Limited cell dose hampers wider use of cord blood transplantation (CBT). By depleting plasma but not RBC during processing, nucleated cell (NC) loss is reduced to <0.1% which increases significantly the proportion of high cell dose products-3-fold for products with NC >or=200 x 10(7). Clinical outcome for plasma depleted (PD) CBT was previously unavailable. A retrospective audited analysis was performed on 118 PD CBT, with mean and median NC doses of 7.6 x 10(7)/kg and 5.6 x 10(7)/kg, respectively, for this mostly pediatric population. The median times to engraftment and engraftment rates for ANC 500 and platelet 20K were 22 and 50 days, respectively, and 90% +/- 3% and 77% +/- 5%, respectively. The incidences of grade III-IV acute graft-versus-host disease (aGVHD) and extensive chronic GVHD (cGVHD) were 13% +/- 4% and 17% +/- 6%, respectively. Relapse rate for malignancies was 25% +/- 6% and 100-day treatment-related mortality (TRM) was 16% +/- 3%. With a median follow-up of 557 days, the 1-year overall survival and relapse-free survival are 65% +/- 5% and 51% +/- 6%, respectively. These results demonstrate that PD CBT is safe and effective, and that eliminating RBC reduction or depletion improves cell recovery during CB processing, resulting in a larger proportion of the inventory with high NC number.
Extracorporeal membrane oxygenation (ECMO) provides lifesaving hemodynamic and respiratory support to neonatal and pediatric patients with a variety of congenital or acquired cardiopulmonary defects. Successful ECMO support requires close collaboration among multiple services, including critical care medicine, perfusion, and transfusion medicine services. Neonatal and pediatric ECMO patients require significant transfusion support, both at the time of cannulation and after the ECMO circuit has been established, often with little advance notice. Thus a number of communication and logistic issues must be addressed through a multidisciplinary approach to ensure both good patient outcome and judicious use of resources. In this article, we describe our protocol for transfusion support for ECMO and potential ECMO patients, which was developed to address a number of issues, including identifying and stratifiying ECMO candidate patients, streamlining the ordering and communication processes, and improving blood product turnaround times and availability. Additional measures of quality improvement are also discussed. As the number of centers performing ECMO procedures remains high, we believe that our experience may be of interest to our colleagues in transfusion medicine and critical care.
T rauma is the leading cause of death in individuals between the ages of 5 and 45 years worldwide and is expected to become the second leading cause of death by 2020 across all age groups. 1 Nationally, approximately 1 out of every 1000 Americans is hospitalized annually for injuries sustained secondary to trauma, with these patients receiving approximately 10% to 15% of the 14.6 million red blood cell (RBC) units transfused in the United States. 2,3 Exsanguination is an important cause of mortality for trauma patients, and the successful management of severely injured patients depends in part on adequate and timely transfusion support. 4 Therefore, it is not surprising that the provision of optimal transfusion support for trauma patients has generated much interest and discussion, especially in recent years with newly emerging data from both civilian and military settings.Transfusion support in acute trauma can be challenging and demanding on the resources of the blood bank. The need for large volumes of blood components for some patients, particularly those with the greatest risk of mortality, can arise before or within minutes of their arrival to the hospital. Recent data from one large trauma center in the United States showed that 62% of all RBC units were administered in the first 24 hours of admission, with 18% given uncrossmatched due to the urgency of transfusion.Although the majority (91%) of trauma patients were not transfused, the few (3%) that were massively transfused (i.e., receiving more than 10 units of RBCs) received more than 71% of all RBC units given. Furthermore, this subgroup of patients also had a high mortality rate of 39%. 5 Occasionally, a single patient can require such massive transfusion support that a significant amount of available blood bank resources can be consumed with the patient's care. For example, at our center, among trauma victims who survived in the past 12 months, the maximum amount of blood products given to a single patient in 1 day was 112 units of RBCs, 70 units of plasma, 40 units of cryoprecipitate, and 6 units of apheresis platelets (PLTs). Such data illustrate that for acute trauma cases, the transfusion service needs to provide large amounts of appropriate blood products quickly and communicate effectively with the clinical team to allow for early recognition of patients with massive transfusion requirements to keep up with their blood product needs.Although there has been much interest recently in what constitutes the optimal transfusion strategy for trauma patients (e.g., role of early plasma transfusion or use of alternative hemostatic agents), there is little information available addressing the logistic issues posed by trauma patients on the transfusion service. All blood banks supporting trauma patients face challenges that include how to minimize delays associated with patient registration and completion of requisition forms, how to provide adequate patient safety measures to avoid misidentification and mistransfusion, how to facilitate effective communi...
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