Background Hemolytic reactions (HTRs) can occur from ABO-incompatible platelet transfusions. After a series of cases at our institution, a procedure to screen all plateletpheresis donors for high-titer ABO antibodies was implemented. Study design and methods Plasma samples from plateletpheresis donors were screened using pooled 0.8% A1 and 0.8% B RBC in buffered gel. Dilutions of 1 in 150, 1 in 200, and 1 in 250 were sequentially evaluated. A component testing positive for high-titer ABO antibodies is restricted to ABO-identical or group O recipients, or washed. Results At the initial dilution of 1 in 150, half of group O components were labeled as high-titer. At the current dilution of 1 in 250, 25% of group O components are labeled as high-titer. No platelet-associated HTR has been reported since screening began. Conclusion Universal screening for high-titer ABO antibodies in plateletpheresis donors can be implemented efficiently to reduce the risk of HTRs. The cutoff for classifying a unit as high-titer depends on the serologic method used, and may be customized by the individual facility. Our screening method uses one gel test per donation regardless of blood group, and a plasma dilution of 1 in 250 with pooled A1/B RBCs in buffered gel.

BACKGROUND Hemolytic transfusion reactions (HTRs) can occur with transfusion of platelets (PLTs) containing ABO-incompatible plasma. Reported cases have involved group O donors. Two cases of PLT-mediated HTRs associated with the same group A plateletpheresis component, collected from a donor taking high doses of probiotics are reported. CASE REPORT Case 1 was a 40-year-old 69-kg group B stem cell transplant patient who received one-half of a group A plateletpheresis component. Severe back pain occurred 10 minutes into the transfusion, accompanied by anemia and hyperbilirubinemia. Case 2 was a 5-year-old 26-kg group B male with aplastic anemia who received the other half of the same plateletpheresis component, volume reduced to 37 mL. Syncope occurred immediately after the transfusion, with laboratory evidence of hemolysis a few hours later. RESULTS Serologic investigation of posttransfusion samples from both patients revealed positive direct anti-globulin tests: C3d only for Case 1 and immunoglobulin (Ig)G and C3d for Case 2; the eluates contained anti-B. The group A donor’s anti-B titer was 16,384 at saline and IgG phases. Donor lookback revealed that the donor had donated 134 apheresis PLTs over many years. For 3 years, he had intermittently taken probiotics; 3 weeks before the index donation, he began taking three tablets of probiotics every day. Lookback of prior group B recipients uncovered a case of acute hemolysis that was not recognized at the time. The solubilized probiotic inhibited anti-B in vitro. CONCLUSION Non–group O PLT donors can have high-titer anti-A or anti-B that might mediate HTRs, and probiotic ingestion in blood donors represents a novel mechanism of stimulating high-titer anti-B.

Background The Pragmatic Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial was a randomized clinical trial comparing survival after transfusion of 2 different blood component ratios for emergency resuscitation of traumatic massive hemorrhage. Transfusion services supporting the study were expected to provide thawed plasma, platelets and red blood cells within 10 minutes of request. Study Design and Methods At the 12 Level 1 trauma centers participating in PROPPR, blood components transfused and delivery times were tabulated, with a focus on universal donor (UD) plasma management. The adequacy of site plans was assessed by comparing the bedside blood availability times to study goals and the new American College of Surgeons (ACS) guidelines. Results Eleven of 12 sites were able to consistently deliver 6 units of thawed UD plasma to their trauma receiving unit within 10 minutes, and 12 units in 20 minutes. Three sites used blood group A plasma instead of AB for massive transfusion without complications. Approximately 4700 units of plasma were given to the 680 patients enrolled in the trial. No site experienced shortages of AB plasma that limited enrollment. Two of 12 sites reported wastage of thawed AB plasma approaching 25% of AB plasma prepared. Conclusion Delivering UD plasma to massively hemorrhaging patients was accomplished consistently, rapidly and without excessive wastage in high-volume trauma centers. The ACS Trauma Quality Improvement Program guidelines for massive transfusion protocol UD plasma availability are practicable in large academic trauma centers. Use of group A plasma in trauma resuscitation needs further study.

Background Iron depletion/deficiency in blood donors frequently results in deferrals for low hemoglobin, yet blood centers remain reluctant to dispense iron replacement therapy to donors. Study Design and Methods During a 39-month period, 1236 blood donors deferred for hemoglobin <12.5 g/dL and 400 non-deferred control donors underwent health history screening and laboratory testing (CBC, iron studies). Iron depletion and deficiency were defined as ferritin of 9–19 mcg/L and <9 mcg/L in females and 18–29 mcg/L and <18 mcg/L in males. Deferred donors and iron-deficient control donors were given a 60-pack of ferrous sulfate 325 mg tablets, and instructed to take one tablet daily. Another 60-pack was dispensed at all subsequent visits. Results In the low hemoglobin group, 30% and 23% of females and 8% and 53% of males had iron depletion or deficiency, respectively, compared with 29% and 10% of females and 18% and 21% of males in the control group. Iron depleted/deficient donors taking iron showed normalization of iron-related laboratory parameters, even as they continued to donate. Compliance with oral iron was 68%. Adverse gastrointestinal effects occurred in 21% of donors. The study identified 13 donors with serious medical conditions, including eight with GI bleeding. No donors had malignancies or hemochromatosis. Conclusion Iron depletion or deficiency was found in 53% of female and 61% of male low hemoglobin donors, and in 39% of female and male control donors. Routine administration of iron replacement therapy is safe, effective, and prevents the development of iron depletion/deficiency in blood donors.

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Anti-N-methyl-D-aspartate receptor (NMDA-R) encephalitis is thought to be one of the common paraneoplastic-associated encephalitides. Between February 2001 and February 2011, nine patients were diagnosed with this disorder at Columbia University Medical Center: eight females (mean age 23 years) and one male (3 years of age). Four female patients had ovarian teratomas, which were removed as part of their treatment. Therapeutic plasma exchange (TPE) was used as one of the treatment modalities in addition to immunosuppressive therapy, including corticosteroids, intravenous immunoglobulin (IVIG), and/or rituximab. A total of 56 TPE procedures were performed in these patients on alternate days (range, 5-14 procedures/patient). Approximately 1 plasma volume (PV) was processed for all patients; 5% albumin and 0.9% normal saline were used as replacement fluid. Complications occurred in 20% of TPE procedures; 9% were possibly due to underlying disease. The remaining 11% of complications were hypotensive episodes that rapidly responded to either a fluid bolus or a vasopressor treatment. One patient demonstrated immediate clinical improvement after three TPE treatments, and four patients had significant improvement at time of discharge from the hospital. Long-term follow-up showed that early initiation of TPE appears to be beneficial, and patients who received IVIG after TPE did better than those who received IVIG before TPE. However, the number of patients in this series is too small to provide statistically significant conclusions. Overall, TPE is a relatively safe treatment option in patients with anti-NMDA-R encephalitis. Further studies are needed to elucidate the benefit of TPE in this disease.

OBJECTIVE: The transfusion of older packed red blood cells (PRBC) may be harmful in critically ill patients. We sought to determine the association between PRBC age and mortality among trauma patients requiring massive PRBC transfusion. Competing interests: JRH receives patent royalties from the United States Army and the University of Maryland for improved red blood cell storage solutions. The rest of the authors declare that they have no competing interests.

In this series, a PaO2 threshold between 250 and 486 mm Hg during the first 72 hours after injury was associated with improved all-cause survival in patients with severe TBI, independent of hypocarbia or hypercarbia.