtaining mean values in each method. The duration of thawing, ease of use, accessibility and the maintenance by these two methods will be assessed are compared.
The mean values of 30 FFPs at the time of preparation: PT: 10.6 secs APTT: 34.5 secs FACTOR VIII: 1.13 U/ml FIBRINOGEN: 313 mg mean values of 30 FFPs after thawing in water bath: PT: 10.7 secs APTT: 36 secs FACTOR VIII: 0.9 U/ml FIBRINOGEN: 265.25 mg.
As the study is going on, the rest of the results will be published later.
Dry plasma thawing device could greatly reduce the contamination risk with no compromise in its quality parameters. This multipurpose warming system is portable with a water leakage alarm and requires once a year water change when compared to thawing bath.
Evaluation of hemoglobin of blood donors deferred by hemocue HB201+ using capillary blood of blood donors in a Tertiary Care Teaching Hospital Blood Bank in Andhra Pradesh, South India
Madithadu Anitha, KV Sreedhar Babu
Hemoglobin estimation is an integral part of donor screening in blood banks. Various methods are available for hemoglobin estimation and each one of them has its advantages and limitations. HemoCue as a hemoglobinometer is gaining widespread popularity for donor screening. This method has been reported to give precise and accurate results when used on venous blood under laboratory conditions. Automated haematology analyzers have been found to have a higher precision than HemoCue. But this instrument is expensive, cannot be used at outdoor blood donation camps because of requirement of laboratory. It has been reported that haemoglobin measurement by HemoCue showed excellent agreement with those measured by automated hematology analyzer but a substantial percentage of capillary haemoglobin values have been shown to be lower than that obtained by venous blood; may result in unnecessary deferral of donor. Hence a pilot study was undertaken to assess the comparability of hemoglobin concentration in capillary and venous blood measured by HemoCue and an automated haematology analyzer and to document the influence of type of blood (capillary or venous) and analysis method on donor deferral.
This prospective cross-sectional analytical study was conducted for a period of 2 months (01.05.2015 to 31.06. 2015) in the department of Transfusion Medicine of a tertiary care referral teaching hospital in Andhra Pradesh, South India i.e. SVIMS, Tirupati. The study population comprised 1672 prospective blood donors. Haemoglobin estimation using HemoCue with capillary blood detected 31 (1.09%) anemic donors (11.4 g/dl-12.4 g/dL). They were subjected to haemoglobin estimation using venous blood by HemoCue and automated haematology analyzer.
Among them 25 donors were found to have a haemoglobin concentration of >12.5 g/dL. The mean venous blood haemoglobin was 13.1 g/dL and 12.4 g/dL using HemoCue and automated cell counter respectively which was more than capillary blood haemoglobin by HemoCue (11.9 g/dL).
The HemoCue can use capillary or venous blood for haemoglobin estimation. The accuracy and precision are very much dependent on the technical skills of the persons performing the procedure, variation with the sequence of drop of blood use, contamination with tissue fluid. Hence the estimation of haemoglobin by capillary method has a risk of false high donor deferral rate. Testing venous blood haemoglobin is impractical, time consuming and leads to double phlebotomy especially during camps. In view of the limitations in the usage of capillary blood sample a range of threshold haemoglobin level is desirable (for example 12 0.5 g/dL) and should be actively considered.
Technological approaches for positive product recipient identification
K Snehil, D Marshall, P Senthil Sunder, R Naveen, D Hani, P Amalraj, D Dolly, JJ Mammen
A serious adverse event is an event that causes harm to a patient and could be ascribed to clerical/transcription errors or technical issues. Transfusion is an everyday activity in hospitals making it necessary to be error free. Once blood is issued, there is often minimal tracking and feedback provided to the blood bank. Positive patient identification and verification against the unit to be transfused is an opportunity to nullify the key error spots and therefore are candidates for new technology intervention.
The study aims to pilot a bedside barcode driven workflow of positive patient identification linked with real-time verification of blood bank database over a secure network to ensure that unit is transfused to the intended patient.
Blood bags were labelled in ISBT128 compliant format. Designed issue label with a unique "Issue ID number" was generated at the time of issue linking the patient and blood unit data with compatibility testing details, stored in the enterprise database. Barcode labels with unique patient identification number were developed. An Android application was developed that allowed scanning of patient ID (wristband) and Issue ID (Blood bag) and also verified the data against the stored data in real time over a WIFI or GSM network. A 7 inch smartphone running Android V5.0 (Lollipop) with 5 MP camera was used. If the scanned data matched with that stored in database, message is displayed: COMPATIBLE following which operator had to acknowledge the message. Healthcare workers were trained to operate the application. SOP was created for user training. The process was monitored and data was collated in a worksheet.
Barcoded blood bags were issued and the application was tested on 50 transfusions for Haematology patients carried out in Outpatient treatment room and in one designated ward. In all but one case (98%) the application worked as intended and the healthcare worker was able to correctly verify the unit prior to transfusion. In one case the barcode would not scan due to a defective barcode print out; the verification process worked successfully when the numbers were keyed in.
We describe a method that can ensure bedside verification prior to transfusion, which is the last verification step that is usually outside the control of the blood bank. A simple easily usable mobile platform at the point of care ensured that the patient received the intended unit. In our country where Haemovigilance is gradually being implemented, such systems will help collection of data in an unbiased and unobtrusive manner avoiding redundant paper based data entry systems.
Type and screen protocol versus coomb's crossmatching for compatibility testing
Nithya M Baiju, Susheela Jacob Innah
Blood, the elixir of life, if not properly used can serve as a conduit of fatality. It is advocated to use the right blood to the right person at the right time. Pre-transfusion compatibility testing forms the backbone of any blood transfusion service. The chances of a clinically significant red cell antibody being missed in a patient with negative antibody screen are 1-4/10,000. These recommendations led to the development of Type and Screen (T & S) protocol. Type and Screen denotes ABO and Rh typing and screening the patients serum for unexpected antibodies by using reagent red cells (Screen cells). If antibody screen is negative and the patient has no past history of unexpected antibodies, then 99.99% of ABO compatible red cell units would be compatible in a Coomb's crossmatch.
Aim: To compare the safety of Type and Screen protocol and coomb's crossmatching for compatibility testing.
This prospective study was conducted in the Department of Transfusion Medicine and Immunohaematology, Jubilee Mission Medical College & RI, Thrissur, Kerala during the time frame January 2015 to July 2015 for all the requisitions received for crossmatching from various departments. Type and Screen protocol followed by coomb's crossmatching of the respectable donor unit was done for the requests without considering the result of the other. The antibodies were screened using cell panel [Diamed I - II - III] and identified using Diamed 11 cell panel. Thus the safety of both type and screen protocol and coomb's crossmatching were analysed.
Out of 3486 requisitions for crossmatching, 14 were antibody screen positive (0.4%). The specificity of antibodies detected are anti D (4), anti M (3), anti Lea, anti Leb, anti e, anti c, anti E, anti K, anti JKb. Out of the 14 antibody screen positive samples, 8 were crossmatch compatible and 6 were crossmatch incompatible. Not even a single antibody screen negative sample turned crossmatch incompatible, thus denoting the safety to be 100% in this study. The specificity of type and screen protocol was found to be 99.7%, positive predictive value 42.8%, negative predictive value 100%.
Hospitals in developed country have adopted the Type and Screen protocol instead of conventional crossmatch for transfusion practices. This technique has proven to be effective without compromising the patient safety. It allows optimal use of donor blood, better inventory management and is cost effective. Coomb's crossmatching is a culture than a necessity.
Sterility testing of peripheral blood stem cell harvests in a tertiary oncology setup
Shruti Bankar, Amol Tirlotkar, Shashank Ojha, Vivek Bhat, Sunil Rajadhyaksha
Peripheral blood stem cells (PBSC) are a specialized transfusion product used for transplantation. Screening of PBSC harvests for microbial contamination is required as per circular of AABB for cellular therapy products. Microbial contamination may occur during harvest or subsequent manipulation of these cells. Detection of contamination is problematic, and the clinical significance of infusing contaminated PBSC remains controversial.
• To know the rate of microbiological contamination of PBSC harvests in a Tertiary Oncology Setup
• To highlight the importance of proper microbiological analysis during cryopreservation and thawing as an important part of quality control procedure.
A retrospective analysis of four and half years data (1st Jan 2011 to 31st July 2015) of microbial cultures performed in 481 consecutive PBSC harvests (Autologous and Allogeneic) from 336 patients, was done. Culture was sent to Microbiology Department for sterility testing of PBSC harvests after collection, after adding Dimethyl Sulphoxide (DMSO) (before cryopreservation) and after thawing (before infusion).
Out of 481 PBSC harvests, 304 harvests were of autologous and 177 harvests were of allogeneic type. 35 out of 304 (11.5%) autologous PBSC harvests were found to be contaminated with bacteria whereas 18 out of 177 (10.16%) allogeneic PBSC harvests were found to be bacterially contaminated. Most commonly found micro-organism was Klebsiella pneumoniae followed by Coagulase negative Staphylococcus aureus (CoNS) in autologous PBSC harvests and E. coli followed by Klebsiella pneumonia were common microorganisms in allogeneic PBSC harvests.
Microbial contamination of hematopoietic stem cell products does occur and there must be ongoing efforts by physicians and laboratory personnel to minimize the risk for introduction of contaminants. Prophylactic antibiotics are useful for certain contaminants; however, caution must be exercised when gram-negative contaminated products are administered. Contamination with pathogens can be eliminated with careful Good Manufacturing Practices (GMP) and Good Laboratory practices (GLP).
Hemolyti C disease of newborn due to abo incompatibility requiring exchange transfusion: Case report
Vikram Kumar Gente, Abhishekh, Rajendra G Kulkarni
ABO incompatibilityis the most common cause for hemolytic disease of newborn (HDN) in mothers whose prenatal antibody screen is negative. Although prevalence of maternal-newborn ABO incompatibility ranges from 40-50%, clinically significant hemolysis is rare and seldom does it cause severe hemolytic disease.
Here we present a case of severe neonatal jaundice due to ABO incompatibility requiring active intervention in the form of exchange transfusion and phototherapy.
A four day old male term, Appropriate for Gestational Age baby was brought to hospital by mother with complaints of yellowish discoloration of the skin since one day.
Baby was born to G1P0L0A0 mother of normal vaginal delivery, cried immediately after birth with no history of significant hospital stay. Mother noticed yellowish discoloration of the skin on 3rd day which was progressively increasing hence brought the baby to the hospital on 4th day. On examination baby was icteric, irritable with high pitched cry, poor feeding with normal neurological examination.
On investigation sample was icteric, Hemoglobin was 10.5 g/dl, bilirubin was found to be 25 g/dl, blood group was A positive and direct comb's test was negative. Mother's blood group was O positive, and indirect coomb's test on mother sample was negative. Hemolysin test on mother sample was positive (complete hemolysis) with a titer of 1 in 512.
Considering very high bilirubin, baby was treated with 1 double volume exchange transfusion with O negative packed cells and AB fresh frozen plasma along with triple surface phototherapy. Post Exchange transfusion bilirubin was found to be 12.5 g/dl. Baby was stable and discharged from the hospital on 5th day of admission. Further follow up was uneventful.
Though ABO incompatibility in majority cases causes only mild, self limiting neonatal jaundice, in very rare cases hemolysisis severe enough to require exchange transfusion. It should be the prominent suspicion in cases of HDN with a negative antenatal antibody screen.
Simplified qc for enumeration of CD34+ cells by flow cytometry in leukapheresis product
Mohandoss Murugesan, Chandran K Nair
The enumeration of CD34+ cells by flow cytometry is commonly employed to assess hematopoietic progenitor/stem cell numbers (HSCs) in peripheral blood, cord blood, and apheresis products used for peripheral blood stem cell transplantation (PBSCT). Accurate enumeration of HSC's is important in estimating the adequate dose and subsequent apheresis collection. Factors like improper gating, inadequate pipetting affects the test result. The aim of this study was to assess the current flow cytometric method for CD34+ enumeration in the leukapheresis product in our centre.
The CD34+ cells were quantified from the fresh leukapheresis product (n = 40) of 24 patients undergoing PBSCT. The method was based on ISHAGE guidelines: four-parameter flow cytometry method (CD45FITC/CD34PE staining, side and forward angle light scatter). The samples from leukapheresis product were stained in duplicate (sample 1 & 2) with two colour CD45-FITC/CD34-PE monoclonal reagents and run in Beckman FC500. Control reagents to check non-specific binding of CD34 antibody and 7 AAD viability dye to distinguish between viable and nonviable cells were used as manufacturer protocol. The assay was accepted if the number of CD34+ HSC falls within 10% of the mean for the duplicate samples, if falls outside 10%, the assay was repeated. For analysis, new variable named variation 1 and 2 were calculated from dispersion of mean values of sample 1 and 2 respectively. For precision, the difference in mean variation was separately observed for 3 groups (Low: <50 CD34+ cells/΅l; Medium: 50 to 100 CD34+ cells/΅l and High >100 CD34+ cells/΅l) and the difference in variation 1 and 2 were compared through t-test.
The mean CD34+ cells present in the leukapheresis product was ranging from 26 to 594 cells/΅l. 7 out of 40 (17.5%) product tested had difference above 10% variation between the duplicates (variation ranging from 11 to 114%). These 7 products test were repeated and variation was found within 10%. No significant difference observed for mean variation value obtained from sample 1 and 2 separated for Low; Medium and High groups. The t-test values observed were 0.15, 0.24 and 0.12 respectively in 3 groups.
Accurate determination of CD34+ HSC cells is most relevant for graft adequacy in transplant settings. One significant limitation being inadequate pipetting, testing the CD34 enumeration in duplicate with error of 10% will provide absolute counts of CD34+ cells in the leukapheresis product.
Effect of thawing temperatures on quality of fresh frozen plasma
Madan Dhantole, Rajendra K Chaudhary, Atul Sonker
The administration of plasma components is primarily used in the treatment or prevention of coagulopathy secondary to multiple plasma factor deficiencies, dilution and consumption coagulopathy, or in patients who need rapid reversal of warfarin treatment. Prior to transfusion, frozen plasma component must be thawed at 37C, which requires ~20 minutes by circulating water bath.
So in order to reduce the thawing time we conducted a prospective study to evaluate the effects of thawing temperatures on quality of fresh frozen plasma.
This was a prospective study carried out over a period of two years, from Oct 2012 to Aug 2014. Blood bags of hundred male whole blood donors with body weight ≥60 kg were subjected for component separation whose plasma was further used for study.
Two ABO group matched plasma were selected and pooled using sterile connecting device in a dedicated plasma container to make 1 pool. Fifty of such ABO identical pools were made for FFP (n = 100). Both the pooled plasma aliquots were then frozen by Contact shock freezer (Dometic MBF21, Luxembourg) which took approximately 30 min to completely freeze the plasma. Thawing of pooled plasma: After complete freezing one aliquot from each pool was thawed at 370C in circulating waterbath and other aliquot from same pool was thawed at 450C in circulating waterbath. The representative samples from these aliquots were then checked for quality parameters. The quality parameters checked were PT, APTT, Factor V, Factor VII, Factor VIII, Fibrinogen using a semi-automated coagulometer. All statistical analyses were performed with SPSS (version 17.0.2, SPSS Inc., Chicago, IL, USA). Significance was assumed with P-values <0.05.
The mean time taken for complete thawing of the FFP at 370C was 20 minutes 30 seconds as compared to 10 minutes 15 seconds for FFP thawed at 450C which was statistically significant (P < 0.05). It was seen that the difference in mean values of PT, APTT, Factor V, Factor VII, and Factor VIII were statistically not significant (P > 0.05) within the study groups.
From the above findings it can be concluded that Plasma components may be thawed at 450C when there is a need to decrease thawing time (eg. Massive transfusions).
AntiHBs Titer among healthcare workers
Prashant Pandey, Nitin Agarawal, Dharmendra Kumar
Inspite of an availability of the safe, effective and affordable vaccine, hepatitis B infection is still the most common serious liver infection. Health care workers who come into contact with human blood and body fluids are at an increased risk for exposure to the hepatitis B virus. The Centers for Disease Control and Prevention recommends that all health care workers who are exposed to blood or body fluids should be vaccinated against hepatitis B. The vaccine is safe and effective and can protect for a lifetime.
The aim of the present study was to find the level of protection among the healthcare workers at the time of joining by doing Anti-HBsAb titer. The later was done amongst the nurses, doctors, housekeeping staff and general duty assistants. Those who were reported titer <10 miu/ml were started with hepatitis B vaccination and kept away for a month from a direct patient contact.
Employees were informed about the study and its implementation at the time of joining. Consent was obtained from each employee for any addition tests, if required. At the time of sampling all the employees were asked to fill a format which had information about history of any previous exposure, needle stick injury and history of vaccination. Anti-HBs antibody titer was done using antiHBs reagent on Vitros 3600 (orthoclinical diagnostics, JnJ, USA). Vaccine being provided is Engerix B (GSK Glaxo, Belgium). Testing of anti-HBs antibody titer and vaccination in low titer individuals were offered free of cost.
The data presented here is for duration of eight months from November 2014 to June 2015. Among the 994 subjects recruited during the study period we received duly filled registration format in 945 individuals only. We observed that only 39.8% (375/940) had history of previous vaccination and only 59.8% (563/940) had titer above 10 miu/ml. Majority of those who had titer below 10 miu/ml (76.86%, 289/376) were unvaccinated for hepatitis B . Around One fifth of (3/14) employees who had history of needle stick injury in past were found non-immune to hep-B infection. Vaccination is being provided to all employees having titer below 10.
Inclusion of anti-HBS titer and hepatitis B vaccination to those who are unprotected are two important measures to reduce the exposure particularly in Indian scenario. Provision of anti-HBs antibody testing and hepatitis B vaccination among the unprotected healthcare workers will increase the protection from the hepatitis B infection.
Role of thromboelastography in a case of systemic envenomation due to snake bite: A case report from a Multispeciality Hospital of South Bengal
Ipsita Nag, Suvro Sankha Datta
In the absence of a direct laboratory test of envenomation, there is a need for an alternative mechanism for the early recognition of envenomation following snake bite. Snake bite is one of the major health problems in India. Anti snake venom (ASV) is the only definitive treatment neutralizing venom in body. Early administration of ASV in an adequate dose is essential to neutralize the maximum circulating venom before it gets fixed over tissues. Thromboelastography (TEG) has been used to monitor the coagulation abnormalities associated with hematotoxic snake bites and assessment of disease severity due to envenomation. Here we narrate a case in which regular monitoring of hemostasis by TEG had helped us to diagnose recurrence of systemic envenomation in a 45 years old male and ASV was administered depending on the TEG results.
A 45 years old male presented with history of snake bite for which earlier he was admitted in a local hospital where 30 vials of ASV was administered within 24 hours. He was referred to our center due to impending compartment syndrome and renal failure. His coagulation status was monitored by TEG in every 6 hours interval along with PT and APTT. On admission TEG graph showed mild hypercoaguable state. After 24 hours of close monitoring TEG graph showed almost a straight line predicting gross hypocoaguable state with severe clinical signs of systemic envenomation. Immediately it was managed by transfusion of six units cryoprecipitate and six units platelet concentrates. In addition 10 vials of ASV was administered to the patient by predicting recurrence of systemic envenomation. Thromboelastography graph showed normal pattern 6 hours after administration of ASV.
On admission TEG parameters R-time: 0.9 (2-8); K: 0.8 (1-3); Angle: 73 deg (55 deg-78 deg); MA: 55.4 mm (51-64); CI: -3.6 (-3 to +3). After 24 hours TEG graph showed almost a straight line. After transfusion of cryo, RDP and ASV administration TEG parameters: R-time: 6.3; K: 1.9; Angle: 63.4 deg; MA: 56.1 mm; CI:-1.
An initial normal thromboelastogram only provide early recognition of patient's clinical course but serial assessment of coagulation status by TEG can help us to identify coagulation diathesis in cases of systemic envenomation. Thus we conclude that TEG does not replace the need of clinical observation in the management of snake bite but can be used as an additional point -of -care test to monitor the effect of ASV. Administration of ASV can be done depending on TEG results along with the other clinical and laboratory parameters.
Two case descriptions of bleeding diathesis complicated by acquired platelet dysfunction
Sujoy Khan, Shilpa Bhartia, Soumya Bhattacharya, Mammen Chandy
The aims are to highlight the importance of recognising that clinically significant platelet dysfunction can develop in background of known causes of bleeding disorders.
We discuss 2 cases of acquired platelet dysfunction (APD) due to (1) eosinophilia with co-existing mild Hemophilia A; and (2) APD due to IgA paraproteinemia complicating a clinical picture of acquired von Willebrand disease.
Case 1: A previously well 8-yr-old boy was diagnosed with mild haemophilia A after he presented with haemorrhagic itchy lesions on the scalp and ecchymosed forearm. He then developed abdominal pain and gross haematuria which only partially responsed to Factor VIII concentrate and cryoprecipitate. Investigations revealed eosinophilia (AEC of 3200/mm3), prolonged bleeding time >15 seconds, FVIIIc 31%, normal vWF: Ag and RICOF with normal mast cell tryptase. Platelet aggregometry showed absent response to collagen (2.0 mcg), epinephrine (10 mcgM), thromboxane receptor agonist and subnormal response to ADP. It was concluded that Acquired Platelet Dysfunction with Eosinophila (APDE) was responsible for his symptoms and not the mild haemophilia A. His symptoms resolved with the treatment of eosinophilia with diethylcarbamazine and albendazole.
Case 2: A 57-year-old lady was admitted with malena following commencement of oral prednisolone for recently diagnosed Sjogrens syndrome. UGI showed multiple gastric erosions. 200 IU of Hemorel A had no clinical response. She finally responded to FFP and cryoprecipitate. She was a known diabetic and treated for carcinoma breast 4 years ago. A year before this presentation with malena, she had her first bleeding episode with epistaxis following septoplasty (APTT 40s, PT 20s). A 2nd episode of spontaneous epistaxis prompted detailed investigations: APTT 55 sec, ACL and LA - absent, bone marrow - iron deficiency anemia & reactive plasmacytosis, immunofixation - IgA lambda, SFLC ratio - normal, FVIII 24%, FIX 105%, FVIII inhibitor assay - negative, vWF Ag 64 (50-160), ANA 4+ with anti-SS A +++, Schirmer's <5 mm wetting. The mucosal bleeds and excellent response to cryoprecipitate and FFP was suggestive of avWD. Platelet aggregometry showed decreased response to ristocetin (1.5 mg/ml) and collagen and absent response to ADP highlighting the possibility of paraprotein associated acquired platelet dysfunction. She responded to rituximab with reduction in IgA levels and no further bleeds. She is on bortezomib since the IgA level remains high.
Identification of acquired platelet dysfunction (due to medications, procedures, underlying hematologic disease) and knowledge of how that may affect bleeding risk are important in optimizing patient care with existing complex autoimmune/hematological disorders.
Evaluation of utilisation pattern of fresh frozen plasma in a Tertiary Care Oncology Centre
Anisha Appa Navkudkar, Priti Desai, Sunil Rajadhyaksha, Puneet Jain, Abhaykumar Gupta, Joseph Sanal
Introduction: Blood component therapy is widely used in an Oncology Centre. Fresh Frozen Plasma (FFP) transfusion is mainly used for treatment of conditions like coagulation derangements, though number of transfusions is less compared to packed red cells and platelets. Transfusion audits are important for clinical transfusion practices. This study is done to understand the utilization pattern of FFP in tertiary care oncology centre.
• To evaluate utilisation pattern of FFP transfusion in various clinical indications
• To correlate effect of FFP transfusion on laboratory parameters of Prothrombin time (PT), activated Plasma Thromboplastin Time (aPTT) and International Normalised Ratio (INR).
Retrospective analysis of 1338 FFP transfusions in 216 patients was done during the period May-July 2015. Detailed analysis mainly according clinical indications and requesting unit was done. Also, the effect of FFP transfusions on laboratory parameters (Pre and Post transfusion PT, aPTT and INR) was analysed.
From May to July 2015, requisitions for 216 patients (Male: 131, Female: 85) for 1338 transfusions were received in Department of Transfusion Medicine (DTM). Based on Clinical Indications; patients with Deranged Coagulation Profile (DCP) required maximum transfusions 737 (55.08%), then bleeding patients 573 (42.83%) and least for patients with Disseminated Intravascular Coagulation (DIC) 28 (2.09%). Of the 737 transfusions in DCP patients maximum were for surgical units (408) especially gastrointestinal (GIT) cancers, then medical units (295) especially leukemia (mostly APML) and least for Radiation oncology (34). Of 573 transfusions for Bleeding patients maximum were for surgical units (343) especially GIT cancers then medical units (221) especially leukaemia and 9 to radiation oncology. Total 28 transfusions were for DIC patients, all diagnosed with leukemia. Vitamin K was given in 5 patients with DCP. A significant difference in pre-transfusion and post-transfusion PT, aPTT and INR values was noted. Mean pre-transfusion PT, aPTT and INR were 25.58, 36.79, 2.13 while mean post-transfusion PT, aPTT and INR were 20.55, 31.86 and 1.62 respectively.
All FFP requisitions were as per the Institutional guidelines. No transfusion was requested as volume expander. Maximum units from surgical oncology were used in post operative phase, during first 48 hours of surgery and were indicated for deranged coagulation. In majority of patients, FFP transfusions were found effective as a significant difference in post transfusion PT, aPTT and INR values was observed.
• FFP transfusion plays a significant role in oncology patients as many have deranged coagulation during course of treatment
• This would help in better inventory management and to understand clinical transfusion practices.
HIV/AIDS: A survey on the knowledge, attitude and practice amongst medical professionals at a Tertiary Healthcare Institution
Ananya Doda, Gita Negi, Dushyant Singh Gaur, Meena Harsh
Health care professionals are trained healthcare providers and include doctors, nurses and laboratory technologists and budding students. They occupy a potential vanguard position in HIV/AIDS prevention programs and the management of AIDS patients. An important factor fuelling the spread of HIV/AIDS in developing countries is believed to be poor knowledge perception, attitude and practice about how the disease is spread and how it can be prevented. The study was aimed at assessing the HIV/AIDS-related knowledge, attitude, practice and perceptions amongst healthcare professionals at a tertiary healthcare institution in Uttarakhand, India.
A cross-sectional survey was conducted at Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand (India) in which awareness and knowledge of human immunodeficiency virus (HIV) infection manifestation and healthcare practices was assessed amongst five groups of 50 participants each comprising of consultants, residents, medical students, technicians and nursing staff who consented to be a part of the study. Survey domains included 30 questions based on health, education, HIV stigma, health service access, pre and post exposure prophylaxis, national aids control policy and suggestions for improvement in the current IEC practices. Data analysis was performed using charts and tables in Microsoft Excel.
All the participants had incomplete knowledge regarding the various aspects of HIV/AIDS. The clinicians had a relatively better knowledge status as compared to the other groups. As far as social stigma was concerned, the attitude of all the study groups was receptive towards people living with HIV/AIDS. Practical application of knowledge was best observed in the clinicians as well as the budding medical students. The technicians and nursing staff performed poorly in prevention and prophylaxis however the undergraduate and postgraduate medical students were much better informed as opposed to the consultants. Almost all the groups were aware of the location and services at the ICTC at our facility although technicians had poor knowledge about the National AIDS Control Policy as compared to undergraduate medical students, postgraduate medical students and clinicians.
Poor knowledge about HIV infection particularly amongst the young medical students is evidence of the lacunae in the teaching system and general practice which must be kept in mind while formulating teaching programs. As suggested by the respondants IEC activities should be improvised making use of print, electronic and social media along with interactive awareness sessions, regular CMEs and seminars to ensure good quality of safe modern medical care.
A case of ABO-hemolytic disease of fetus and newborn: Report from a superspeciality hospital of South Bengal
Suman Biswas, Suvro Sankha Datta
ABO incompatibility between the mother and child occurs in 15-20% of all pregnancies, which produces HDFN in 10% of these cases. Most of the ABO blood groups have predominantly IgM naturally occurring antibodies but 40-93% of the group O individuals also have IgG anti-A and anti-B antibodies. The Ig subclass, titer, presence of hemolysin in maternal serum are important factors for diagnosis of HDFN. Other relevant laboratory parameters are - low hemoglobin, elevation of reticulocyte count, unconjugated hyperbilirubinemia and positive direct antiglobulin test (DAT) in child. The diagnosis can be confirmed by elution method or by detection of high titer maternal IgG antibody. Here we narrate a case of ABO-HDFN in a B+ child of an O+ mother diagnosed by extensive immunohematological evaluations in our blood bank.
Case Report: A female child weighing 2.73 kg was born by LSCS at 38 weeks to an O Rh (D)-positive multigravida (gravida 2) mother after an uneventful pregnancy. At 48 hours after birth the baby was observed to be deeply icteric. Investigations revealed total serum bilirubin of 12.4 mg/dL predominantly unconjugated with elevated reticulocyte count (6%). ABO Rh (D) typing and DAT were performed on the patient sample. Antibody screening with commercial 3-cell panel (Diacell, Switzerland) was performed on maternal serum, infant's serum and eluate from the newborn's red cell. Elution from newborn red cells and antibody titration (anti-B) in maternal serum were performed after DTT treatment of serum. Maternal serum was also tested for anti-B hemolysin. The child recovered on day10 of her life after double-surface phototherapy and discharged in hemodynamic stable condition.
Newborn, maternal and paternal blood groups were found to be B Rh (D) positive, O Rh (D) positive and B Rh (D) positive respectively with newborn blood sample was DAT positive using polyspecific antihuman globulin (anti-IgG + anti-C 3 d). With monospecific antihuman globulin both anti-IgG and anti-C 3 d were found to be positive and antibody screening were negative both in mother and child. Eluate from newborn red blood cells demonstrated presence of anti-B, which confirmed the diagnosis of ABO HDFN. Maternal serum had high titer anti-B (IgG titer 1:1012) detected after DTT treatment. Hemolysin test was found to be positive in maternal serum.
It is therefore concluded that detail immunohematological evaluation has utmost importance in diagnosis of ABO-HDFN in early stage.
Transfusion medicine: A step ahead in delivering community health care
Lekshmi Sudev, Aboobacker Mohamed Rafi, Susheela J Innah
Blood donors are an integral part of functioning of every blood bank. Blood banks daily deal with a lot of donors, these donors being the representative of general population. Medical Officer in a blood bank not only has role in accepting and deferring donors, but has got a crucial role in identifying many health issues in donors which might go unnoticed, thus contributing to individual and ultimately to community well-being and health.
The study was conducted on blood donors who reported to Department of Transfusion Medicine in a tertiary care hospital in Kerala from July 2015 to October 2015. Donor screening process includes enquiry about history of significant disease, symptoms of high risk behavior. The height, weight and vital signs are recorded. Hemoglobin estimation and preliminary ABO blood grouping are done. Donors who do not fit the eligibility criteria were referred to a physician accordingly.
Out of the 623 donations during the initial phase of our study there were 567 males and 56 females. There were 125 deferrals of which 78 were males and 47 were females. The causes of deferral in the order of frequency were:
• Alcohol and substance abuse
• Dental procedures
They were referred for expert management accordingly. As the study is still going on, we may come across other situations in which the blood bank can act more and be a step ahead in delivering community health care.
The primary responsibility of a blood bank is to provide safe and adequate blood for needy patients. The donor's health is of prime importance for catering to the need of ever growing requirement of safe blood supply. This study confirms that early detection and prompt support by the blood bank physician is of utmost importance in promoting a safe and healthy donor and henceforth a healthy community.
Presence of irregular ABO discrepancy in a HIV seropositive antenatal case
Amit Kumar Biswas, RS Mallhi, Amit Pawar, Joseph Philip, Tathagata Chatterjee
Anti-P1 is a naturally occurring cold reactive IgM antibody found in the sera of approximately 25% of P2 (P-) individuals and may not be seen during routine testing. It may be found in pregnant women with no history suggestive of alloimmunization. Alloantibodies can be found in the sera of immunosuppressed patients. One such case of anti-P1 antibody in a HIV seropositive antenatal patient is presented below.
We present a 23 year old HIV seropositive antenatal case referred to our department for ABO and Rh grouping, as a part of routine antenatal investigations. On initial work up there was agglutination seen with anti-A only in forward grouping while on reverse grouping agglutination was seen with A, B and O cells with both tube and gel method. Subsequent immunohematological work up showed the presence of anti P1 responsible for the ABO discrepancy.
Subsequent immunohematological work up showed the presence of anti P1 responsible for the ABO discrepancy.
Anti-P1 is found in almost 90% of pregnant P2 women with no history suggestive of alloimmunization. There have been few instances of acute as well as delayed hemolytic reactions attributed to this antibody where it has reacted at 37C. When anti-P1 is suspected, testing patients serum against enzyme treated red cells or incubating tests at lower (4C) can enhance reactions to confirm specificity. Providing units that are crossmatch-compatible at 37C and the antiglobulin phase, without typing for P1, is an acceptable approach to transfusion in such cases.
Successful blood transfusion management in a patient of mixed autoimmune hemolytic anemia
Nowroz Afroza, Eeshita Samanta, Krishnendu Mukherjee, Prasun Bhattacharya
Autoimmune hemolytic anemias (AIHA) are relatively uncommon with an incidence of 1 in 80,000 to 1,00,000 individuals. Incidence of mixed AIHA (with features of both warm and cold type autoantibodies) has been found in 6% to 8% of AIHA.
They may present as blood group discrepancy and difficulty in cross matching.
Here we are presenting immunohematological work-up in a case of mixed AIHA in an eleven years old male child. He was referred to our department for the resolution of his blood group discrepancy and issue of compatible units of packed red cells. Prior to admission, he had high grade fever (102 F), weakness and fatigue for 5 days. There was no significant history of prior sensitization.
Preadmission Laboratory Investigation: His complete haemogram showed hemoglobin 40 gm/L, RBC count 1.3 X 10^12/L, total leucocyte count 14.9 X 10^9/L with 63% neutrophils and 33% lymphocytes.
RBC morphology showed marked hypochromia with anisopoikilocytosis and reticulocyte count was 3%.
Liver Function Tests showed mild unconjugated hyperbilirubinemia (3.2 mg/dl) with normal enzymes.
He was serologically non-reactive to Dengue, HBsAg, HCV and HIV.
Immunohematological (IH) Work-up: Both EDTA (3 ml) and clotted (4 ml) blood sample taken for IH work-up. Blood grouping was done by conventional tube technique (CTT) using monoclonal antibodies and reverse grouping was done by using in-house reagent pooled red cells. Compatibility testing was done by immediate spin at room temperature (RT) and Coombs test in antihuman globulin (AHG) phase at 37C.
However, any discrepancy results were resoluted by using specialized reagents like 0.01 (M) Dithiothreitol (DTT) and Chloroquine diphosphate (CDP).
His forward blood group was 'AB' positive and reverse blood group was 'O' and saline control was positive at RT. The results were same after 6 time's warm saline wash. The blood group discrepancy was resolved after treating the red cells with 0.01(M) DTT and the final blood group came as 'O' positive with negative saline control.
The direct antihuman globulin test (DAT) before and after DTT treatment was (2+) by tube method.
The DAT of CDP treated cells become (1+) i.e. weakened. Extended Rh and Kell (K) phenotype of DTT treated red cells showed CCeeKo (R1R1) phenotype. Patient was transfused with best matched PRBC unit (phenotype matched) and after 3 unit of PRBC transfusion along with systemic steroid therapy his hemoglobin level raises from 40 gm/L to 109 gm/L and the patient was discharged from the hospital uneventfully.
The patient had both Immunoglobulin M and Immunoglobulin G type of auto antibody. This Immunoglobulin M is reacting at high thermal amplitude over 37C producing persistent auto-agglutination.
Donor deferral: In a blood bank attached to a Tertiary Care Centre in Chhattisgarh, understanding causes and implementing changes
Prerna Mohan, Akhilesh Bhave, Rupma Ruha
To assess the incidence and reasons for deferral among Blood donors in a Blood Bank attached to a tertiary care centre.
A retrospective study of blood donor deferral from January 2013 till December 2014 was done. Selection criteria as per Drugs & Cosmetics Act 1940, was followed. Data study is based on pre donation screening interviews and physical examination.
Out of donors presenting for donation (n = 9590), 390 (4.06%) were deferred. Most of the donors were deferred on physical examination and Hb testing. Low Hb (75%) was the most common cause of deferral in Chattisgarh, followed by history of jaundice (4%) in past 5 years. H/O alcohol intake in the past 24 hours was responsible for 2% of deferrals. H/O malaria was equally responsible for 2% of deferrals. Typhoid history in the past 12 months, and vein problem, each accorded for 1.5% of deferrals. Aspirin intake became a common cause of deferral in 1.42% of cases, followed by leucoderma, H/O epilepsy, H/O fever and H/O vaccination in 0.94% of cases.
Other causes were high Hb, low body weight, H/o diabetes on insulin, H/o Surgery, H/o chicken pox and high BP.
As in other states, Chattisgarh also has anaemia as the basic cause of deferral which needs to be looked into. H/O jaundice and History of malaria and typhoid also are basic sanitation factors which need to be looked into for better donation profile from our state.
Role of column agglutination technology to resolve mixed field reaction due to Rh Kell alloantibodies in multi-transfused thalassaemic patients
Anju Verma, Kinjal Upadhyay
Introduction: Good transfusion practices involve phenotype matched blood transfusion specially for transfusion dependent thalassaemics to minimize the alloimmunization. Studies have revealed that alloantibodies against Rh and Kell blood group systems are most frequent in Indian thalassaemic population. Rotary Blood Bank started Rh+K phenotyping (D, C, c, E, e and K) of thalassaemics in 2014 and issues phenotype matched blood to all the patients.
A study was conducted on thalassemic patients who are regularly taking blood from Rotary Blood Bank. Rh and Kell phenotyping by Column Agglutination Technology (CAT) was done everytime they came for transfusion and their actual phenotype was determined.
Materials and Methods: Performed Rh+K phenotyping of 30 thalassaemics by using BioVue Rh+K cassette (BioVue C, E, c, e, K cassette) based on Column Agglutination Technology (CAT) in fully automated system, AutoVue Innova. The manufacturer's guidelines were followed for performing the tests.
Mixed field reactions which were interpreted by AutoVue Innova were verified by manual review of cassettes.
In cases with mixed field reaction, blood negative for that particular antigen was selected for transfusion. When double cell population was observed in the column with E antigen patient was transfused with E negative PRBC.
For next transfusion, again phenotype matched blood was transfused. This process was repeated until the mixed field reaction completely disappeared.
Phenotyping of all donor units is being performed by microplate technology using Neo by Immucor, USA.
Result: Mixed field reaction was observed in 16 out of 30 thalassemics. Randomly 17 patients were selected for the study those who were coming regularly to Rotary blood bank. All 17 samples were phenotyped for Rh+K. Out of 17 patients 11 had mixed field reaction and in 6 patients, actual phenotype was determined and phenotype matched blood was transfused.
After first transfusion it was observed that 2 patients out of 11 showed complete removal of mixed field reaction. Two new patients were included who had mixed field reaction.
After 2nd, 3rd & 4th transfusions 8 patients showed clear picture. So, out of 13 patients with mixed field reaction 8 patients had clear phenotype. Out of total 17 patients 4 showed clear picture throughout, 10 showed clear phenotype after repeat transfusions and 3 are still showing mixed field picture. The study is continuing.
Conclusion: Phenotype test by CAT is very useful to determine the actual phenotype of patients. It is useful in patients who were transfused previously by phenotype unmatched blood showing mixed field reaction.
Transfusion support in liver transplantation
S Damodhar, Vinod Kumar Panicker, R Krishnamoorthy
Background: Blood transfusion plays an important role in liver transplantation. Liver transplantation is now the successful treatment available for the treatment of end stage liver disease. Large numbers of blood products are used in these procedures like FFP and PRBCs. The need for transfusion is determined by the severity of bleeding during the transplantation. Bleeding is due to factors like poor hemostatic capabilities of the patients and technical difficulty of the surgical procedure.
Due to the improvement in the surgical techniques the demand for the blood products have come down compared to the older surgical techniques.
However when compared to other surgical procedures the demand for blood products in liver transplantation is more.
It is difficult to predict the blood losses and transfusion requirement in cases of adult liver transplantation.
Aim: To assess the transfusion requirements in adult liver transplantations those have been performed in our hospital till now.
Materials and Methods: This is a retrospective study based on six cases those have undergone liver transplantation and required transfusion of blood products. All of them were adults and underwent cadaveric liver transplantation for end stage liver disease. The quantities of blood products transfused were ascertained. Transplant surgical team and other physicians caring ordered the transfusions for the patient.
Results: Components used were, fresh frozen plasma: 46% packed red blood cells: 26.3% cryoprecipitate: 14.7% platelets: 12.7%. In two out of six procedures platelets were not used. PRBCs, FFP and CRYOPRECIPITATE usage was consistent through all the cases.
Conclusion: Large number of Fresh Frozen Plasma and Packed Red Blood Cells were used and mostly during the intraoperative and postoperative period. Followed by Cryoprecipitate and platelets. Increased number of FFP and pRBCs transfusion can be attributed to poor hemostatic capabilities in these patients and bleeding during the surgical procedure.
Proper inventory management can significantly reduce or prevent avoidable blood wastage: Experience from a tertiary care blood bank
Naveen Akhtar, Renu Bala, Vijay Sawhney
Blood transfusion services are one of the essentials of the modern day healthcare system. BTS cater to all the major specialities and superspecialities of healthcare system. Presently there is a 30-40% shortage of safe blood supply in our country. Thus judicious and efficacious use blood becomes more important in this resource poor setting. Unnecessary blood wastage due to avoidable causes like expiry, splitting, hemolysis etc. becomes more so important. Though certain amount of blood wastage or discard is unavoidable to maintain the safety of blood transfusion services. The blood wastage due to these causes can be avoided or reduced by implementation of certain policies for proper inventory management. This study aims to analyse the effect of implementation of certain policies for inventory management on the blood wastage.
This study was done in the PG Departmrnt of Transfusion Medicine, GMC Jammu Blood Bank from July 2014-June 2015. Certain policies were formulated and implemented for Blood Inventory Management. The discarded blood units were included in the study and results compiled were compared to previous year's (July 2013-June 2014) blood discard rates and causes.
The discard rate of blood was observed to be 3.07%. Blood wastage rate was reduced by 0.92% as compared to previous year discard rate of 3.99%. Among the various causes of blood discard maximum wastage reduction was seen due to expiry (52.3%) and splitting (40%) which are the avoidable causes of blood wastage. There was no much reduction in wastage due to unavoidable causes of blood wastage like TTIs, Undercollection and others. An overall 22.9% reduction in blood wastage was noted as compared to previous year's blood discard.
There is a significant scope of blood wastage reduction especially due avoidable causes like expiry, splitting, hemolysis etc. by adopting and implementing certain policies for proper and effective Blood Inventory Management. This will to some extent can mitigate the blood supply shortage in a resource poor setting like our country.
Insight into disparity between number of projected blood donors versus actual blood units collected in outdoor blood donation camp setup: An observational study
V Naveen Kumar, R Rajbharath, S Hamsavardhini, P Arumugam
The primary importance of voluntary Blood Donation is to ensure availability of safe, stable and sufficient blood in the blood banks. Voluntary blood donation camps organised by blood banks, help in better reach of voluntary blood donors thereby increasing the blood reserve in our blood banks. The success of blood donation camp depends on the corroborative work between camp organizers, blood bank team and blood donors. However, there exists a significant disparity between the projected (or) expected blood donors to the actual blood units collected during such outdoor blood donation drives.
The aim of our study is to reveal probable factors and to improve the strategy for increasing the volume of blood donor pool that contribute to the disparity between projected (or) expected number of blood donors to the actual blood units collected during outdoor blood donation camps.
This was a prospective observational study conducted in our outdoor blood donation camps organised by the Department of Transfusion Medicine, The TN Dr. MGR Medical University, Tamil Nadu between the time period June 2015 and August 2015. Using a structured questionnaire, data was collected from the blood camp organizers and social welfare officers from our blood bank.
During our study period, a total of 10 outdoor camps were conducted. Out of the 10 camps conducted, 3 camps were conducted under "I.T. sector" category, 3 camps under "Colleges" category, 3 camps under "NGO" category and 1 camp under "Political/Film Fraternity" category. 755 donors were projected, 656 donors (83.2%) attended the outdoor camps, 453 blood units (58.8%) were collected and 203 donors were rejected. The 24% disparity rate from the attended donors is mainly due to rejection of blood donors not fulfilling the requirements of donor selection criteria. The 17% disparity rate from the projected estimate is mainly due to poor turnout of donors due to personal commitments, peer pressure among potential blood donors, inadequate awareness of donor selection criteria among camp organizers.
Proper identification of potential healthy blood donors by increasing the blood donation awareness campaigns and re-assurance of blood donors regarding blood donation procedures will help in reducing the disparity between the projected count and actual number of blood units collected.
CMV seroprevalence and seroincidence among South Indian donor population: An age related study
Nittin Henry, Susheela J Innah
Background: Cytomegalovirus (CMV) can lead to serious health hazards in terms of morbidity and mortality in neonates and immunocompromised patients. Latent infection makes CMV dangerous even years after the infection. Very few studies have been undertaken on seroprevalence of CMV in South Indian population.
Aim: To determine CMV seroprevalence (IgG and IgM) among blood donors in South India.
Cross sectional descriptive study on 500 donors in a teaching institute in Kerala. IgG and IgM seroprevalence was measured by Enhanced Chemiluminescence Technology using Orthocare Vitrios. Their relation of age, gender and other transfusion transmissible infection status of the donor's were analysed.
16 blood donors were CMV IgG positive while none among the study group was seropositive for CMV IgM. All the seronegative donors were < 40 years. There was no association to gender and other TTI seroprevalence.
96.8% was the CMV IgG seroprevalence, while 100% were seronegative for CMV IgM. This makes CMV serology impractical as a predonation workup, making leukoreduction the best possible method for prevention of CMV transmission to susceptible recepients in the respected donor population. The absence of recently seroconverted donors, the group which could have been having a higher risk make CMV serology viability even lesser. A better idea regarding recent seroconversion can be obtained from testing of seroconversion of seronegative donors over a period of time. The higher seroprevalence of elderly donors in our study along with previous studies showing higher viremia (DNA positive rate) among elderly adults makes it significant to consider about avoiding the transfusion of blood components collected from elderly population from being transfused to susceptible recepients. Till testing for CMV viral DNA (viral load ) becomes a reality , viable and substitutes CMV serology leukoreduction should be considered as the sole method of preventing transfusion transmissible CMV infection.
An analysis of adverse donor reaction of the healthy blood donors
Rajesh Kumar, Sanjay Prakash, Vandna Chhabra
Background: Blood transfusion services is the vital part of modern health care system without which efficient medical care is impossible. To meet the potential needs for adequate blood supplies, it is beneficial to increase the number of blood donors and the blood donation rate. Although the blood donation is the safe and uncomplicated procedure, occasionally donors experience adverse reactions during or after donation; but they are usually harmless.
Complication associate with blood donation are not only the problem of donors but they are also important to transfusion services as some complication may negatively affect donor recruitment and retention.
Aim: To analyse adverse donor reactions during and after donation of blood in healthy blood donors.
Methodology: The prospective study was conducted in blood bank R.N.T. Medical College, Udaipur during may 2015 to august 2015 to analyse adverse donor reaction in 5000 blood donors. Blood donors were selected as per the SOP of our department and donation were collected under observation. Donor were observed during the donation period and post donation instruction were given before the donor left the centre. Complication which the donor attributed to blood donations were also noted during study.
Result: Among 5000 healthy blood donors 1195 are voluntary blood donor and 4805 are replacement donor. Among these 4918 are males and 82 females. During the study period 67 adverse donor reactions occurred with 3.65% (3/82) in females and 1.3% (64/4918) in males. Among 67 adverse reactions 45 reactions where in first time donors. Total of 58 post donation complications were noticed as against 9 reaction during donation.
Vasovegal reactons being the most common (55/67) classified as mild moderate and severe. In our study we noticed mild (46/67) moderate (6/67) severe (3/67) reactions. Apart from this 12 donors had developed haematoma. No other adverse donor reaction noticed.
Conclusion: Complication during the post donation are common hence post donation care must be warranted. Adverse donor reaction are more common in females so proper observation is mandatory. Mild vasovagal reaction are most common. First time donors encountered 67% adverse donor reaction.
Reactions especially in first time donors create an ill impression of blood donation and safety of the procedure. These are usually self limiting event but can paralyse the blood transfusion services.
It can decrease return donation and disrupt blood collection activities vital for proper functioning of any hospital.
Donor and machine variables that influence plateletpheresis yields on trima accel gambro BCT: An experience in a Tertiary Care Centre in South India
Pragya Kafley, Dolly Daniel, Mahasampath Gowri, Joy Mammen
Change in treatment protocols in recent times have led to an increase in platelet demand for thrombocytopenic patients. Apheresis platelets have distinct advantages over random pool platelets and results in lesser donor exposure, better post transfusion platelet increment and increase in inter-transfusion interval. Therefore it becomes imperative to study the factors that influence platelet yield in apheresis so as to optimize the final yield. While all studies agree on the fact that higher pre-donation platelet count results in higher platelet yield, other variables have given inconsistent results. Many studies have shown donor hemoglobin to have inverse relationship with platelet yield while other studies have shown no correlation. In our hospital while donors with hemoglobin lower than 12.5 gm/dl are rejected, we do not have an upper cut-off for Hemoglobin. The study was conducted to analyze the impact of various donor and apheresis machine parameters on platelet yield.
To analyze the impact of various donor and apheresis machine parameters on platelet yield. 86 platelet apheresis procedures conducted in our blood bank between, June to December 2014, were retrospectively analyzed. Age, volume of plasma processed, Hemoglobin, Body Mass Index (BMI) and platelet pre-counts were included as donor associated variables. Anticoagulant used, processing time, and plasma volume collected with platelets were assessed as machine parameters. The apheresis machine used was Trima Accel- GAMBRO BCT. The correlation of these variables with post apheresis platelet yield was seen.
Only pre donation platelet count of donors was found to be statistically significant with (P = 0.02). All the other machine parameters and donor variables including haemoglobin (P = 0.2579) did not show any significant correlation with apheresis platelet concentration.
Donor platelet count influences platelet yield, higher platelet count corresponds to higher yield, while pre donation hemoglobin showed no correlation with platelet yield. Therefore our current policy of not having a higher cut off levels for hemoglobin in case of apheresis donor is correct.
Prevalence of principal Rh blood group antigens (D, C, E, C and E) in blood donors at the blood bank of a Tertiary Care Teaching Hospital in Andhra Pradesh
G Deepthi Krishna, KV Sreedhar Babu, R Arun, DS Jothi Bai
Rhesus (Rh) antigen was discovered in 1940 by Karl Landsteiner and Wiener. Due to its immunogenicity along with A, B antigens, Rh D antigen testing was made mandatory in pre transfusion testing. Presently there are more than 50 antigens in Rh blood group system but major ones are D, C, E, c, and e. Very few reports are available regarding their prevalence in India and no reports are available from Andhra Pradesh.
A prospective cross-sectional non interventional study was carried out on 1000 healthy voluntary blood donors from August 2013 to July 2014 to evaluate the prevalence of principal Rh blood group antigens like D, C, E, c & e at our blood bank. Donors were grouped and typed for ABO and Rh major antigens using monoclonal blood grouping reagents as per the manufacturer's instructions. Statistical analysis was carried out using SPSS version 16. Comparison of categorical data between antigen positive and negative individuals was done using Chi-square test. Descriptive statistics for the categorical variables were performed by computing the frequencies (percentages) in each category. Incidence was given in proportion with 95% confidence interval.
A total of 1000 blood sample from donors were phenotyped. Among Rh antigens, e was the most common antigen (98.4%) followed by D-94.1%, C-88%, c-54.9% and E-18.8% with DCe/DCe (R1R1) (43.4%) being the most common phenotype and the least common phenotype is r'r' (0.1%).
Database for antigen frequency to at least Rh blood group system in local donors helps to provide antigen negative blood to patients with multiple alloantibodies, minimize alloimmunization rate, and thereby improve blood safety.
Generation "C" first time blood donation is path to 100% voluntary blood donation
Trupti Laxman Lokhande, Sanjay Prakash, Vandna Chhabra
Background: Blood transfusion is the core service within healthcare system. Blood bank need to provide safe, adequate supply of blood. '100% voluntary non-remunerated donation of blood and blood components - by 2020' is goal by WHO and IFRS as per 'Melbourne Declaration'. To meet potential needs for adequate blood supplies, it is essential to increase number of blood donors, donation rate and recruit first time donors.
Generation C' belongs to age group 18-24 yrs where C stands for Connect, Communicate and Change. To foster the culture of blood donation and for building and maintaining safe, sustainable voluntary blood donation , we will study current involvement of Generation C as first time blood donor in order to connect this generation for motivation and recruitment of blood donors.
• To assess proportion of first time blood donation in view to generate blood bank data for motivation and recruitment of these donors for repeated donation
• To study present trend of blood donation in Generation-C so as to define strategy to target this group.
A descriptive cross-sectional study was carried out on 1000 healthy blood donors who have donated blood to Blood bank, R.N.T. Medical College, Udaipur in the blood bank and at outside camp organized by blood bank during 01/06/2015 to 21/06/2015.
Of 1000 donors, 572 were replacement (57%) and 428(43%) were voluntary blood donors. Among 1000 donors 533 were first time donors (53%).
First time voluntary blood donor proportion as per age is 18-24 yrs (38%), 25-49 yrs(57%), >50 yrs (5%) and first time replacement blood donors proportion as per age is 18-24 yrs (25%), 25-49 yrs (72%), >50 yrs (3%).
Female donation accounts for 3%donation in both first time voluntary and first time replacement donors. Students in Generation C as first time blood donor were 10% (51/533). Seroprevalence among first time donors was 1.7% (9/533) with absolute seronegativity found in first time voluntary donation.
First time donation is 53% which denotes motivation and recruitment strategies for this group will increase pool of safe donors. Seronegativity found in first time voluntary donation assures safe blood supply by voluntary donation. Generation C involvement in voluntary blood donation (38%) could be increased if communication through mass media is done. Students (10%) participation should be targeted through educational programmes. Generation C is easy to connect and communicate. This will really benefit by bringing change in society through awareness towards blood donation and to achieve 100% voluntary blood donation.
Minor red cell antigens in allogeneic hemopoietic stem cell transplant
Sabita Basu, Mahua Reddy, Mammen Chandy
Among the red cell antigens, only ABO antigens are considered for donor-recipient red cell compatibility in hemopoietic stem cell transplantation (HSCT). Minor red cell antigens have been implicated in post transplant immune hemolysis. We present our observations on donor-recipient red cell antigen phenotyping in allogeneic HSCT.
The study included 7 donor-recipient pairs where allogeneic HSCT was performed. ABO blood group, major and minor cross match, antibody screen and red cell phenotype was done pre-transplant in both donor and recipient, and post transplant in the recipient. Tube technique and column agglutination technique (CAT) (Ortho Biovue micro bead system) was used. Red cell phenotyping was done using Ortho bioclone antisera.
This analysis included 5 cases of thalassemia major and one case each of T-ALL and B-ALL; these included 4 ABO compatible, 1 major and 2 minor mismatches. One case though ABO compatible showed minor incompatibility due to anti M (IgG) in the stem cell donor. The recipient here was M antigen positive, hence plasma depletion of the stem cell harvest had to be done prior to transfusion. Change from donor to recipient red cell phenotype was noted as early as the seventeenth day. In one donor- recipient pair, with blood groups A negative and A positive; the D and C antigens in the recipient simultaneously weakened and disappeared over 2 months, however the Fyb antigen continued to persist. Complete change to the donor red cell phenotype for all clinically significant antigens was observed in two ABO compatible, one major and one minor incompatible HSCT.
Both major and minor cross match along with antibody screen are necessary during pre-transplant evaluation to detect clinically significant antibodies; and plan for manipulation of the harvest and management of the recipient.
Alloimmunisation in a case of primigravida with thallasemia intermedia
Panduranga Rao Sanagapati, Sudhir Kumar Vujhini, B Shanthi
Transfusion is the mainstay treatment of patients with thalassemia major and occasionally in thalassemia intermediate. Alloimmunization is an unwanted side effect of blood transfusion. We present a case report of alloimmunisation to "c" in primi with Thallasemia intermedia.
Case Report: An eighteen year old female with 18 weeks gestation and a known case of Thallasemia intermedia presented with severe anemia. Her hemoglogin was 4 gm%. Patient was receiving one unit of blood transfusion every three months up to the age of 12 years. At the age of 12, she underwent spleenectomy and from then onwards, she was receiving one unit of transfusion every year. Fifteen days back, she received two units of transfusion for which there was a post-transfusion reaction in the form of fever with chills and body pains. Her blood sample was sent to the blood bank for evaluation.
Results: Her blood grouping showed cell and serum grouping discrepancy. ICT was positive. 3 cell and 11 cell panels were suggestive of presence of "c" antibodies in the serum. Rh extended phenotyping revealed that the patient's cells were "c" antigen negative.
Conclusion: Patients receiving multiple transfusions should be transfused with extended red cell phenotype-matched blood in order to prevent alloimmunisation.
Seroprevalence of transfusion transmitted diseases among blood donors in Chhattisgarh region
Human Immunodeficiency virus, Hepatitis B virus, Hepatitis C virus, syphilis and malaria are important transfusion transmissible infections. Screening of blood donors for these infections not only reduces the risk of transmission but also gives an idea of epidemiology of these infections in the community. Aim of this study is to compare the seroprevalence of TTD's among blood donors and thereby assessing the blood safety.
The data is collected form O.P. Jindal Hospital & Research centre, Blood Bank from 20th July 2010 to 19th July 2015. First the donors were underwent routine blood selection process and then samples were screened for HIV, HBsAg, HCV using 3rd generation ELISA kit. Syphilis screening was done using RPR method and malaria by using rapid kits.
Total 8992 donated blood and screened for TTDs. Out of 8992 blood donors, 209 (2.32%) were tested reactive for TTDs.
• The prevalence for HIV was 0.16% (15 cases) in total donors
• The prevalence for HBsAg was 1.2% (108 cases) in total donors
• The prevalence for HCV was 0.20% (18 cases) in total donors
• The prevalence for syphilis was 0.16% (67 cases) in total donors
• The prevalence for malaria parasite was 0.01% (1 donor) in total donors.
Seroreactivity rate among voluntary donors was 0.13% and in the replacement donors was 2.19%.
The prevalence of infection was higher in the replacement donors compared to voluntary donors. Therefore to decrease the risk of transfusion transmitted infections, voluntary blood donation shall be encouraged. Appropriate and compulsory screening of blood donors using sensitive methods must be ensured.
Cryopreservation of stem cells using human serum albumin and autologous plasma as cryoprotective solutions: Its clinical impact
Mohandoss Murugesan, Chandran K Nair
Cryopreservation of stem cells in autologous hematopoietic stem cell transplantation (HSCT) was performed to maintain their cell viability and recovery during storage. Commonly followed practice was to dilute cryoprotectant DMSO with Human serum albumin (HSA) for achieving optimal concentration. Autologous Plasma (AP) is less expensive and ready availability makes it an easy alternative for HSA in preparing cryoprotective solutions. The aim of our study was to study the process HSA and AP cryopreservative solutions and to compare the time intervals for engraftment after transplantation of stem cells stored using these cryoprotectants.
Retrospective study, cryoprotective solutions prepared using 100% DMSO (Cryopur, Origen) with HSA in Group I (8 patients) were compared with AP in Group II (8 patients). AP was partly collected during the leukapheresis procedure and the rest obtained from volume reduction of the final product. In addition, we studied the loss of CD34+ HSCs after plasma reduction. During this study period, only 6 patients underwent stem cell infusion, out of which 3 had been placed in each group. The rest 10 patients are to be infused in future. We compared time interval for engraftment in both the groups. Engraftment is considered when peripheral blood WBC >1 x 109/L, absolute neutrophil count >0.5 x 109/L and for platelets three consecutive days >20 x 109/L without transfusion.
The dose of CD34 cells infused in both groups varies widely, HSA (7.1 to 12 x 106/kg), AP (4.5 to 6.5 x 106/kg). In the AP group, the mean plasma volume recovered after the leukapheresis was 170 ml (80-200 ml). After the plasma volume reduction, the mean loss of CD34+ cells was found to be 15%. The mean percentage of viable cells after plasma reduction in AP group was similar to HSA group. (90% vs 86%). The median engraftment time for WBC & ANC in peripheral blood was similar in both groups; HSA: 9 days (9-10 days) and AP: 11 days (9-16 days). The platelet engraftment showed a wide variation with HSA had a median of 15 days (13-25 days) and AP 27 days (12-28 days).
This study reflects the autologous plasma can be a cheaper alternative to albumin in cryopreservation of HSCs. We refrain from drawing any conclusions from this study due to the insufficient sample and further studies are being carried out.
Managing AIHA in thalassemia major patient
Hardik Pankajbhai Raval, Nidhi Bhatnagar, Maitrey Gajjar, Tarak Patel, Kamini Gupta, Jaymin Bhatt
β Thalassemia is one of the most prevalent autosomal disorders, which affects more than 4,00,000 new born per year worldwide. In India, the carrier rate of β thalassemia varies from 3-17%. The development of anti-red blood cell antibodies (both allo-and autoantibodies) remains a major problem in thalassemia major patients. Red cell autoantibodies appear less frequently but they can result in clinical hemolysis called autoimmune hemolytic anemia (AIHA) and result in difficulty in cross-matching blood. Patients with autoantibodies may have a higher transfusion rate and often require immunosuppressive drugs or alternative treatments including intravenous immunoglobulin (IVIg) and rituximab (anti-CD20 monoclonal antibody).
Here we describe a case of 1.6 year old female patient, who was admitted with a diagnosis of thalassemia major and received multiple transfusions from several centers. She developed coomb's positive hemolytic anemia which was showing panpositive reactivity on 11 cell panel suggestive of autoimmune hemolytic anemia. Finding a compatible blood unit for her was a major challenge. To maintain her hemoglobin level, least incompatible blood unit was issued under steroid cover.
Blood transfusion was required every 3-4 weeks and each time least incompatible blood was issued to maintain her hemoglobin level. Oral steroids and rituximab were given post transfusion for 1 week. At the time of discharge, patient's Hemoglobin was 9.2 gm/dL.
Corticosteriods therapy and rituximab with regular transfusion of extended red cell phenotype-matched blood is a very effective regimen for such patients.
Blood discard as a quality indicator in a Tertiary Care Teaching Hospital in South India
Nittin Henry, Ganesh Mohan, Susheela Jacob Innah
A well organized blood transfusion service is necessary for ensuring the sufficiency, quality and safety of blood supply and an efficient quality management system through out various levels of blood banking ensures it. The efficiency of various processes and practices involved in blood banking can be monitored by various quality indicators. According to AABB, quality indicators are the specific performance measurements designed to monitor one or more processes during a defined time and are useful for evaluating service demands, production, adequacy of personnel, inventory control and process stability. Rate of blood discard is an efficient quality indicator denoting the effective collection processing and utilization of blood products that can have direct effect on inventory management, safety and availability of blood for utilization.
The study was conducted in Jubilee Mission Medical College and Research Institute. The data regarding blood discard in the blood bank was obtained in a prospective manner from August 2014 to August 2015, while the data regarding blood discards post issue in various wards were collected in a prospective manner from January to June 2015 from patient records. The discard rates of various components and their reasons were analyzed objectively and were compared with other studies from across the globe.
219 (2.4%) blood collections were low volume which were discarded even before component preparation. Rate of discards for prbcs, FFP, platelets and cryoprecipitate were 1.4 %, 4.5 %, 12.4% and 2.9% respectively. TTI reactivity (53.54%), expiry (40.94%) and leakage (4.72%) were the reasons for prbc discards. Out of 398 FFP discards TTI reactivity (17.1%), multiparous female collection (25.6%), icteric (12.1%), lipemic (18.84%), rbc contamination (5.8%), leakage (18.3%) and ict positivity (6.8%) were the reasons. Platelet discards were due to expiry, TTI positivity and red cell contamination. None of the issued blood products to the wards were found to be discarded.
Better donor selection and counseling, staff training and evaluation and a better inventory management can reduce the discard rate. The data showing absence of discards post issue forced us to takeup a more proactive study in this respect. Comparatively lower rate of FFP discards focuses on the absence of expiry mostly due to indiscriminate use of the same across the hospital.
Study of donor adverse reactions: Frequency, predisposing factors and preventive measures
G Shanthi Ramanujam, Hamsavardhini, Rajbharath,
Whole blood donation is generally considered to be a safe procedure with minimal or nil adverse donor reactions. Even then, donors experience mild adverse reactions, which are unpleasant for donors and have a negative impact on donors returning for further donation. Therefore, aim of our study is to assess the frequency of adverse reactions, analyze the predisposing factors and recommend the best practices with the help of haemovigilance we can minimize the adverse reactions in voluntary blood donors.
Retrospective study of Voluntary blood donors attending the blood donation camps and walk-in donors to our blood bank were included in this study and data regarding the adverse reactions were collected from donor adverse reactions register. The study was conducted on blood donors over a period of 12 months. During the initial period of the study, data was collected from July 2013 to December 2013. Then specific intervening measures were taken, followed by data collection from January 2014 to June 2014.
A total of 2046 donors were included and adverse reactions were observed in 2.5%. Among all adverse reactions, giddiness constituted 60.37% haematomas 35.84% and arterial puncture (1.8%). In the initial period of the study, total donors were 941. Among these donors, adverse reactions were noticed in 2.85% (male = 96.22%, female = 3.77%). Most common reaction observed was giddiness 55% followed by haematoma 37% and vomiting 7.5%. Among the adverse reactions, haematoma showed a significant association with younger age 18 to 25 yrs 68.42% and in donors weighing more than 70 kg 52.63%. Giddiness also seen in young age 59.37% and thin built persons 28.1%. One arterial puncture was noticed. The incidence of haematoma were more when phlebotomy was done by less experienced persons and failure to select best veins in obese donors. Giddiness was common in first time donors, because of their anxiety and fear about the donation. Specific preventive measures were taken with special attention to young college students, first time donors and thin built persons. We insist them to have 8 hrs overnight sleep, light breakfast 1 hour before donation and to drink plenty of water. Following these specific measures the overall adverse reactions were reduced from 2.8% to 2.5%. Specifically the incidence of haematoma was reduced from 37% to 34.4%.
Donor adverse events analysis, helps in identifying the donors at risk and adopting appropriate measures to reduce the risks and make them as a regular voluntary donors.
Incidence and causes of wastage of blood and blood components in a blood bank of tertiary care hospital: A retrospective study
Puneet Kaur, Victor Masih, Rupinder Kaur
Transfusion of safe blood and blood products are integral part of patient management. Human blood has no substitute and there is always a gap between demand and supply of blood which can be reduced by more efficient utilization of blood/blood components. The current study was aimed at finding the reasons for discarding blood/blood components and to develop plans to reduce wastage.
This was a retrospective study in blood bank unit of a tertiary care hospital and included one year data from blood bank records from 1st Jan 2014 to 31st Dec, 2014. Blood donations collected from both voluntary and replacement donors were subjected to blood components processing - Packed Red Blood Cells (PRBC), Fresh Frozen Plasma (FFP) and Random Donor Platelets (RDP). The study involved analysis of various reasons for discarding blood/blood components viz transfusion transmitted infections (TTI), outdated/expired bags, leakage/breakage, bags sent for quality control, bags of FFP/PC's showing discoloration due to RBC contamination, DCT positive PRBC's, PRBC with no segment left for further cross match due repeated cross matching.
A total of 11923 blood bags were collected in the study period, of which 11804 were subjected to component preparation. Majority of donors were males (97.23%). Overall discard rate of whole blood and blood components was 5.71%. Most common reason for discard was Transfusion Transmitted Diseases (TTI) which comprised 74.18% and of which HCV formed the majority. This was followed by non-utilization due to expiry (17.08%), followed by blood sent for quality control (3.92%) and various other causes (leakage, contamination, DCT positivity and no segment available for cross match) constituted 4.82% of the discard rate.
Blood is a very precious resource which needs proper utilization with ideally zero percent wastage. Most common reason for discard of blood/blood products in our study was seropositivity. Proper screening of donors, with detailed history avoids wastage due to TTI's. The second common reason of discard in our study was non utilization of blood/blood products beyond expiry date. Issuing blood/components based on FIFO (First in First out) policy and regular audit by hospital transfusion committee will help to reduce wastage due to non-utilization.
A case report: multiple myeloma with hyperviscosity symptoms treated with therapeutic plasma exchange
Abhaykumar Malind Gupta, Anita Tendulkar, Puneet Jain, Anisha Navkudkar, Joseph Sanal
Introduction: Multiple myeloma (MM) represents a malignant proliferation of plasma cells derived from a single clone. One of the common symptoms of MM is hyperviscosity which may manifest as gangrenous changes in extremities. This can be life threatening and needs prompt measures to reduce the blood viscosity and prevent further complications.
Case Details: A 47 year old male, farmer by occupation with diagnosis of Multiple Myeloma ISS II IgG Kappa type since 28 months with 10 months of chemotherapy had been operated for D12 Vertebroplasty 2 years ago; 33 Gy radiotherapy was given to the same area. Patient presented with fever followed by joint swelling and joint pain with headache and blurring of vision, gangrenous changes in toe, ulcer with purulent discharge.
In view of hyperglobulinaemia with symptoms of hyperviscosity, a TPE was performed as an emergency procedure and one plasma volume was processed. Before procedure commencement, the following investigations were analyzed: Hemoglobin 7.1 gm/dl, hematocrit 21.7%, platelets 70000/ml, INR 1.5, aspartate aminotransferase 67 U/L, alanine aminotransferase 32 U/L, serum protein 14.4 gm/dl, globulin 13.2 gm/dl, albumin 1.3 gm/dl and serum electrolytes. Symptomatic relief with reference to fever, joint pain and swelling was observed after the procedure. In view of this, more sessions were planned to further improve the clinical manifestations and to reduce the serum proteins. Subsequently, two additional TPEs on alternate days were performed which helped to salvage his extremities. Patient's serum proteins decreased from 14.4 g/dl to 7.36 g/dl and albumin decreased from 13.1 g/dl to 4.86 g/dl after the last procedure, thus tapering it to normal levels.
TPE was performed on the MCS+ as a single arm procedure. Procedure details are as follow: In the first procedure 2626 ml plasma volume was replaced with 1625 ml of Fresh Frozen Plasma (FFP) and 1000 ml normal saline (NS), in second procedure 2630 ml of plasma was replaced by 1558 ml of FFP and 1000 ml of NS, in third procedure 2370 ml plasma was replaced by 1763 ml FFP and 500 ml NS. Patient was monitored throughout the procedure for blood pressure, pulse, respiratory rate and oxygen saturation. All sessions were uneventful and there were no adverse events.
Patient was discharged 2 days after the last TPE procedure. On follow up, after 10 days he had not developed any new hyperviscosity symptoms.
Conclusion: TPE when performed in timely manner can be a life saving procedure. Limb salvage can be achieved in diseases of increased blood viscosity like multiple myeloma.
Clinical and biologic profile of multiple myeloma patients undergoing treatment at a tertiary care centre
Seema Subhash Revankar, Col. PB Mukherjee
Multiple myeloma is a neoplastic plasma-cell disorder that is characterized by clonal proliferation of malignant plasma cells in the bone marrow micro environment, monoclonal protein in the blood or urine, and associated end organ damage (i.e., hypercalcemia, renal insufficiency, anemia, or bone lesions) that is attributable to the underlying plasma cell disorder. An observational study (18 months) on a subset of 50 patients of multiple myeloma undergoing treatment at a tertiary care centre in Pune was done to assess the common disease presentation and lab profile of these patients in addition to assessing the utility of International Staging System (ISS) in predicting the outcome post treatment.
A relation between the various variables eg. Age, sex, complete haemogram, bone marrow studies, renal function tests , S. electrolytes, S.β2 microglobulin levels, S. electrophoresis, total protein, albumin and globulin levels, presence of Bence Jones proteins in urine, presence of lytic bone lesions, FISH and karyotyping studies and different stages of International Staging System was made using Chi-square test. t-test was used to compare the pre and post treatment serum albumin and serum β2 micro globulin (S. β2 M) levels. Wilcoxon test was used to find association between pre and post treatment International Staging System (ISS) stages.
In this study, in addition to S. β2 Microglobulin (P < 0.0001) and albumin (P < 0.0001) levels, total leucocyte count (P < 0.05), bone marrow plasma cells (P < 0.05) and serum globulin levels (P < 0.05) at presentation also had a significant statistical bearing on different stages of at presentation with S. β2 Microglobulin (P < 0.0001) and albumin levels (P < 0.005) showing considerable reduction post treatment and significant improvement in International Staging System stages post therapy (P < 0.0001).
The presence of raised β2 Microglobulin levels with reduced serum albumin levels are poor prognostic markers as suggested by the International Staging System. However more cases will need to be analysed for a longer duration to conclusively ascertain if the other statistically significant parameters found in this study like total leucocyte count, serum globulin levels and percentage of bone marrow plasma cells at initial presentation, have any impact on the treatment outcome. There were no conflicts of interest noted in this study.
Eight years study of TTI trend in voluntary blood donors: In-house V/S outdoor collection
Chandni Nalinbhai Karia, Ekta Pankhania, Nishith A Vachhani, Sanjiv Nandani
Blood is indeed a miracle medicine for patients in need. The problem of transfusion transmitted infections is directly proportionate to the prevalence of the infection in the blood donor community. Rajkot voluntary blood bank & research centre works only on voluntary blood donation. The aim of this study was to know the prevalence, changing trend of TTIs and effective screening procedures to improve the blood safety.
Total 150145 (109879 from camp site and 40266 from in-house) voluntary blood donors were analyzed from January, 2008 to July, 2015. Donors were screened thoroughly based on the history, physical and hematological examinations before donating blood. Serological markers of HBV, HCV and HIV-1, 2 were tested by enzyme-linked immunosorbent assay (ELISA); HIV testing was done by using fourth generation ELISA kits from 2009. Syphilis was tested by rapid flocculation method. Malaria was tested using rapid immunochromatographic assay.
Prevalence of HIV, HBV, HCV, syphilis and malaria was 0.15%, 0.67%, 0.11%, 0.10%, 0.03% respectively. Results of all infections were segregated in two years time period to analyze the trend of sero prevalence i.e. 2008-09, 2010-11, 2012-13 and 2014-15. Decreasing trend was found in case of HIV from 0.21% to 0.06% and in HBV 0.83% to 0.41% and for syphilis it ranges from 0.13% to 0.03%. Stable trend was found in case of HCV of about 0.12% and in malaria of about 0.03%. Sero reactive rate has been markedly decreased in in-house blood donors (about 91%) than outdoor donors (about 53%) from 2008-09 to 2014-15 time period.
In developing countries like India, voluntary blood donation that too in-house, extensive donor selection and screening in terms of pre-donation counselling is the best choice to decrease the risk of TTI. The reduced TTI prevalence rate is an encouraging sign. However advanced technologies like NAT is a need of today's blood banking field but effective counselling definitely helps to produce safest next generation medicine: Blood.
Comparison between PCR-SSP and euro array (bio-chip technology) in the detection of HLA B*27 for the diagnosis of ankylosing spondylitis
R Sam Arul Doss, Mary P Chacko, Dolly Daniel
Background: HLA B*27 is associated with several autoimmune disorders and is currently detected in our laboratory using the PCR-SSP (Sequence Specific Primers) technique. This involves DNA extraction, amplification and further analysis of PCR products by agarose gel electrophoresis. One of the alternate methods available is the Euro Array (Bio-Chip) technique based on the principle of hybridization of the amplified DNA to complementary probes which are subsequently applied to a bio-chip. It has an option of using either whole blood or DNA as test sample.
Aim: To compare the Euro array (Bio-Chip) an alternate technology to our current PCR-SSP platform and also to determine its sensitivity and specificity.
Our study included a total of 60 samples processed for HLA B*27 using PCR-SSP (Invitrogen, USA) between January and July 2015. Of these 39 were found to be positive and 21 were negative. These were subsequently processed on Euro array (Luebeck, Germany) of which 42 were processed as whole blood samples and the remaining 18 using DNA samples.
A total of 60 samples previously processed on PCR-SSP in which 39 were found to be positive and 21 were negative, same set of samples were run on Euro array platform. Results on Euro array showed all 39 samples to be positive and 21 negative. Of the 39 positive samples, 26 were processed from whole blood and remaining 13 using DNA samples. Of the 21 negative samples 16 were processed from whole blood and remaining 5 using DNA samples. All the results could be obtained on the same day when processed using whole blood. Our results showed a 100% concordance between both platforms irrespective of whether samples were processed from whole blood or DNA.
The DNA Euro array (Bio-Chip) method when compared to PCR-SSP had a sensitivity and specificity of 100%. The former technique by virtue of not requiring DNA extraction, offers the additional advantage of decreasing the turn-around time of the results. It is a far less labor intensive methodology, thus offering a practicable and alternate platform for HLA B*27 testing.
Presence of clinically significant atypical antibody in a voluntary blood donor - In a blood bank of tertiary care hospital: A case report
Mangayarkarasi Amirthalingam, Synthiya Selvakumari, Ajju Agnihotri, Lokesh Pal
A 27 year old known B+ve healthy male presented himself voluntarily to donate blood in the blood bank of a tertiary care hospital. He had donated blood thrice before at various hospitals and did not have any past history of transfusion or illness. His vitals and hemoglobin were normal and donated blood. As a routine his blood was tested to confirm the blood group.
The sample showed B+ve in Forward grouping and in reverse grouping A, B and O cells showed positive reaction. Major crossmatching was compatible with B, AB group. We suspected a ParaBombay blood group and proceeded for antibody screening.
On further testing for atypical antibodies a rare antibody Lewis a+ was found, which is produced by the components of exocrine epithelial cells and absorbed on the surface of red cells but not actually produced by the red cell itself and is predominantly IgM, where such incidences are very low. A person can have both Lewis a, b together and Lewis a - b+. The commonest is Le a-b+. We found an uncommon presentation that is Le a+. Lewis antibodies are generally insignificant. Since this Le a+ produced significant reaction in saline and Coombs phase it was considered significant.
Conventional tube technique and Matrix Gel System (Tulip) with Matrix ERYGEN cell panels from Indian origin were used.
Blood group serology plays important role in transfusion medicine. Most of the corresponding antibodies were results of isoimmunization during pregnancy, previous transfusion or natural antibodies. Lewis antibodies are considered naturally occurring and can activate complement and occasionally cause in-vivo and in-vitro hemolysis. The Lewis antibodies are reactive at 37C and causes in-vivo hemolysis. Lewis antibodies are mostly of IgM type and detected only by very sensitive assays. Some cases of HTR caused by anti Le a+, and cases of in-vivo hemolysis due to anti Le b+ have been reported.
In this specific case, atypical antibody was detected by testing the sample in Saline and Coombs phase by Gel technology. Antibody screening was positive in Screen cell 1 and 2. DAT was negative and identification confirmed Le a+ antibody. Studies have reported that presence of Lewis antibodies in recipients. In our study we found Lewis antibody in a donor's blood sample.
Basic forward and reverse grouping are very important and should be performed. Discrepancies suggests further workup. For antibody screening and identification use of sensitive technologies and cell panels should be given importance.
A case of weak "A" subgroup
Jessica Prathap, KC Usha
Two principal subgroups of blood group A are A1 and A2. In Indian population the frequency of A2 is 0.8-3.0% & A2B is 0.6-1.4%. 22-26% of A2B individuals can have anti A1 antibodies that react at temperature below 25 degrees and cause hemolytic transfusion reaction. The antibodies of the ABO system are primarily IgM in nature, although some IgG and IgA antibodies may also be present. Anti-A is able to agglutinate RBCs suspended in saline & activate complement. It may cause rapid intravascular destruction of RBCs carrying the A antigen. Anti-A can be functionally divided into two forms: one form which reacts with A1 but not A2 cells (anti-A1) and another form which reacts with both A1 and A2 cells (anti-A common). A1 and A2 phenotypes are best differentiated using the anti-A1 (lectin) extracted from the seeds of the plant Dolichos biflorus. Considering the lesser survival of A1-RBCs transfused to A2B or A2 persons, whose sera contain anti-A1, we propose to distinguish A1 and A2 subgroups in individuals with A and AB blood groups prior to blood transfusion, especially in those with history of transfusion reactions following iso group blood transfusions.
A 28 year old female was admitted in the Department of Medicine with complaints of excessive fatigue and weight loss. Her Hb was 5 gm%. Her peripheral smear showed features of iron deficiency anemia. Her blood grouping was done by forward grouping and reverse grouping and Rh typing. Forward grouping with Anti A showed (+2) agglutination, Anti B no agglutination, Anti D (+4) and on reverse grouping we got (+3) agglutination with A cells and (+4) agglutination with B cells, no agglutination with O cells. Hence a weak sub group of A was suspected and on using Anti A1 lectin showed no agglutination with A cells. Weak sub group of A could not be identified by phenotyping and genotyping with the available infrastructure. Cross match compatibility with O-ve packed RBC's was done using LISS COOMB's gel card method and patient was transfused with 2 units of PRBC's and her Hb improved to 7 gm%.
Patient was symptomatically better and discharged.
Considering the lesser survival of A1- RBCs transfused to A2B or A2 persons, whose serum contain anti-A1, we propose to distinguish A1 and A2 subgroups in individuals with A and AB blood groups prior to blood transfusion, especially in those with a previous history of transfusion reactions following iso group blood transfusions.
Effectiveness of thrombocytapheresis in patients with reactive thrombocytosis
Shamee Shastry, Manish Raturi, Deepika Chenna, B Poornima Baliga
Increase in platelet count (>450 x 103/΅l) secondary to other systemic disorders is called reactive thrombocytosis, a benign form compared to the clonal thrombocytosis. The role of thrombocytapheresis in such conditions is not well defined and its therapeutic efficacy is unproven. We studied the efficacy of thrombocytapheresis in such cases.
Patients with reactive thrombocytosis with platelet count more than 900 x 103/΅l underwent therapeutic cytoreduction by apheresis. Pre-procedural assessment of the patients was done to ensure patient safety and tolerability to the procedure. Thrombocytapheresis was done using ComTec by Fresenius Kabi. We used donor apheresis kits with slight modification in the system settings to increase the efficiency of the procedure. Laboratory parameters were checked to assess the extent of platelet depletion. We reviewed the existing literature using key words 'reactive thrombocytosis' and 'thrombocytapheresis'.
Eight thrombocytapheresis were performed. Five patients had thrombocytosis secondary to coronary artery bypass surgery and increase in platelet count was observed 7-10 days after surgery. Mean pre-procedure platelet count was 1455 x 103/΅L. Average blood volume processed was 4902 mL, 1.2 times the blood volume (TBV) of the patient (Range: 1 to 1.6 times TBV). Most procedures were uneventful except for symptoms of hypocalcaemia in 6 patients who received intravenous calcium infusions. Mean ACD volume used during the procedure was 650 mL. Percentage reduction in platelet count was 46 (range: 26-75) and no significant reduction in WBC count was noted. All except one case consistently maintained normal platelet counts. We could find only five reports in the literature on this subject and the present study is the largest case series of its kind.
Thrombocytaphesis is safe and effective in patients with reactive thrombocytosis. Regular donor plateletpheresis kits can be used for therapeutic cytoreduction as shown in this study.
Distribution of ABO and Rh blood group system among voluntary blood donors
Gayathiri Chellaiya, Rajbharath, Hamsavardhini, P Arumugam
ABO and Rh blood group system is the most essential blood group system in blood transfusion service. The knowledge about the distribution of ABO and Rh blood group system among a population helps in genetic study, researching migration patterns and also helpful in resolving certain medico-legal issues. In blood transfusion services, it is helpful in better inventory management. The aim of this study is to determine the distribution of ABO and Rh blood group system among voluntary blood donors.
A retrospective cross sectional study was done in The Department of Transfusion Medicine, The Tamilnadu Dr M.G.R. Medical University, Chennai and the data was analyzed from January 2012-August 2015 among voluntary blood donors who attended the camp and walk in donors to The Department of Transfusion Medicine. Forward and reverse blood grouping were done by tube technique.
Out of the 6,370 voluntary blood donors data analyzed, 21% (n = 1353) donors belong to 'A' Blood group, 35% (n = 2230) donors belong to 'B' Blood group, 38% (n = 2435) donors belong to 'O' Blood group and 6% (n = 352) donors belong to 'AB' Blood group. 93% (n = 5930) were Rh positive whereas only 7% (n = 440) were Rh negative. Weak D variant was not present among Rh negative voluntary blood donors. Out of the 1353 'A' Blood group donors, 946 (70%) donors were 'A1' subgroup. Out of the 352 'AB' Blood group donors, 159 (45%) donors were 'A1B' subgroup. Bombay blood group was not present among the voluntary blood donors in our study.
The present study shows the 'O' Blood group is the commonest blood group system among voluntary blood donors in Chennai. 'B' is the next prevalent blood group followed by 'A' and 'AB' Bood group system respectively. Rh positive blood group is more prevalent than Rh negative blood group.
Performance indicators: A tool for continuous quality improvement
Nidhi Manish Bhatnagar, Shital Soni, Maitry Gajjar, Mamta Shah, Sangita Shah, Vaidehi Patel
A quality management system includes the organizational structure, responsibilities, policies, processes, procedures and resources, established by management, to achieve and maintain quality. The purpose of quality checks is to provide feedback to the operational staff about the state of a process that is in progress. Performance monitoring is an important tool which can be used for setting priorities for process improvement. We conducted a study to measure the impact of monitoring Performance Indicators and how it could be used as a tool for Continuous Quality Improvement (CQI).
The present study was a retrospective study where the performance indicator (PI) data of blood bank was analyzed for over four years. For certain parameters, benchmarks or thresholds are set that represent warning limits or action limits. The yearly data were collated from monthly data. "Shifts" or "Trends", if any, were identified and Corrective and Preventive Action (CAPA) taken accordingly. At the end, outcomes of the analysis were charted. Some Performance Indicators measured yearly were -
• Total number of blood donations with type of donations
• Cross match: Transfusion ratio
• Total number of components discarded
• Number of adverse transfusion reactions.
Apart from this, the critical and other consumables used in the centre were monitored monthly for the usage pattern and available stock.
After the yearly data evaluation, outcomes obtained were used to plan, correct and amend processes and systems in the blood center. It was observed that the workload of the center showed an upward trend. This helped us to plan for the purchase of consumables and management of manpower. The monitoring of usage and discard of blood helped in the efficient management of blood stocks. The C:T ratio was within acceptable limits which indicated maintenance of quality standards. Decrease in TTI reactive status showed that the donor screening was effective. There was no increase in the number of transfusion reactions, so good quality blood products were being prepared. The inventory monitoring enabled us to keep a check on the stock of critical items. The need for any new equipment could also be judged by the trends in workload.
Performance indicators are indispensible tools which various stakeholders in the Blood Transfusion centres should implement to improve on quality performance.
Tube technique: Still a gold standard in resolving group discrepancy
Shoganraj Selvaraj, Raj Bharath, Hamsavardhini
Blood grouping and typing is usually done by conventional tube technique (CTT). Gel technology (GT) was introduced in 1985 to standardize traditional tube testing methods. While resolving group discrepancies there is still a debate regarding the preferred method. Though some of the studies has shown that gel technique is more sensitive and easier to do than conventional tube technique, we have come across cases in our blood bank in which conventional tube technique was found to resolve group discrepancy much easier than gel technique.
Blood sample of a 70 year old female with h/o diabetes mellitus, hypertension and CAD was received in our blood bank with requisition to confirm the blood group of the patient as there was some group discrepancy. The patient's haemoglobin was 6 gms%. There was no h/o previous transfusion.
The grouping and typing was first done by gel technique. By forward grouping, the patient was "O" positive as there was no agglutination except in anti-D. The result by reverse grouping was "A", as agglutination was seen only with B cells. Here the forward and reverse testing did not match as expected, so Group I discrepancy was suspected. To resolve this discrepancy, the gel card was incubated at 37C for 15 minutes. But the results were same. So the grouping and typing was repeated in the conventional tube technique and the results were similar to gel card test. To resolve the discrepancy, the amount of patient's serum was doubled in reverse grouping and repeated. Now agglutination was seen with A cells and B cells with a reaction strength of 4+. Though the steps in Gel technique are predetermined, the amount of serum was doubled in reverse grouping but the discrepancy was not resolved by gel technique.
In this case, the group discrepancy which was not initially resolved by gel technique was resolved by tube technique easily by simple steps even without incubation. Here the tube technique had the advantage of increasing the sample volume. Even though the gel technique is simple, reliable and very sensitive, requires less specimen volume, overcomes washing step, in resolving ABO discrepancy tube technique still holds good compared to gel technique.
Intrauterine and exchange transfusion in hemolytic disease of fetus and newborn due to high titre saline reacting IGG anti-D: A case report
Amit Ajay Pawar
Hemolytic disease of the fetus and the newborn (HDFN) is the consequence of destruction of the fetal and neonatal red blood cells by IgG antibodies acquired by transplacental route from the mother.
Anti-D titre above the critical level of 32 necessitates shifting the mother to a higher centre specialized in the management of HDFN for constant monitoring of the fetus using colour doppler imaging studies to assess the middle cerebral artery peak systolic velocity (MCA-PSV). One such case of high titre anti-D referred to our centre for specialized care requiring both intrauterine and exchange transfusion of the fetus, is presented below.
EDTA and sterile blood sample of a 33 year old Rh isoimmunized antenatal case with bad obstetrical history at 31 weeks of gestation was sent to our Immunohematology lab (IHL) for indirect antiglobulin test (IAT) and antibody titre.
IAT done by gel card showed 4+ agglutination. There was agglutination seen in saline phase at room temperature while performing IAT by tube method, prior to addition of anti human globulin (AHG). Suspecting the presence of an IgM component along with high titre IgG anti-D, we used 2-Mercaptoethanol (2-ME) to remove IgM and find the IgG titre which was 256. The offending antibody was identified as anti-D.
At 33 weeks of gestation, in view of MCA-PSV more than 1.5 times Multiples of median, intrauterine transfusion was done. At 35 weeks of gestation a male newborn with blood group A Rh 'D' positive and a direct antiglubulin test of 4+ was delivered. Post delivery, in view of hyperbilirubinemia, a double volume exchange transfusion was done.
In this case, it appeared that it was a combination of an IgM and a high titer IgG anti-D which showed agglutination in saline phase and AHG phase at room temperature. High titer IgG anti-D if acquired by the Rh positive fetus transplacentally from the mother can lead to massive destruction of the fetal red cells leading to death of the fetus. To our knowledge, HDFN due to high titer IgG anti-D reacting in saline and AHG phase and leading to IUT and exchange transfusion of the fetus is the first of its kind in India.
Therefore we suggest that while dealing with cases of HDFN with a critical titer, it is in best interest of the fetus, to shift the mother to a tertiary care center for specialized treatment, if at all required.
Para-Bombay phenotype: A case report
Sridhar Gopal, B Abhishekh
Background: Bombay and Para-Bombay are rare blood group phenotypes with an incidence of around 1 in 10000 in western India. These are due to deficient 'H' antigen on the Red cell membrane. And consequently there may be development of "Anti -H" antibody. Here we present a case of 23 year old male donor whom we came across, with one previous donation as "O Positive".
In a routine blood camp, while doing blood grouping (forward grouping) for all donors by slide method, we found a donor who was known "O Rh D positive" which complied with our testing.
We proceeded with using Anti-H lectin, as we routinely do for all individuals and it turned to be Anti-H - Negative. We confirmed the same by repeating again in slide method with a different lot number reagent and got similar results. We collected 2 ml EDTA and 5 ml Plain sample from the donor for further workup.
Immunohematology Workup: We performed forward grouping for the sample with commercially available Anti-sera and reverse grouping with pooled cells by tube method. We got clear cut negative reaction with anti-A, anti-B, anti-AB and 4+ agglutination of the serum with pooled A1 and B cells. Further it gave 4+ agglutination with anti-D but no agglutination with anti-H. Hence we suspected it to be a case of "Bombay blood group" but it failed to give agglutination in serum grouping with pooled "O cells". We proceeded with IAT (Indirect Antiglobulin Test) which was negative.
Secretor Study: "No agglutination in the test sample and agglutination in the corresponding control tube" indicated that the antiserum has been neutralized by the blood group specific substance A, B, or H and the individual is a "Secretor".
With this secretor study, we concluded that the donor is a "Para-Bombay" phenotype as donor is not taking immunosuppressive drugs, not immunocompromised and not a Bombay group. We have added this donor in our blood bank rare donor register.
Conclusion: Identification of Bombay and Parabombay phenotype is very important as this blood group may be mislabeled as group O with which it may actually not be compatible with. This emphasizes the use of "Anti-H antisera (Ulex Europeaus)" mandatorily for all O group samples while performing cell grouping.
Audit of seroreactive blood donors in a tertiary care hospital blood
Rakesh Kumar Ranjan, Santanu Kumar
Safe Blood transfusion always starts with safe screening of Blood Donors; either they are Voluntary or Replacement. TTI testing plays an important role in safe Blood transfusion. The Aim of study find out the Sero-Reactivity in the donor coming for Voluntary/Replacement Blood Donation in the Blood Bank.
The study is conducted in the Blood Bank for a period of year Apr'14 to Mar'15. TTI results are collected and data are prepared monthly. Voluntary donor included for male & female both. Replacement donor included for both male and female. Around 243 Voluntary unit and 4612 replacement donor unit are screened. HIV, HBV, and HCV Screening done by Vitros ECI (Johnson & Johnson).
Out of 243 voluntary donors, only 2 donors are HBVreactive. Out of 4612 Replacement donor, 2 donors are HIV reactive, 59 donors are HBV reactive and 26 donors are HCV reactive.
· HIV 0.00%
· HBV 0.82%
· HCV 0.00%
· HIV 0.04%
· HBV 1.28%
· HCV 0.56%.
The rate of reactivity is lower in voluntary donor in comparison to replacement donor. There is need to be encourage voluntary donation for ensure the safety of blood supply.
A pilot survey to assess internal medicine residents regarding transfusion medicine
Siddharth Mittal, Dolly Daniel, Joy Mammen
Blood transfusion is one of the most common procedures performed in hospitals. Every transfusion carries its own risks and benefits. Although postgraduate and fellowship courses exist in transfusion medicine, majority of transfusion decisions are made by clinicians with minimal structured training. Assessment of knowledge of transfusion medicine of residents is essential to identify gaps in undergraduate and postgraduate training.
We used the BEST (Biomedical Excellence for Safer Transfusion)-test validated transfusion medicine knowledge assessment tool in conducting survey among 23 internal medicine residents at our hospital. The 20 question survey was designed to determine prior training, attitudes, perceived ability, knowledge and practical aspects related to transfusion medicine. The questionnaire contained questions that tested knowledge (35%) besides attitude and training related ones. The questionnaire was offered as paper based and electronic (web based) to the participants.
Out of the 23 post-graduates who participated in the survey, 22 had completed the same. The average score of residents in regards to transfusion medicine knowledge was 25.45 (72.7%) of a maximum achievable score of 35 with range being 15-35 (42.8% to 100%). The mean score for postgraduate year (PGY) 1 (64.2%) and PGY2 (50%) was lower than PGY3 (77.5%). Most residents (82%) adhered to hospital rules regarding taking of pre-transfusion consent from the patient. More than a third of participants (43%) were unable to answer questions related to important serious adverse events associated with transfusion. More than 50% of residents found sessions in medical college and post-graduate training not at all helpful or slightly helpful for managing transfusion medicine related issues. The majority of residents (78%) would find additional training in transfusion medicine very or extremely helpful.
Post-graduate trainees receive very short or no exposure to transfusion medicine during their busy curricula of medical college and residency training which could potentially affect clinical practice. Although results from this pilot survey have shown that internal medicine residents have limited transfusion medicine knowledge, especially in areas of transfusion reactions, which is consistent with other studies done previously, more number of internal medicine and other specialty residents need to be included to get a clearer idea of transfusion medicine knowledge among them. Further, deficits in medical college and residency training need to be addressed by a systematic review and implementation of effective educational interventions.
Determination of rate and causes of wastage of blood and blood products
Harsh Sharma, Rajesh Kumar
The purpose of this study is to determine the rate and causes of wastage of blood and blood products (whole blood, packed red cells, plasma, platelets, and cryoprecipitate) and minimize wastage. Blood transfusion services need to embrace high quality standard guidelines to ensure a safe blood processing and utilization, so to limit the rate of blood discard.
This study was done from January 2014 to June 2015 in the department of Immunohaemotology, Dayanand Medical College, Ludhiana. All blood units were tested for HIV, HbsAg, anti HCV, syphilis and malaria using the standard methods. The units that were seropositive for any of the transfusion transmitted disease were discarded. The units that were expired, showed any signs of leakage, inadequate quantity or showed any signs of hemolyis/turbidity were also discarded. Data on the number of discarded whole blood units and its components, reasons for discard, and the number of blood components processed as well as the number of collected blood units were obtained from the blood transfusion services.
Total blood collection during the period was 42,576 units, of which voluntary donors constituted 55.02% and the replacement donors were 44.97%. Of the 42,576 donations, 3062 (7.19%) packed cells were discarded. Seropositivity (3.57%) for Transfusion ttransmitted infection TTI constituted the major reason for PC discard. Seropositivity for HCV (28.95%) was the main reason for TTI discard. This was followed by expired and unsufficient quantity. Out of 40,511 blood components prepared, platelets (15.55%) were the most common component discarded. Platelet components due to short shelf life were discarded the most. Blood wastage may occur due to several reasons including expired units, medically or surgically ordered blood not used, red blood cell contamination of platelets and plasma were the cause of discard. Other causes include leakage, lipemia and underweight.
Blood transfusion is an essential part of patient care. Proper blood utilization and management practices will help in decreasing discard rate. Seropositivity of TTIs can further be reduced by proper donor selection and phlebotomy technique.
Management of immune thrombocytopenia in a tertiary health care
Revathy Nair, Debasish Gupta, M Unnikrishnan, Jaisy Mathai
Background: Immune Thrombocyopenia (ITP) is an autoimmune condition characterized by isolated low platelet count (<1,00,000/cumm) in the absence of other underlying causes. Among adults, the incidence of ITP is 1.6/1,00,000 population.
Aim: We report a case of Immune thrombocytopenia in a patient who underwent Aortic aneurysm repair. It was managed with steroids with minimal platelet transfusion.
A 58 year old man who underwent an Aortic saccular aneurysm repair in the month of March 2015 and had a normal postoperative recovery course, was found to have unexplained, profound and progressive thrombocytopenia during a regular follow up in the Vascular surgery clinic. Patient was completely asymptomatic. On examination, there were no cutaneous bleeding manifestations or bleeding from natural orifices. All investigations to diagnose thrombocytopenia was carried out which includes complete blood picture, coagulation profile, peripheral smear, ultrasonography of the abdomen and platelet aggregation test.
On the day of admission, platelet count was 9000/cu mm and coagulation parameters were within normal limits. Peripheral smear showed reduced number of platelets and presence of megakaryocytes. Platelet aggregation tests showed reduced responsiveness of platelets to ADP and collagen. Spleen and Liver were normal on Ultrasound Abdomen. Since the platelet count was dangerously low on the day of presentation, he was transfused 3 units of group-specific platelet concentrates. The clinical picture was suggestive of immune thrombocytopenia and hence, he was started on Prednisolone 40 mg OD. The count reached 31000/cumm on the third day and gradually elevated with intermittent fluctuations. Got discharged on the 11th day due to personal reasons with a platelet count of 23000/cumm. He was asked to continue Prednisolone 40 mg OD and Acitrom 2 mg to avoid thrombosis of the vascular graft. He returned to the OPD clinic 3 days later with ecchymotic patches over the both forearms and popliteal region. Prothrombin Time was 78.3 sec, APTT: 41.8 sec, INR: 7.3. Platelet count: 30000/cumm. Large platelets were found on peripheral smear. Hb: 11.5 g/dL. The dose of Acitrom was reduced to 0.5 mg and 1 mg on alternate days. On the next follow-up, 2 weeks later, his ecchymotic patches had disappeared and platelet count was 1,10,000/cu mm.
The first line of management of ITP is Steroids. Platelet transfusion is not recommended unless the platelet count is threateningly low (<10,000/cumm). If indicated, HLA matched or cross-match compatible platelets are advisable.
Frequency of seropreavalance of transfusion transmitted diseases in blood donors in a Tertiary Care Hospital of North India
Jasmeet Singh, Amarjit Kaur, Rajesh Kumar, Sonia Gupta
Seroprevalance of transfusion transmissible diseases (TTD) is an important factor for safety of blood during transfusion of blood and blood components.
This study is aimed to estimate the prevalence of transfusion transmitted infections in at a tertiary care teaching hospital in Punjab, India.
It is a retrospective study carried out at blood bank of Dayanand Medical College and Hospital, Ludhiana using Hospital records from January 2014 to December 2014. The transfusion transmitted diseases were detected by ELISA testing for HBsAg, Anti-HCV, Anti-HIV 1-2, VDRL, Malaria and ID-NAT for HBV, HCV and HIV for all blood donors coming to the hospital.
A total of 29204 blood donors were screened, out of which 13618 were replacement donors and 15586 were voluntary. The seroprevalance of HIV 1 and 2 was 0.1 %, HCV was 1.06 %, HBV was 0.81%, VDRL was 1.54% and Malaria was 0.000034%.
Blood is still one of the main sources of transmission of infections. Hence, it is very important to continue screening of donated blood with highly sensitive and specific tests and to counsel donors who are positive to any of the above diseases/infections.
Transfusion-related adverse events: An initial experience of a blood storage centre encourages establishment of Institutional Hemovigilance Program
Somnath Mukherjee, Babita Raghuwanshi
Background: Hemovigilance is aimed to detect and analyze all untoward effects of blood transfusion in order to correct their cause and prevent recurrence. Many countries in the developed world have established national hemovigilance systems to report adverse transfusion reactions (ATRs). In India, Hemovigilance Program of India (HvPI) has been launched for surveillance of ATRs. This program has been running successfully as number of centres reporting to HvPI is reportedly increasing. However, there is still lack of awareness regarding the reporting of adverse transfusion related events in Eastern part of this country which results in marked paucity of data on ATRs.
Aims: In present study we have tried to detect and analyze the incidence and type of ATRs as a pilot institutional effort toward hemovigilance.
This new institute has initially established a Blood Storage centre with the main objective to provide blood transfusion service to few major clinical disciplines. As our Institute got approval for Blood Storage Centre in February 2014, the ATRs data has been taken from April 2014 till June 2015 for evaluation. All ATRs were worked up as outlined in the department's standard operating procedures prepared in accordance with the guidelines of the Directorate General of Health Services (DGHS) Technical Manual Ministry of Health, Government of India. The data includes age, sex, total number of patients as well as blood components transfused and different types of adverse reactions attributable to blood or blood components.
During the 1-year study period 1160 units of blood and blood components (1082 RBCs including WB and PRBC, 66 FFPs, 12 Platelets) were transfused to 732 patients. Out of the 732 patients, 14 patients (3 males, 9 females, 2 pediatrics: mean age 34.07) had adverse events during or after transfusion with an incidence of 1.9%. Components implicated for ATRs were mainly WB and PRBC 13; followed by FFP 1. Out of total ATRs (14) reported, 7 (50%) were FNHTR, 4 (29%) allergic, 2 (14%) anaphylactoid and 1 (7%) were bacterial sepsis which was confirmed by the blood culture of the patient and the transfused RBC contained the same organism with same pattern of antibiotic sensitivity.
The preliminary ATRs data highlight the necessity of establishing functional hospital transfusion committee and importance of hemovigilance system. An encouraging environment and nonblaming culture need to be developed for reporting of adverse events and near-misses in order to have an effective hemovigilance program.
'Anti IH', an antibody worth mention: A case report
Nittin Henry, Nithya Mohanan, Susheela J Innah
A 72 year old multiparous female with a Hb of 7 g/dl was being planned for PRBC transfusion for surgical correction of fracture neck of femur. Forward grouping suggested AB, D Rh positive while the reverse grouping showed varying grades of agglutination where O cells showed a higher grade of agglutination than A1 and B cells. The reverse grouping was repeated after incubating for 15 min at 4C and 37C which showed the antibody had a preferential action at lower temperature. The reverse grouping at 37C was done with a prewarmed sample which showed a weakening of reaction. Direct coombs test and autocontrol was negative. Antibody screening with commercially available panel showed panagglutination at room temperature (CTT) and weaker reactions at 37C (CTT) and coombs phase (gel phase and CTT). The serum gave 3+ reaction during an immediate spin with A2 cells while it was weak with A1. Anti I and Anti H could be ruled out as 'Bombay cells' and O 'Cord Cells' failed to show any agglutination with the patient's sera. The patient was found to be compatible with A1B cells but not with O cells. The broad thermal amplitude of the anti IH antibody makes it clinically significant and hence the patient was transfused with compatible A1B PRBCs. Post transfusion there was no increment in patients unconjugated bilirubin, LDH and liver function tests. Titration studies at 4C and 20-22 showed 1/32 and 1/16 respectively.
This case provides a rare example of a clinically significant complex antibody with specificity against coexpression of I and H moiety. Anti IH occurs usually with A1, A1B and B blood groups and presents as benign antibody but may cause hemolytic reactions. The severity of hemolysis depends on the extent of H antigen expression. Unlike anti H and anti I antibodies, anti HI reacts only in the presence of the two antigens together. Agglutination with OI adult cells and not with Oi cord cells and Bombay cells confirmed the specificity of anti IH. Unlike earlier case reports, we detected anti IH during grouping itself, characterized it and was able to avert a hemolytic transfusion reaction by transfusing A1B PRBCs.
Evaluation of therapeutic phlebotomy in a Tertiary Care Oncology Hospital
Abhaykumar Malind Gupta
Introduction: Therapeutic phlebotomy (TP) is defined as withdrawal of blood from a patient to cure or prevent illness in diseases such as Polycythemia Vera (PV), Hemochromatosis, Porphyria cutanea tarda etc. It was claimed to have been the most common medical practice performed by surgeons from antiquity up to late 19th century for a time span of almost 2000 years.
Aims: To evaluate clinical outcome of patient after TP and to correlate frequency of TP with clinical diagnosis, JAK2 mutation, Smoking and Hypertension.
This is retrospective analysis of all TP performed at our center over a span of 5 years. Detailed analysis was done according to age, sex, diagnosis, clinical indicators for TP with clinical outcome and laboratory parameters [hemoglobin (Hb), hematocrit (Hct), platelet count, red blood cell count (RBC)].
Total 61 TP were performed for 20 patients. Of these 20 patients 13 patients have the diagnosis of PV and 7 have other diagnosis. Of 13 PV patients JAK2 mutation was present in 9 and absent in 4 patients. 2 out of 7 non PV patients have JAK2 mutation positive.
Twenty subsequent TP in 7 patients were done in ≤ 1 week, 8 subsequent TP in 5 patients were done in 1-3 weeks and 13 subsequent TP in 7 patients were done in ≥3 weeks. Six patients came for TP only once, 5 patients came for TP twice, 5 patients came for TP thrice and only 4 patients came for ≥4 TP.
At the time of first TP, before procedure Hb ranges from 15.7-22.1 gm/dl with a mean of 19.32 gm/dl, Hct ranges from 50-68% with a mean of 59.99%, RBC counts ranges from 5.92-8.49 Χ 10Ή with a mean of 6.94 Χ 10Ή, platelet counts ranges from 1.46-6.99 L/ml with a mean of 3.79 L/ml and all the data follows normal distribution.
After first TP, laboratory parameters are as follows: Hb ranges from 15.4-19.6 gm/dl with mean of 17.81 gm/dl, Hct ranges from 46.1-62% with a mean of 53.58%, RBC counts ranges from 5.25-8.04 Χ 10Ή with a mean of 6.16 Χ 10Ή, Platelet counts ranges from 6.31-1.83 L/ml with a mean of 3.11 L/ml and all the data follows normal distribution.
TP is done on a regular basis at our center and it has shown to be of good clinical benefit. Other confounding parameters like Hypertension should be taken in account before planning treatment. Analysis of all TP done would help in future management of patients with high hematocrit.
Role of direct Coomb's test in haematological and non haematological diseases
Binay Bhusan Sahoo, Smita Mahapatra, Debasis Mishra, Gopal Krushna Ray, Rashmita Panigrahi, Satyabrata Patajoshi
The Direct coomb's test (DCT) is also known as Antiglobulin test used to determine whether red blood cells (RBCs) have been coated in vivo with immunoglobulin, complement or both.
The Aim of the study is interpretation of DCT in Haematological diseases like AIHA (Auto Immunohaemolytic Anaemia), Rh Incompatibility, Evan's Syndrome, Pancytopenia, ITP(Immune Thrombocytopenic Purpura) and non - haematological diseases like SLE (Systemic Lupus Erythematous), Arthritis and CKD(Chronic Kidney Diseases).
The Present Study was carried out in the Department of Transfusion Medicine, SCB MCH, a Cuttack on 238 Patients whose blood samples had been sent for Coomb's test to our laboratory. The test was carried out by using Polyspecific Column Agglutination Technology (OrthoBiovue). In DCT, 2-3 drops EDTA samples washed three times with isotonic saline and the decant was removed. The Sample was made 5% by adding 95 μl Normal Saline and 5 μl of cell. 10 μl of 5% cell suspension was taken in the polyspecific card then the card was centrifuged at 1500 rpm for 5 min. Interpretation of result was based on Grading of Agglutination (from 1+ to 4+).
The study shown that, out of 238 tests, DCT was positive in 56 test (23.5%). There were 86 Male patients including male child and 152 Female patients including female child, out of whom test was in positive 17 (19.8%) Male and 39 (25.6%) female. 56 positive tests included 31.6% (M 22.2%, F 35.9%) Auto immunohaemolytic Anaemia, 18.2% (Mch - 17.8%, fch - 18.7%) Rh Incompatibility, 15.4% (M - 25%, F - 11.1%) ITP, 16.7% (M-14.3%, F-20%) Evan's Syndrome, 14.3% (M - 8.3%, F - 22.2%) Pancytopenia, 29.1% (M - 40%, F - 28.1%) Systemic Lupus Erythematous 17.6% (M - 18.2%, F - 16.7%) Arthritis and 16.7%(M - 14.3% F - 20%) CKD cases.
The result of this study allowed us to conclude that the overall DCT positive percentage in haematological and non- haematological diseases was 23.5% and highest positivity found among haematological diseases was Auto immunohaemolytic anaemia (31.6%) and among non- haematological diseases the highest positivity was seen in Systemic Lupus Erythematous (29.1%). Thus ideally it should be mandatory to perform DCT both in haematological cases and non- haematological cases for better management of Patient.
Hemovigilance: Experiences, interventions and current practices in a Tertiary Care Hospital, Kerala
Ganesh Mohan, Susheela J Innah
Hemovigilance is defined as ' a set of surveillance procedures covering the whole transfusion chain from the collection of blood and its components to the follow up of its recipients, intended to collect and assess information on unexpected or undesirable effects resulting from therapeutic use of labile blood products and to prevent their occurrence and recurrence'. The importance of hemovigilance is to ensure and improve the safety, efficacy and efficiency of blood transfusion. In India, National Hemovigilance Programme started in December 10, 2012, under National Institute Biologicals (NIB) & Indian Pharmacopoeia Commision (IPC) governed by Ministry Of Health & Family Welfare. We did this study to understand and evaluate the blood transfusion practices in our hospital and what we can do to improve the quality of transfusion practices and contribute to the future of transfusion medicine.
• To identify the transfusion practices in the clinical wards
• As a transfusion medicine expert, what changes can we implement to improve the safety of blood transfusion.
Prospective, experimental study carried out by the Department of Immuno Hematololgy & Blood Transfusion in Jubilee mission Medical College & Research Institute, Thrissur, Kerala.
Study was conducted in three phases:
Phase 1: Surveillance data of transfusions during the period of January - March, 2014 were collected and analyzed. Main things assessed were traceability, time gap between issue of the product and commencing transfusion, duration of transfusion and occurrence of transfusion reactions
Phase 2: Identified the incorrect transfusion practices in our clinical wards. We did induction training for the staff nurses & Interns during this phase from August 2014 to April 2015
Phase 3: Like in Phase 1, surveillance data of blood transfusions from June - August, 2015 is being collected. We analyzed the same criteria which were analyzed in phase 1. (Study is still Going On).
a. Traceability was 31.26% for all the components
b. 51%- had time gap >30 minutes
c. 55.3%- transfusion completed time was not documented
d. 46.7%- transfusion reaction occurred or not was not documented.
Phase 2: Conducted induction training for 546 Interns & staff nurses. In each batches we had 20 staffs & batches were determined based on Hospital blocks.
Phase 3: (This phase is going on) Hemovigilance is a continous surveillance process to improve the quality as well as the safety of blood transfusion from vein to vein.
Hemolytic disease of fetus and newborn due to ABO incompatibility
Dnyaneshwar Shridharrao Patale, Jayashree Sharma, Charusmita Modi, Swarupa Bhagwat
Background: Hemolytic disease of the fetus and newborn (HDFN) due to ABO incompatibility is one of the most common cause of neonatal hyper bilirubinaemia (NH). It is characterized by the presence of IgG antibodies in maternal circulation, which causes hemolysis in the fetus by crossing the placenta and sensitizing red cells for destruction by macrophages in the fetal spleen with consequent hyperbilirubinemia.
Aim: To identify the incidence and severity of jaundice in patients with ABO incompatibility. Also to correlate the Cord Blood Bilirubin (CBB) levels with subsequent NH in newborns with setting of ABO incompatibility and to study the incidence of Direct Antiglobulin test (DAT) positivity in ABO incompatibility.
This was a prospective observational study conducted at Department of Transfusion Medicine, KEM Hospital, Mumbai. Healthy term new born (n = 100) with A or B blood group born to healthy mothers with blood group O positive, were prospectively enrolled in the study. Cord Blood Bilirubin (CBB) was estimated. Postnatal Serum Bilirubin estimation was done at 72 hours. DAT was performed on cord sample.
Of 100 ABO incompatible neonates, 10 (O-A, 4; O-B, 6) had significant hyperbilirubinemia. Significant Neonatal hyperbilirubinemia in our study is 10%. Mean total bilirubin at postnatal 72 hours was 11.25 mg/dl. Using CBB level of ≥3.5 mg/dl as a cut-off, NH can be correlated with sensitivity of 80%, specificity of 98 %, Positive predictive value of 88.8% and Negative predictive value of 97%. Direct Coombs Test was positive in 18% of patient. 4 out of 10 pts having significant NH had positive DAT.
DAT positivity and high Cord Blood bilirubin level in ABO incompatibility is associated with increased hemolysis and a high incidence of neonatal hyperbilirubinemia. Early detection of ABO incompatibility in the affected newborns may be important for reducing the risk of severe hyperbilirubinemia, kernicterus, and the need for exchange transfusion.
Therapetic plasma exchange in paediatric patients of Guillain-Barre syndrome-experience from tertiary care centre
Meghana Virchandbhai Solanki, Nidhi Bhatnagar, Maitrey Gajjar, Tarak Patel, Vaidehi Patel, Shital Soni
Therapeutic Plasma Exchange (TPE) is performed effectively and safely in adult patients, but the use of TPE is limited in paediatric patients due to lack of universally accepted indications and technical challenges like establishment of adequate vascular access, low blood volume, increased incidence of adverse events during procedure and poor co-operation of patients during procedure. We present our experience of TPE in paediatric patients to assess the effectiveness and safety of TPE in paediatric patients.
A total 122 TPE procedures were performed in 40 paediatric patients between the 3 to 15 years of age group with Guillain Barre Syndrome (GBS). TPE procedures were performed on alternate days depending on the clinical condition of the patient. Patient's total blood volume was calculated as per Nadler's formula and processed through central double lumen catheter.1-1.5 plasma volume was exchanged with normal saline and fresh frozen plasma.
A total of 122 TPE procedures (with an average of three procedures per patient) were performed on 40 paediatric patients. More than three TPE procedures were performed in 29 patients, of which 27 patients showed improvement from grade-0 and grade-I to grade-III. One did not show any response and succumbed to the disease. Complications were observed in 14 patients which were well managed. Inadequate vascular access was most common complication observed in 11 patients.
TPE in paediatric patients has been increasing and has been shown to be effective as first line or adjunctive therapy in selected diseases. It is safe procedure when volume shifts, calcium supplementation and venous access are taken care.
Case report: Bombay blood group an incidental finding in critically ill patients
Rashmita Panigrahi, Smita Mahapatra
Bombay blood group is a rare autosomal recessive blood group with an incidence 1 in 10,000 in India. First case reported in Mumbai by Bhende et al. To diagnose this rare phenotype in all the patients and donors having O Rh positive blood group to prevent hemolytic transfusion reaction.
Study conducted from June 2015 to august 2015 on patients & donors of O Rh D positive blood group. Blood grouping of patients & donors done by standrard tube method & samples identified as Bombay phenotype after testing with anti -H. In this study three cases (patients) having rare Bombay Oh blood group were found.
In our blood bank we did both forward and reverse grouping by tube method in all these cases. Out of all these, in three cases agglutination shows with O cell on reverse grouping & Test with anti-H (ulex europeus) shows no agglutination, thus confirming as Bombay phenotype. All these three cases typed as 0 RhD positive blood group in forward grouping. Two were known cases of Bombay blood group previously and one was diagnosed incedentally as Bombay blood group after a hemolytic transfusion reaction with O RhD positive blood group. First case manged by receiving transfusion from a known Bombay phenotype donor (from donor register), second cases didn't appear further & third one was manged by receiving tranfusion from one of his relatives having Bombay blood group.
Bombay phenotyping can be wrongly catagorized as O group because the cell don't react with anti -A & anti-B as is seen in group O individuals. Hence reverse grouping (serum grouping) is recommended and crucial to detect Bombay blood group. Individuals belongs to this group should receive blood transfusion of Bombay blood group only to prevent lethal consequences. Availability of Bombay group is challenging for its rarity. So maintainance of registar having information of Bombay blood group can help during emergencies. There should be provision for cell saver in CTVS dept to reduce blood loss in rare cases like Bombay blood group. Its possible to detect rare blood groups during routine screening of blood. The staff need to alert & aware about various blood group systems to make an accurate diagnosis. By doing this we can able to reduce hemolytic reactions in these cases.
Impact of lean transformation process in a Tertiary Care Blood Bank in South India
Divya Venugopal, Aboobacker Mohamed Rafi, Susheela J Innah
Health care reforms are the mainstream of all political and personal discussions. Nowadays, reforms in the field of Transfusion Medicine are the most sought after. Lean Six Sigma is a value based approach and focuses on standardizing work processes by eliminating the non-value added processes, identifies process improving methodologies and maximizes capacity and expertise of the staff.
Our aim is to study the impact of the lean transformation process within transfusion services. Our Objectives are to define the value added steps involved from donor entry to donor exit from blood bank premises and to evaluate times for process steps and wait times between various processes involved.
We established an approach to monitor the blood collection system in our blood bank. We analyzed the existing scenario and recognized the need to use the lean six sigma improvement methods in order to optimize input. This will be achieved by identifying the value added steps in the current workflow pattern, assessing improvement opportunities to increase the percentage of the same and eliminate the non-value added activities.
The study is still under process. So far, the lessons learned and the improvements expected are in the following areas: use of technology as a support of information system; turnaround times; education of users so that the most appropriate tests are correctly used; efficient allocation of staff skills; analysis and removal of waste from the processes involved.
This paper will set a framework for Lean Six Sigma concept application to plan improvements in Blood Transfusion Services. The ultimate goal of applying these improvements is continual optimal function of a blood bank and minimum wastage.
The following conclusions are expected from this study:
• The Transfusion Medicine Department and its environment can be improved considerably by applying Lean Tools
• Implementing the DMAIC approach will improve, optimize and stabilize the work flow pattern in the blood bank
• MUDA application can reduce the total work time, a remarkable achievement of the application
• Heijunka application will provide staff equal workload and they will perform explicitly better than they used to
• 5-S tools (sort, straighten, shine, standardize, sustain.) will provide the staff the opportunity to manage the blood bank in an effective way
• More application of the Lean Tools should be explored to have a more effective and efficient blood bank.
Frequency of occult hepatitis b infection in HBsAg seronegative blood donors in a Tertiary Care Hospital in South India
Background: With millions of carriers of the hepatitis B virus in India, blood banks require faultless screening. The advent of routine HBsAg immunoassay drastically reduced transfusion associated HBV. Clinical cases still occur due to false negative blood donors harboring the occult hepatitis B virus infection.
Occult HBV infection (OHB) is characterized by the absence of HBsAg and the presence of HBV DNA in the blood or liver tissue. HBV could be occult pre-seroconversion, due to mutations or low concentration in blood. Nucleic Acid Testing for HBV DNA is the gold standard. However, NAT is commonly being substituted by Anti-HBc immunoassay; which screens anyone exposed to HBV, regardless of HBV DNA positivity. This results in a high discard rate of healthy blood. In resource poor areas, this could be avoided by implementing more sensitive HBsAg immunoassays or NAT.
Aims: To determine the percentage of HBV DNA positivity among HBsAg negative blood donors at Amrita Institute of Medical Sciences, a tertiary care hospital in Kochi, Kerala and assess Anti-HBc and Anti-HBs positivity in HBV DNA positive donors.
Materials and Methods: It is cross sectional study in 20,000 apparently healthy voluntary donors donating blood to our blood bank during the study period. Serum from donors were tested for HBsAg, HIV and HCV antibody using Vitros Enhanced Chemiluminescent Immunoassay (Ortho-Clinical Diagnostics, Raritan, NJ, USA). Negative samples were screened by Individual donor Nucleic Acid Testing for Viral DNA & RNA using (Procleix Ultrio Plus assay, Gen-Probe). NAT positive samples were subjected to discriminatory NAT. All HBV positive samples were tested for Anti-HBc, Anti-HBs & viral load by RT-PCR.
Results: In the 22,005 donors who were screened, 21970 were HBsAg negative. HBV seropositivity was 0.2%. Of all the donors, 96% were males and 4% were female. Of this group, 5 donors were NAT positive for HBV excluding one indeterminate case. 80% of the NAT Reactive cases were hepatitis B core antibody positive. Anti Hbs antibody attained immune levels in two, two were non immune and one gave indeterminate value. Out of the 5 NAT reactive samples, viral load were below detection limit of quantitative PCR in three donors.
Conclusion: NAT testing is necessary in the diagnosis of Occult Hepatitis B. OHB prior to seroconversion will not be immune. However OHB after seroconversion will have Anti-HBc and AntiHBs. We must understand that detecting and discarding blood that is OHB positive is essential to prevent transfusion transmitted HBV infection.
Evaluation of incompatible crosssmatch
Meghana Virchandbhai Solanki, Nidhi Bhatnagar, Maitrey Gajjar, Jaymin Bhatt, Tarak Patel, Bhargav Prajapati
Compatibility testing is performed to ensure maximum safety of blood transfusion. The transfused Red Blood Cells (RBCs) will have acceptable survival rate, and there will be no significant destruction of recipient's own RBCs4. It assures ABO compatibility between donor and patient blood as well as detects most clinically significant RBC allo antibodies that react with antigens on donor RBCs. To evaluate the incidence and causes of incompatible cross matches in patients, by column agglutination method.
A total of 148 incompatible cross matches were reviewed, out of total 67,582 cross matches performed by column agglutination technique in a period of 1 year. A root cause analysis protocol was formulated to resolve the incompatibility, which would help to ensure safe transfusion to patients.
The overall incidence of incompatible cross matches was found to be 0.21%. The major cause for incompatibility found in patients was autoimmune haemolytic anaemia (40%). Other causes of incompatibility were multiple transfusions (17%), Rh Incompatibility in newborn (10%), trauma (5%), infections (10%), ABO Incompatibility in newborn (2%), incompatibility due to DAT (Direct Agglutination Test) positive PCV (Packed Cell Volume) (10%), SLE (2%), arthritis (2%), Clerical and technical error accounted for (2%). Majority of incompatible cross matches in patients were found in females than in males.
The commonest cause of incompatibility was autoimmune haemolytic anaemia. Incompatibility was found more in females than in males. Clerical and technical error has a low incidence (3%). The root cause analysis protocol involves a thorough evaluation of the patient's clinical condition and underlying pathology to identify the cause. A logical stepwise approach will enable provision of safe transfusion to the patient and protocols should be developed in each transfusion set up.
Various aspects of plateletpheresis, its impact on donor and patients
Dibyajyoti Sahoo, Smita Mahapatra
Platelet transfusion plays an important role in treatment of hematological, oncological, surgical, transplant patients. Aphaeresis technology is widely available in world & some part of India but it is new for our region. The present study aims at various aspects of plateletpheresis including donor safety, donor haematological changes following SDP donation, quality of product and impact on patient following SDP transfusion.
We receive SDP requisition from various departments like oncology, hematology, ICU etc. Donor are selected as per guidelines. SDP collection was done by using cobe spectra. COBE Spectra is capable of collecting single, double, or triple aphaeresis platelet units as well as concurrent plasma, depending on the size and platelet count of the donor. During the procedure donor was observed for any adverse reaction. After donation the donor was asked for rest for 30 min and a blood sample was collected to observe the hematological parameter changes due to plateletpheresis procedure.
Quality control of each SDP product was done. Patient was observed for any transfusion reaction during transfusion and post transfusion. 24 hour post transfusion count of TPC was observed in all patients. Final observation was made on each patient on morbidity, mortality, improvement of conditions, overall therapeutic benefits.
Observation of 52 plateletpheresis donors shows there is not a single adverse donor reaction. This makes it safer in compare to whole blood donation (2-3% ADR)*. Comparing predonation and postdonation Complete blood count, there is transient decrease in WBC, RBC, PLATELET, Hemoglobin, HEMATOCRIT seen with post donation 30 minute sample. Recovery of above parameters up to 90% of initial values seen with postdonation 24 hour sample.
Quality control of all the SDP shows there is more than log 3 reduction >90% cases. Yield in all cases were >3 X 1011 except 2 cases having 2.1 & 2.3 whose pre TPC were 1.7 & 1.8 respectively.
Platelet increment following SDP transfusion was good (varies from 50,000 to 1,00,000) in 43 episodes. In rest 9 cases the increment was 2000 to 30,000 (all these transfusion was in oncology patients with ongoing chemotherapy).
Adverse transfusion reactions were only 1 (Allergic). Therapeutic benefits in most cases were achieved.
The above study concludes that donors with TPC 1.5 to 2 lac/cumm may result into less platelet yield. SDP donation is safer than whole blood donation. There is transient decrease in haematological parameters following plateletpheresis, which get recovered subsequently. Transfusion reactions following SDP administration is less. Overall patient improvement is satisfactory.
A study on the blood transfusion practice in the first trimester of pregnancy
M Sri Devi, Hamsavardhini
Background: The complications during the first trimester of pregnancy are Abortions, Ectopic and Molar pregnancy. Abortions and molar pregnancy commonly present with bleeding per vaginum and sometimes present with shock. An ectopic pregnancy is a life threatening clinical condition with hemoperitoneum.
Aim: To study the blood transfusion practice in the management of the complications during the first trimester of pregnancy.
Materials and Methods: The case records and the blood requests were accessed for the clinical/blood transfusion details of Abortion, Molar pregnancy, and Ectopic pregnancy cases of our institute during the six months period (August 2014 -January 2015).
Results: Total cases-95 (Abortion --64, Molar pregnancy --2, Ectopic pregnancy--29).
Abortion: 54 cases had dilation & curettage for incomplete abortion and missed abortion. The remaining 10 cases were complete abortion. 22 cases were within the hemoglobin range 8-10 gms % and 7 cases with >10 gms %. Overall, utilization of whole blood - 5 units, red cell - 88 units, plasma - 8 units, platelets - 12 unit. Red cells (8 units) transfused for 5 cases with anemia in the hemoglobin range >10 gms %. One case with >10 gms % is a Septic abortion managed with plasma and platelets in addition to red cells. The abortion cases with anemia were not symptomatic.
Ectopic: Medically managed cases are 5, surgically managed were 23, failed medical treatment, and subsequently treated surgically case was one. Whole blood -24 units, red cell - 43 units, plasma-10 units were the blood usage pattern for ectopic pregnancy. Red cells of 26 units transfused for anemia in medically managed cases (1 case each with hemoglobin 7-8 gms % and 8-10 gms %, 4 cases in >10 gms %).
Molar Pregnancy: 2 cases utilized 3 red cell units, with one case each in Hemoglobin of 7-8 gms % and 8-10 gms % had suction evacuation.
Conclusion: Restricting allogeneic blood use to treat anemia alone with the Hemoglobin of 8-10 gms % and >10 gms % in Abortion and medically managed cases of Ectopic pregnancy, if considered as per the transfusion guidelines for anemia would prevent the hazards of transfusion and better blood inventory management.
Analysis of donor deferral data at O. P. Jindal, blood bank
Proper selection of healthy blood donor is the main pre-requisite of blood transfusion service. Blood bank has a responsibility to ensure that blood donation does not harm the donor or the recipient of the blood. Acceptance of healthy donor depends on their satisfying criteria designed to protect both donor and recipient. Donors are deferred for multiple reasons. In order to quantify the losses due to deferred donors and to understand the health problems of blood donor population data is analyzed.
Aim of this study is to analyze the rate & the different reasons for which donors were deferred.
The data is collected form O.P. Jindal Hospital & Research Centre, Blood Bank from 20th July 2010 to 19th July 2015. A retrospective study of the donor deferral data is done from the donor deferral register and the data is analyzed.
Total 10,704 blood donors were screened, out of which 8992 donated and 1712 were deferred which is 15.9 % of the total donors.
Donors were rejected under 41 different causes.
• Commonest cause of donor rejection was low hemoglobin which constituted 57.9% of total rejected donors
• Second cause of rejection was skin disease and open wound which constituted 8.7%
• Rejection due to H/O malaria and typhoid was 4.03% and 1.4% respectively
• 3.9% of donors were under medication which included antibiotics
• Alcohol intoxication was the cause of donor rejection in 2.6% of donors
• Rejection due to H/O vaccination and Tattoo was 2.1% and 1.7% respectively
• Rejection due to H/O jaundice and cough/cold was 1.1% and 0.9% respectively
• 0.8% of donors were rejected due to high blood pressure
• H/O multiple sex partner was given by 0.1% donors.
Analysis of donor rejection pattern may help blood bank personnel to be more focused on blood donor screening. The potential donors need proper counseling. This will help in improving donor and recipient safety and maintaining a healthy donor pool.
Simple exchange transfusion in sickle cell disease with vaso-occlusive crisis
Dibyajyoti Sahoo, R K Jena
Vaso-occlusive crisis are frequently seen in sickle cell disease patients. A case of 21 year old male was presented to our haematology department with severe pain of multiple joints due to vaso-occlusive crisis. Patient was refractory to all conservative treatment. He was managed with simple red cell exchange transfusion and improved subsequently.
20 year old male, diagnosed case of sickle cell anaemia (homozygous) presented with complains of severe pain of multiple joint and chest pain. Diagnosis was made as sickle cell disease with vaso-occlusive crisis. Treatment was started with iv fluids, hydroxyurea, sodium bicarbonate, folic acid, analgesics.
Patient reviewed with laboratory reports next day. There was no improvement in clinical condition. There was no relaxation from pain even after 48 hours of pain. IV ketorolac was administered to alleviate pain, but symptoms did not subside. Keeping these clinical situations in mind red cell exchange was planned. Red cell exchange by aphaeresis facility was not available. The next day we planned for simple red cell exchange. Till that time there was continuous ongoing pain. Around 250 ml of blood removed from patient by phlebotomy. IV fluid was administered followed by replacement of 1 unit pack red cell.
Pain decreased within 3 hours of simple exchange transfusion. Patient felt much better following exchange transfusion. Gradually all the clinical symptoms subsided within 2 days of red cell exchange. Patient was discharged on very next day with normal conditions.
Similar 6 cases were treated in our department in last 9 months. All these 6 cases were successfully managed with simple exchange transfusion to reduce acute pain crisis.
The exchange prevents the removed sickle cells from participating in new vaso-occlusive events, reduces haemolytic complications, and provides added oxygen carrying capacity while decreasing the blood viscosity.
Red cell exchange is quite promising in the field of management of symptoms due to vaso-occlusive crisis in case of sickle cell disease. Aphaeresis red cell exchange is preferred but not available in all centres. Even when available it is not affordable by many poor patients. In such circumstances simple red cell exchange is alternative choice i.e. Removing 1 unit of blood manually, by phlebotomy and replacement with one unit normal red cell is useful. The present case shows that red cell exchange has definite role in alleviating pain of patients who are refractory to conservative treatments.
Can the traditional methodology of analyzing HLA antibody specificity towards HLA antigens be made finer?
Anutha Mary Augustin, Mary P Chacko, Dolly Daniel
Background: Major histocompatibility complex is a highly polymorphic region comprising a series of polymorphic aminoacid residues known as epitopes present in the peptide binding grooves located between two helices. Exposure to mismatched epitopes can induce development of anti-HLA antibodies directed against an allele or an antigen or a group of alleles. If the latter enjoy wide arena of distribution, are labeled as public epitopes. Presence of antibodies to public epitopes results in cross reactivity between different alleles/antigens leading to the concept of Cross-reactive epitopes groups (CREGs). Against this background it becomes essential to analyze the antibodies in this context.
Aim: To analyze the epitope specificity of antibodies recognized in 85 patients awaiting renal transplant using the Single Antigen Bead (SAB) Assay.
A total of 103 Sera samples from 85 patients were analyzed by SAB assay between June 2013 and August 2015. Matchit software was used for assessing antibody reactivity pattern and epitopes specificities of these samples. The outcome was scrutinized to see how many private or public epitopes were identified. The latter was subsequently examined further for CREG reactivity.
The antibody reactivity pattern revealed 43 of 103(41.74%) samples with class I antibody specificities and 35 of 103(33.98%) with class II specificities in SAB assay.
Analyzing Class I antibody specificities, it was observed that 17/43 had antibodies against single private epitopes, 18/43 against single CREG, 8/43 against a wide array of epitopes encumbering multiple CREGs.
Common epitopes observed were 71TTD, 62GRN, 62GE, 76ESN, 82LR, 253Q, 80 L and 163 LV.
Analyzing Class II antibody specificities, it displayed that 15/35 had antibodies against single CREG, 20/35 against a wide array of epitopes encumbering multiple CREGs.
Common epitopes observed were 96Y2, 96H, 16Y, 55PP, 52PR, 45GE, 56E, and 57EE.
SAB assay identified 41.74% with HLA class I antibody specificities and 33.98% with Class II anti-HLA antibodies. However analyzing at epitopic level revealed larger proportion of antibodies was against epitopes that spanned public antigens or multiple CREGs. This imparts significantly on donor selection as the presence of these antibodies interpreted at an epitopic level indicate donor specificity, which might otherwise be missed.
Correlation of CDC results and DSA performed on the Luminex platform: Deriving cut-off MFI for prediction of positive donor specific crossmatch: A pilot study
Ramila Sandesh Patil, Suchita Jogale, Rajesh Sawant, Anand Deshpande
Background: Complement dependent cytotoxicity (CDC) crossmatch has been routinely used in our centre to evaluate the risk of renal allograft rejection. The Luminex platform has being recently installed in our laboratory for donor specific antibody (DSA) testing. Establishing an accurate cut-off for MFI values which correlates well with positive CDC results is of paramount clinical importance.
Aim: To study correlation of CDC results with MFI values and establish a cut-off MFI value accurately correlating with a positive HLA crossmatch result.
Materials and Methods: DSA strength (MFI) and CDC crossmatch results in 1070 consecutive samples of candidates for a potential renal transplant were analyzed. DSA was assessed by Luminex; 200™ System and HLA crossmatching by complement dependent microlymphocytotoxicity assay. Correlation co-efficient between MFI and CDC crossmatch results and sensitivity and specificity of MFI values to predict positive CDC crossmatch were analyzed.
Results: Total 1070 samples were run in parallel with CDC and Luminex technology. Samples with positive CDC crossmatch results showed significantly (P = 0.001) higher DSA strength, as assessed by Luminex MFI values. Positive result was obtained by Luminex technology for Class I antibodies in 18 cases and in 63 cases for Class II antibodies when CDC was negative, whereas Luminex crossmatch for Class I antibodies was negative in 3 cases inspite of a positive CDC. In 84 cases discrepancy between CDC and Luminex results was observed, 4 of which showed CDC positivity between 15% to 60% and MFI values between 781 to 6533; whereas in a single case CDC result was clearly negative and MFI value was 694 for Class I and 973 for Class II antibodies. ROC curve plot for Class I antibodies indicated that MFI value of 290 correlates with sensitivity of 90% and 97% specificity to predict a positive CDC result. Similarly for Class II antibodies MFI value of 462 correlates well with a positive CDC result with 79% sensitivity and specificity.
Conclusion: The DSA strength correlates well with CDC cross-match results. MFI values of 290 for Class I and 462 for Class II antibodies predict a positive CDC cross-match result in our laboratory. Further parallel testing and clinical correlation will enable us to establish an accurate cut-off value or defining a grey zone area for accurate clinical interpretation.
Role of therapeutic plasma exchange in successful ABO incompatible renal transplantation
S Viveka Priyadharshni, Ilangovan Veerappan, S Ramasamy
To evaluate the outcome of patients who had undergone ABO incompatible renal transplantation after plasma exchange procedures.
This study was conducted in our hospital between the period of June 2014 to June 2015. Four patients underwent ABO incompatible renal transplantation after evaluating their anti-A and anti-B titre levels. 3 to 5 plasma exchange procedures were performed in each patients to reduce the anti-A or anti-B titre levels before the renal transplantation. After each plasma exchange there was significant reduction in titre levels.
ABO incompatible renal transplantation was successful and all the patients were on immunosuppressant therapy. Postoperative titre levels were remind the same. Out of 4 patients, one patient developed fungal infection and died and remaining three were on regular follow up and their creatinine values are normal.
Because of shortage of donors there are many chronic renal failure patients waiting for renal transplantation. ABO incompatible renal transplantation is a boon to them. Therapeutic plasma exchange helps in reducing the antibody titres in these patients and helps in the successful outcome.
Estimating feto-maternal haemorrhage on maternal samples using HbF% by capillary electrophoresis (Capillarys 2 flex piercing)
Sujoy Khan, Biswajit Ghosh, Sudipta Sekhar Das
Feto-maternal haemorrhage (FMH) mainly occurs due to Rh/ABO incompatibility and responsible for 14% of all unexplained fetal deaths. We determined the feasibility of measuring HbF% on fetal erythrocytes as an estimate of FMH using capillary electrophoresis, CE (Capillarys2 Flex Piercing, SEBIA) as it is a rapid, analytically simple and completely automated method.
Serial dilutions of adult D-negative red cells were incubated in the presence of various amounts of fetal D-positive cells (0.06, 0.12, 0.25, 0.50, 0.75, 1.0, 2.0, 3.0, 4.0, 5.0, 6.0 and 7.0%). After incubation, the samples were tested for HbF% using CE. The Capillarys2 Flex Piercing instrument uses capillary separation technology and cap piercing capability to provide whole blood analyses for hemoglobinopathies. This method was compared against the previously published gel agglutination technique (GAT). Mothers with hemoglobinopathies were excluded in this proof-of-concept study. Statistical analysis was performed using Microsoft Excel 2013.
HbF% was undetectable at first 3 concentrations (0.06, 0.12, 0.25%) and was first detectable at 0.2% at 0.50% fetal RBC, 0.4 HbF% at 0.75% RBC. The best-fit curve regression analysis showed increase in HbF% at subsequent concentrations (y = 0.5251x−0.0904) with R2 = 0.9394, suggesting excellent linear reliability. There was good agreement with GAT.
To establish the HbF% that could determine significant FMH (ml), we used the formula, FMH (ml) = [HbF% x 1.22 x maternal Hct x 100 ml/kg bw (maternal blood volume at term)]/1000. Using above formula (Hct 0.28 and blood volume 6 L), a HbF% at 0.2% calculates to FMH 0.41 ml and 0.7 HbF% calculates to 1.43 ml FMH.
FMH estimation using HbF% by CE is rapid and simple but prior knowledge of HbF% would be required for mothers with hemoglobinopathies. Further studies comparing CE with flow cytometry technique are required to assess its utility as an effective screening tool.
A retrospective study of platelet increment after SDP transfusion in a Tertiary Care Hospital
Prerna Mohan, Akhilesh Bhave
SDP transfusions are used for the treatment of bleeding patients with a decreased number or function of platelets. The study was done to find a correlation between initial platelet count of the donors, their weight, height and the ultimate yield of the product.
ABO matched donors who weighed more than 55 kgs with platelet count more than 1,50,000/mm3 and not on any anti platelet medication underwent routine donor screening procedure before Apheresis. Single donor platelets were collected using COBE SPECTRA and the QC was ensured for each product using WBC, RBC, platelet count, and the yield by using Cell counter. This was a retrospective study from January 2015 till July 2015 through the Blood Bank records to look into the patient characterstics like age, gender, Blood group, height, weight, BSA and post SDP transfusion platelet count , and their effect on the CCI.
A total of 23 donors were taken for SDP procedure.
· Only 1 donor was between 55 kg-60 kg weight with an yield of 3.0
· 7 donors were between 60-70 kg of weight with an average yield of 3.42
· 9 donors were between 70-80 kg of weight with an average yield of 3.67
· 6 donors were more than 80 kgs with an average yield of 4.41.
· 12 donors were between 150-160 cm of height giving an average yield of 3.71.8 donors were between 161-170 cm of height giving an average yield of 3.72
· Only 4 donors were between 171-180 cm giving an average yield of 4.26.
Keeping the result of this study in mind, it is worthwhile to observe that the yield directly depends upon height and weight of the SDP donor.
A comparison of peripheral blood stem cell collections on three cell separators in a single centre
Dhaval Harsukhlal Fadadu, RN Makroo, Mohit Chowdhry, Akanksha Bhatia
Peripheral Blood Stem Cells (PBSC) have become one of the most common source of hematopoietic cells for autologous and allogenic transplantation. Several cell separators are currently available for stem cell harvesting. We performed an evaluation of PBSC collection using three different Apheresis machines at our center.
All PBSC collection procedures performed from 2010 till August 2015 were analyzed. This included both autologous and allogenic stem cell collections. Three cell separators COBE Spectra (TERUMO BCT), MCS+ (Haemonetics Corporation) or Spectra Optia (TERUMO BCT) were used for collection. Data pertaining to the CD34+ counts, collection time, per Kg stem cell yield and procedure related complications, if any, were analyzed.
Total of 106 individual collection procedures performed on 83 patients and 25 allogenic donors, were evaluated. Of these, 86 procedures were performed on COBE Spectra (68 autologous, 18 allogenic), 3 on MCS+ (1 autologous, 2 allogenic) and 17 on Spectra Optia (12 autologous, 5 allogenic). The average blood volume processed was 15.4 L (3.5 L-27.3 L) in COBE Spectra, 16.03 L (9.7 L-22.8 L) in MCS+, and 17.74 L (6.4 L-29.2 L) on Spectra Optia. Average processing time per liter of whole blood was comparable in all the three instruments, being 37.7 minutes in COBE Spectra, 40.2 minutes in MCS+, and 38.7 minutes in Spectra Optia. The CD34+ yield in the final product was 3.74 Χ 106/Kg body weight of the recipient (0.5-11.6 x 106/Kg) in COBE spectra, 4.52 x 106/Kg (1.94-6.7 x 106/Kg) in MCS+ and 4.11 x 106/Kg (0.99 - 28.77 x 106/Kg) in Spectra Optia. The viable CD34+ counts obtained in the product ranged from 31-4415 (avg. 765) in COBE Spectra, 861-1239 (avg. 967) in MCS+ and 103-2767 (avg. 462) in Spectra Optia. Procedure related adverse reactions were noted during 23.5% of Cobe spectra procedures, 17.6% of Optia procedures and 33.3% of MCS+ procedures. The common adverse effects observed were related to hypocalcemia and ranged from mild tingling (treated by calcium supplementation) to severe carpopedal spasm, observed in 2 procedures, both allogenic female donors, with ECG changes requiring medical intervention.
Our results suggest that all the 3 cell separators were comparable in terms of processing time, CD34+ count and yield per Kg. Although a relatively higher CD34+ yield was observed with the 3 procedures on MCS+, and the reaction rates were marginally lower with the Optia, the differences did not reach statistical significance. This initial analysis therefore paves way for a larger, in depth study on this subject.
Seroprevalence of transfusion transmissible infections among blood donors in a tertiary care hospital-based blood bank at South-East of Kerala; India
PK Indu, D Meena, N Sasikala
Transfusion of blood and blood product can save the life at the same time if not screened properly can transmit life threatening infection to patients. Aim of the present study is to find out the seroprevalence of HIV, HBV, HCV, Syphilis and Malaria among blood donors in a tertiary care hospital-based blood bank at South-East of Kerala; India.
All voluntary donors reporting to the blood bank were screened for HBsAg, Hepatitis C Virus (HCV) and HIV by using the appropriate enzyme-linked immunosorbent assay, Rapid Plasma Reagin (RPR) test for syphilis and rapid malarial antigen card test for malaria. Data was analysed statistically to find out the prevalence of Transfusion Transmitted Infections. The study was designed for a duration of one year between July2014 to June 2015.
• Out of 10313 total donation 65 gave positive screening result (0.63%). Among them most prevalent was HBV (0.29%) followed by HCV (0.16%), HIV (0.12%), Syphilis (0.039%), least prevalent was Malaria (0.019%)
• Prevalence of Transfusion Transmitted Infections was more among replacement blood donors (92.3%)
• Female donors were less among total donation (9.72%).
• Pre donation counselling and donor self exclusion will be effective in decreasing the Transfusion transmitted infections
• Public health education programmes will be beneficial to prevent vaccine preventable diseases like HBV by giving adult Hepatitis B vaccination
• Provide advanced screening methods for Transfusion transmitted infections
• Voluntary blood donation should be motivated
• Since more female donors were deferred due anemia, we can advise iron supplementation to females donors.
Significance of detecting weak-D/partial-D in patients and donors
Keyuri Farasram Jariwala, Snehalata Gupte, Swati Kulkarni
Background: The RH blood group system is one of the most polymorphic and antigenic blood group systems and a major cause of haemolytic disease of the fetus and newborn (HDFN). There are more than 37 epitopes of D antigen. In partial D subjects there is an absence of number of epitopes, while weak D subjects have less number of D antigenic sites.
Aim: To detect weak-D or partial-D in patient as well as donor.
The study included 600 samples which were RH negative. All negative samples were tested with monoclonal IgM and a blend of IgG + IgM serologically and on fully automated Immunohaematology analyzer (Diagast). Among these 8 samples gave discrepant results. These samples were further tested with anti-D reagent of different companies. All 600 samples were referred to the ICMR for molecular genotyping. Family study of two patients for RH D determination was done.
Out of 600 samples tested, eight samples (1.3%) were discrepant. On testing these eight samples with different anti-D panel, one sample showed clearly negative result serologically and was typed as weak D by molecular genotyping. Seven other samples showed weak reaction serologically among which one was partial D and six were weak D by molecular genotyping.
Serological testing with panel of anti-D reagents in blood bank may not identify D variants and also not distinguish between partial-D/weak-D. Identification of these variants is important as these individuals are considered as RH D positive as donor and RH D negative as recipient of blood transfusion.
Review of blood donor deferrals in a Superspeciality Hospital of South Bengal: Seven years experience
Debasis Mondal, Suvro Sankha Datta
Modern techniques of blood collection in blood bank require donor screening by using general guidelines according to DGHS or AABB. A large number of blood donors are deferred each year and many of the temporarily deferred donors do not return to donate blood. A retrograde study was performed in our blood bank to get the rate of donor deferrals, rates of deferrals among male/female and different age groups. The study also analyzed the various reasons of deferrals during pre-donation donor screening.
The study period was from 2008 to 2015 and 46252 donors were screened during this period in our blood bank. Total 4034 donors were deferred during the screening process. Standard Operating Procedures based on national guidelines were used for donor selection and deferral. The deferrals rate was calculated in each year. The deferrals rates were analyzed among male/female and different age groups. An analysis was also conducted to identify the various reasons for deferrals. Donor deferrals reasons were divided into six categories such as low Hb (<12.5 g/dl), low body weight (<45 kg), high BP, taking medicines or antibiotics, suffering from any chronic diseases and miscellaneous. The rate of deferrals in each category was calculated year wise.
Total 4034 donors were deferred after screening of 46252 persons. The mean deferral rate was 8.72% during this study period. Deferral rate was maximum in male 3356 (83.19%) and in the age group of 28-37 years 1392 (34.51%). Among total deferrals 33.7% were due to low Hb; 18.09% were due to low body weight; 14.65% were due to high BP, 10.23% were due to medications, 8.50% were due to chronic diseases and 17.79% were due to other reasons like excessive menstrual bleeding, tattoo piercing, history of major surgery or blood transfusion in last one year etc. The rate of donor deferrals due to low Hb was significantly high when compare with each category.
As donor screening is the most important primary step to ensure blood safety thus it was concluded that donor should be made aware about the reason for deferral and donor-deferral slip must be issued to the unfit donor stating the reason for defer. By this way we can try to assess impact of donor deferrals on future donor availability.
Transfusion services play key role in successful management of patients with sickle cell disease: two case reports
Prashant Pandey, Pawan Kumar Singh, Notin Agarwal, Ajay Shanker, Abdul Salam Ansari
A key component in the successful management of patients with SCD is red blood cell transfusion therapy. Finding a blood unit for these patients poses a challenge for blood bank On the other hand, for patients presenting with acute complications, Red cell exchange offers a better control as prophylaxis and therapy for these complications. Here we present two complex cases of SCD patients who posed great challenge but were managed effectively by our transfusion services.
In case one, red cell exchange was done using a continuous apheresis machine (COMTEC, Fresenius Kabi Ltd.). In case two, alloadsorption was done using methods in AABB (16 TH EDITION). Rh, kell and duffy phenotypes were done using SPRCA (NEO, G amma Immucor).
Case 1: A 22 year 'O' positive Nigerian male SCD patient presented with painful sickle cell crisis as an indication for Red Cell exchange. A total of 1800 ml of his red cells was exchanged with six units of red cell concentrates. All the blood units were ABO identical, Rh and Kell phenotype. Procedure lasted for 68 minutes. Post procedure, we observed a significant rise in Hematocrit from 18% to 32%. We observed a dramatic decrease in LDH just after one procedure. Postprocedure day 4 patient was discharged.
Case 2: A 33 year old female patient presented with infection and low hemoglobin after total hip replacement (done elsewhere) and 3 units of compatible red blood cells were transfused. Patient got discharged with hemoglobin of 10 gm/dl. After two weeks, patient again got admitted in hospital with low hemoglobin with hemoglobin and on evaluation she was diagnosed a case sickle cell anemia. Routine cross match demonstrated incompatible results with all the units and antibody screening demonstrated pan-reactivity along with positive auto control, confirming the presence of auto-antibodies. Multiple allo-adsorptions revealed presence of anti C, Fya and E antibodies. We provided her C, E and Fya compatible units to patient. On follow up after one month she did not present with any significant drop in hemoglobin.
Performing extended phenotyping (Rh and Kell) of all donor units is helpful in quickly finding antigen negative units for these patients. We would suggest to provide Rh and Kell phenotyped matched to sickle cell anemia patients. Red cell exchange is an effective supportive care for SCD patients as it provides needed oxygen carrying capacity while reducing the overall viscosity of blood.
Para-Bombay phenotype: A rare finding
Debdutta Bhattacharyya, Lutika Nepram Lyngdoh, SA Hassan
The Para-Bombay phenotype is a very rare blood group and only a few cases have been reported in India till date. H antigen is expressed in almost all the individuals. Absence or very weak expression of H antigen may be termed as H antigen deficient phenotype which results in Bombay or Para Bombay blood group in an individual. A 27 yr old lady was referred to the Department of Blood Bank for blood grouping as a part of routine antenatal check up. The patient came with pregnancy for the third time and was in the first trimester. Last child birth was nine (09) years back. She gave a history of one time abortion. She also gave a history of joint pains for which she was put on medication with analgesics and steroids. As we got some discrepancy in blood grouping she was advised for repeat testing after one month after stopping the medication. After one month, the patient turned up with a hemoglobin concentration of 8.6 gm%, Platelet count 1,50,000/cmm and unremarkable biochemical and immunological reports.
ABO, Rh typing were been performed by tube technique. Forward & Reverse groupings were performed using commercial anti-sera of monoclonal A, B, AB, D (IgM), D (IgG + IgM), H (prepared from plant Ulex europeus extract) & "A1", "B" & "O" reagent red cells, which indicated the presence of anti H in patient's serum. Following the observation of presence of anti H antibody, adsorption at 4C and heat elution at 56C with commercially available anti H anti-sera were performed. Antibody screening showed reactivity in IgM phase and auto control showed a negative result for IgM & IgG phase. Secretor status & presence of Le (a, b) were also performed.
In ABO & Rh typing, forward group showed "O" with non-reactivity for H antigen and Rh(D) positivity. Reverse grouping showed reaction in "A1", "B" & "O" cells which indicated the presence of anti H in the patient's serum. Adsorption and elution studies confirmed absence of H antigen. Rare antigen typing showed patient's Lewis status as Le (a-b+) and secretor study showed the patient as an H secretor.
The H antigen is the precursor of the A and B antigens on red blood cell surface. The ABO locus determines the A & B antigens, where as FUT genes, FUT1 determines the H antigen, the precursor of A and B antigens. FUT1 encodes a fucosyltransferase that catalyzes the final step in the synthesis of the H antigen. The FUT2 gene indirectly encodes a soluble form of the H antigen, which is found in bodily secretions. The Para Bombay phenotype individuals are H-deficient or partially H-deficient. Genetically, these individuals are homozygous or heterozygous for a non-functional H gene, but they inherit at least one functional secretor genes (Se). In this case patient had absence of H antigen and her serum contained anti H antibodies with secretion of H antigen with Le (a-b+). Thus the patient's blood group was concluded as Para Bombay O (h). The prevalence of Bombay and Para Bombay phenotypes in Indians is reportedly 1/10,000. Out of these, a single case of Para-Bombay blood group has been reported from South India. Proper identification of such a group is extremely important to avoid any transfusion reactions. Maintenance of rare blood group registries, cryopreservation of red cells, autologous transfusions and blood conservative measures are recommended for managing requirements of transfusions in such patients.
1. Dean L. Blood Groups and Red Cell Antigens. Bethesda, MD, US: National Centre for Biotechnology Information (NCBI), Natonal Library of Medicine, National Institute of Health; 2005. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2268/. [Last cited on 2010 Mar 03].
2. Mathai J, Sulochana PV, Sathyabhama S. Para Bombay phenotype - a case report. Indian J Pathol Microbiol 1997;40:553-4.
3. Pourazar A, Joshi S, Vander A, Clearke MD, Ala F. Another case of para-Bombay phenotype in an Iranian donor. Arch Iran Med 2004;7:284-6.
4. Chacko MP, Mathan A, Daniel D. Para-Bombay: A blind spot in blood grouping? Asian J Transfus Sci 2011;5:182-3.
5. Jonnavithula N, Bonagiri S, Ramachandran G, Mishra R. Peri-operative red cell transfusion management in a rare H-deficient (Para-Bombay) blood group variant. Indian J Anaesth 2013;57:78-9.
A rare 'B' subgroup in a patient: A case report
PN Sindhu, Jaisy Mathai, PV Sulochana, Sathyabhama, Revathy Nair
Subgroups of B are very rare and much less frequent than A subgroups. Inheritance of B subgroup is considered to be a result of alternate alleles at the B locus.
A 60 year old male patient with hypertrophic cardiomyopathy was admitted for ICD implantation. Blood sample was sent to blood bank for routine blood grouping. A discrepancy was observed in patient's grouping results. The following criteria was used for differentiation of weak B phenotype.
• Strength and type of agglutination with anti-B, anti-AB and anti-H
• Presence or absence of ABO agglutinins in serum
• Adsorption-elution studies with anti-B
• Presence of B substance in saliva
• Study of sibling's blood group.
On forward grouping, no B antigen was detected by routine testing with anti-B and anti-AB. In serum grouping there was no anti-B. Weak subgroup was suspected and enhancement techniques like prolonged incubation at lower temperature and enzyme treatment showed the same reaction pattern. In adsorption-elution study with serum from group A individual, the eluate reacted with B cells and AB cells and there was no reaction with O cells. The individual is a non-secretor. One of his siblings was also showing a similar pattern.
Identification of sub groups is important because they are usually wrongly typed as group O. Transfusion of a subgroup to an O group individual may result in decreased survival of donor cells due to A or B agglutinins in O group individual. Transfusion of O group cells to a weak subgroup may lead to Hemolytic Transfusion Reaction especially in peadiatric patients when high titre agglutinins are present in donor's serum.
Source of Support: None, Conflict of Interest: None
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