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Future directions in blood transfusion medicine
16
ABSTRACTS
FUTURE DIRECTIONS IN BLOOD TRANSFUSION MEDICINE r P. ISBISTER Haematology Department, Royal North Shore Hospital of Sydney, NSW, St Leonards, 2065. Few would question that blood transfusion has been one of the greatest medical advances. The provision of safe blood component therapy has always been a primary consideration of the blood transfusion services. however, the increased centralisation o f transfusion services resulted in 8 dearth of clinical transfusion expertise at the hospital and patient level. The introduction of in vivo blood cell separators into clinical medicine and to a greater extent the appearance of HIV infection became the stimuli to an increased clinical and consumer awareness of the potential hazards of blood transfusion. The old question of What is a Safe Blood Transfusion? will be addressed and possible new answers given. Careful and scientific analysis of the risk/benefit equation for blood component therapy is of paramount importance if patients are to receive appropriate therapy with the minimum risk. I. A transfusion should have a clearly defined indication and
h
2.
3. 4.
5.
supply, in adequate amount. the functional component/s needed by the patient. The infusion should not be associated with any i l l effects. There should be no delayed sequelae from the transfusion and it should not transmit disease. The safety and ef/icacy of future transfusion therapy should not be jeopardized. The transfusion should be adminislered with due care and adequate monitoring to ensure t h d the anticipated aims are achieved and any adverse effects are quickly noted and appropriate action instituted.
Unfortunately, it is clearly impossible for all these criteria to be fulfilled with certainty. As with any form of therapy there is an element of uncertainty, and risk is acceptable if the potential gains are sufficient.
Maryann D. N i d i o l l s
- Ceprtment
o f Ha-tology
R e p a t r i a t i o n General Hospital Concord A u s t r a l i a 2139
Autologous 81ood T r a n s f u s i o n (m)has become the starxhrd of t r a n s f u s i o n practice i n elective surgery and s h o u l d complement techniques that are aimed t o &serve blood and t o minimise the u s e of homolgous b l o o d eg a p p r o p r i a t e preoperative a s s e s s m e n t , the use of DMVP (demopressin) o r T r a s y l o l t o decrease surgical blood loss, m m o l a a n i c haemdilution w i t h c o l l e c t i o n o f a u t o l o g o u s blood, surgical a t t e n t i o n t o h a m s t a s i s and the application of blood s a l v a g e techniques. m-edeposit autologous prcqrams can c o n t r i b u t e 10% to the t o t a l blood usage and can and s h o u l d be used for 50% of elective s u r g i c a l cases. C o n t m v e r s i e s a s t o ' h i g h r i s k ' d o n o r s eg e l d e r l y , pregknt, children or cardiac suryery patients have been dispelled and residual c o n t r o v e r s i e s p e r t a i n i n g t o p r e t r a n s f u s i o n testirq and crossrnatdiing, the r e d i r e c t i o n o f unused ABT u n i t s and the u s e of d i r e c t e d d o n o r s are being c l a r i f i e d and resolved.
' N e w e r ' aspects o f blood t r a n s f u s i o n practice s u c h a s the e v o l u t i o n of change in the criteria for b l o o d a c b n i n i s t m t i o n ie t r a n s f u s i o n triggers, the irlcreask u s e of whole blood in mssive b l o o d t r a n s f u s i o n s i t u a t i o n s , the d e v e l o p n e n t of t r a n s f u s i o n c o n t r o l or surveillance t e a m s a t the h o s p i t a l level and the increasing m e d i d involvement and clinical i n p u t a t the user level are a l l d e v e l o p i n g and are progressing in parallel w i t h the e v o l u t i o n o f t r a n s f u s i o n m e d i c i n e as a s p e c i a l i t y in its own r i g h t .
BLcxlD TRANSFUSION I N ASIA
Dr. S. Leonq: liong Kong Red Cross B l o o d Transfusion Service
T r a n s f u s i o n t r a n s m i t t e d i n f e c t i o n s continued t o be
one o f t h e mst s e r i o u s concern o f blood t r a n s f u s i o n services i n Asia. World wide p o p u l a t i o n surveys show
that t h e r e are h i g h e r i n c i d e n c e s o f Hepatitis B a n t i genaemia i n Asian c o u n t r i e s ( 3 t o 2 0 % ) than i n A u s t r a l i a , E u r o p e or the &rims (0.5 to 3 % ) . Mass s c r e e n i n g test f o r HBsAg by EIA m t h o d on a l l donated blood has been carried o u t s i n c e 1984. Positive results are checked and c o n f i m d by n e u t r a l i z a t i o n method. Asynptmtic carrier rate has been found to be high. A p p r o x i m t e l y 9.7% of f i r s t t i m e donors are p o s i t i v e f o r HBsAg whereas t h e i n c i d e n c e of p o s i t i v i t y f o r a n t i - l B s a n d / o r anti-HEk is around 35%. To e n s u r e a safe blood s u p p l y , p m t e c t i v e m a s u r e s a.re d i r e c t e d at tw m i n areas of w r k . A t t h e B l o o d Dcnor @ n t r e s , t h i s is approached by i d e n t i f y i n g and e x c l u d i n g p o t e n t i a l v o l u n t a r y n o n - r e n m r a t e d donors a t r i s k . I n the laboratories, the f o c u s i s on inproved methods o f d e t e c t i n g weak positive FBsAg. S i n c e 1987, 109 samples which gave u l t r a heak positive r e s u l t s were encountered. Follow up s t u d i e s i n v o l v i n g o t h e r mkers o f HBV are s t i l l b e i n g continued at t h r e e m n t h l y i n t e r v a l s . 77% o f these samples retrain weakly reactive, w h i l e 15% are non-reactive and 8% produce i n c o n s i s t e n t r e s u l t s . Results w i l l be updated periodically. Weakly positive sarrples which l i e beyond t h e lover limits o f d e t e c t i o n b y r o u t i n e c o n v e n t i o n a l methods might w l l be a c o n t r i b u t o r y cause o f Pnl, and could o f t e n be m i s t a k e n l y Labelled as that caused by W .
C W U T E R I S A T I O N OF ANTICOAGULANT RECORDS - W A G E I I E N T OF 2 LARGE ANTICOAGULANT C L I N I C S ON A PERSONAL C W U T E R Andrew P o l l o c k * and E u l d i Bho a1 Haematology Departme+al Birmingham 84 6NH England
Hospital,
An e s s e n t i a l for safe anticoagulant therapy is e f f i c i e n t management o f p a t i e n t s and t h e i r records. S e v e r a l computer systems have been introduc,ed w i t h v a r y i n g success and t h e s e have u s u a l l y i n v o l v e d s p e c i f i c a l l y w r i t t e n programmes. We have d e v i s e d a system u s i n g an i n e x p e n s i v e personal computer and a standard database package "Datamaster". Data i s stored i n 3 f i l e s containing: 1.
P a t i e n t ' s personal d e t a i l s , d i a g n o s i s , name referring physicial, other r e l e v a n t items medical h i s t o r y , and m e d i c a t i o n .
2.
Blood counts.
3.
Prothrombin t i m e r e s u l t ( I N R ) and t r e a t m e n t a t each v i s i t t o t h e c l i n i c .
of of
recomnended
The system produces c l i n i c l i s t s , l i s t s o f d e f a u l t e r s
2nd l i s t s o f anaemic p a t i e n t s , a s w e l l a s dosage i n s t r u c t i o n s f o r t h e p a t i e n t and r e m i n d e r l e t t e r s f o r defaulters. O t h e r i n f o r m a t i o n and s t a t i s t i c s a r e A r e l a t i v e l y small PC w i t h d i s c e a s i l y obtained. s t o r a g e c a p a c i t y o f 10 megabytes i s c a p a b l e o f h a n d l i n g d a t a f o r a c l i n i c of up t o 1 0 0 0 p a t i e n t s .
ABSTRACTS
FUTURE DIRECTIONS IN BLOOD TRANSFUSION MEDICINE r P. ISBISTER Haematology Department, Royal North Shore Hospital of Sydney, NSW, St Leonards, 2065. Few would question that blood transfusion has been one of the greatest medical advances. The provision of safe blood component therapy has always been a primary consideration of the blood transfusion services. however, the increased centralisation o f transfusion services resulted in 8 dearth of clinical transfusion expertise at the hospital and patient level. The introduction of in vivo blood cell separators into clinical medicine and to a greater extent the appearance of HIV infection became the stimuli to an increased clinical and consumer awareness of the potential hazards of blood transfusion. The old question of What is a Safe Blood Transfusion? will be addressed and possible new answers given. Careful and scientific analysis of the risk/benefit equation for blood component therapy is of paramount importance if patients are to receive appropriate therapy with the minimum risk. I. A transfusion should have a clearly defined indication and
h
2.
3. 4.
5.
supply, in adequate amount. the functional component/s needed by the patient. The infusion should not be associated with any i l l effects. There should be no delayed sequelae from the transfusion and it should not transmit disease. The safety and ef/icacy of future transfusion therapy should not be jeopardized. The transfusion should be adminislered with due care and adequate monitoring to ensure t h d the anticipated aims are achieved and any adverse effects are quickly noted and appropriate action instituted.
Unfortunately, it is clearly impossible for all these criteria to be fulfilled with certainty. As with any form of therapy there is an element of uncertainty, and risk is acceptable if the potential gains are sufficient.
Maryann D. N i d i o l l s
- Ceprtment
o f Ha-tology
R e p a t r i a t i o n General Hospital Concord A u s t r a l i a 2139
Autologous 81ood T r a n s f u s i o n (m)has become the starxhrd of t r a n s f u s i o n practice i n elective surgery and s h o u l d complement techniques that are aimed t o &serve blood and t o minimise the u s e of homolgous b l o o d eg a p p r o p r i a t e preoperative a s s e s s m e n t , the use of DMVP (demopressin) o r T r a s y l o l t o decrease surgical blood loss, m m o l a a n i c haemdilution w i t h c o l l e c t i o n o f a u t o l o g o u s blood, surgical a t t e n t i o n t o h a m s t a s i s and the application of blood s a l v a g e techniques. m-edeposit autologous prcqrams can c o n t r i b u t e 10% to the t o t a l blood usage and can and s h o u l d be used for 50% of elective s u r g i c a l cases. C o n t m v e r s i e s a s t o ' h i g h r i s k ' d o n o r s eg e l d e r l y , pregknt, children or cardiac suryery patients have been dispelled and residual c o n t r o v e r s i e s p e r t a i n i n g t o p r e t r a n s f u s i o n testirq and crossrnatdiing, the r e d i r e c t i o n o f unused ABT u n i t s and the u s e of d i r e c t e d d o n o r s are being c l a r i f i e d and resolved.
' N e w e r ' aspects o f blood t r a n s f u s i o n practice s u c h a s the e v o l u t i o n of change in the criteria for b l o o d a c b n i n i s t m t i o n ie t r a n s f u s i o n triggers, the irlcreask u s e of whole blood in mssive b l o o d t r a n s f u s i o n s i t u a t i o n s , the d e v e l o p n e n t of t r a n s f u s i o n c o n t r o l or surveillance t e a m s a t the h o s p i t a l level and the increasing m e d i d involvement and clinical i n p u t a t the user level are a l l d e v e l o p i n g and are progressing in parallel w i t h the e v o l u t i o n o f t r a n s f u s i o n m e d i c i n e as a s p e c i a l i t y in its own r i g h t .
BLcxlD TRANSFUSION I N ASIA
Dr. S. Leonq: liong Kong Red Cross B l o o d Transfusion Service
T r a n s f u s i o n t r a n s m i t t e d i n f e c t i o n s continued t o be
one o f t h e mst s e r i o u s concern o f blood t r a n s f u s i o n services i n Asia. World wide p o p u l a t i o n surveys show
that t h e r e are h i g h e r i n c i d e n c e s o f Hepatitis B a n t i genaemia i n Asian c o u n t r i e s ( 3 t o 2 0 % ) than i n A u s t r a l i a , E u r o p e or the &rims (0.5 to 3 % ) . Mass s c r e e n i n g test f o r HBsAg by EIA m t h o d on a l l donated blood has been carried o u t s i n c e 1984. Positive results are checked and c o n f i m d by n e u t r a l i z a t i o n method. Asynptmtic carrier rate has been found to be high. A p p r o x i m t e l y 9.7% of f i r s t t i m e donors are p o s i t i v e f o r HBsAg whereas t h e i n c i d e n c e of p o s i t i v i t y f o r a n t i - l B s a n d / o r anti-HEk is around 35%. To e n s u r e a safe blood s u p p l y , p m t e c t i v e m a s u r e s a.re d i r e c t e d at tw m i n areas of w r k . A t t h e B l o o d Dcnor @ n t r e s , t h i s is approached by i d e n t i f y i n g and e x c l u d i n g p o t e n t i a l v o l u n t a r y n o n - r e n m r a t e d donors a t r i s k . I n the laboratories, the f o c u s i s on inproved methods o f d e t e c t i n g weak positive FBsAg. S i n c e 1987, 109 samples which gave u l t r a heak positive r e s u l t s were encountered. Follow up s t u d i e s i n v o l v i n g o t h e r mkers o f HBV are s t i l l b e i n g continued at t h r e e m n t h l y i n t e r v a l s . 77% o f these samples retrain weakly reactive, w h i l e 15% are non-reactive and 8% produce i n c o n s i s t e n t r e s u l t s . Results w i l l be updated periodically. Weakly positive sarrples which l i e beyond t h e lover limits o f d e t e c t i o n b y r o u t i n e c o n v e n t i o n a l methods might w l l be a c o n t r i b u t o r y cause o f Pnl, and could o f t e n be m i s t a k e n l y Labelled as that caused by W .
C W U T E R I S A T I O N OF ANTICOAGULANT RECORDS - W A G E I I E N T OF 2 LARGE ANTICOAGULANT C L I N I C S ON A PERSONAL C W U T E R Andrew P o l l o c k * and E u l d i Bho a1 Haematology Departme+al Birmingham 84 6NH England
Hospital,
An e s s e n t i a l for safe anticoagulant therapy is e f f i c i e n t management o f p a t i e n t s and t h e i r records. S e v e r a l computer systems have been introduc,ed w i t h v a r y i n g success and t h e s e have u s u a l l y i n v o l v e d s p e c i f i c a l l y w r i t t e n programmes. We have d e v i s e d a system u s i n g an i n e x p e n s i v e personal computer and a standard database package "Datamaster". Data i s stored i n 3 f i l e s containing: 1.
P a t i e n t ' s personal d e t a i l s , d i a g n o s i s , name referring physicial, other r e l e v a n t items medical h i s t o r y , and m e d i c a t i o n .
2.
Blood counts.
3.
Prothrombin t i m e r e s u l t ( I N R ) and t r e a t m e n t a t each v i s i t t o t h e c l i n i c .
of of
recomnended
The system produces c l i n i c l i s t s , l i s t s o f d e f a u l t e r s
2nd l i s t s o f anaemic p a t i e n t s , a s w e l l a s dosage i n s t r u c t i o n s f o r t h e p a t i e n t and r e m i n d e r l e t t e r s f o r defaulters. O t h e r i n f o r m a t i o n and s t a t i s t i c s a r e A r e l a t i v e l y small PC w i t h d i s c e a s i l y obtained. s t o r a g e c a p a c i t y o f 10 megabytes i s c a p a b l e o f h a n d l i n g d a t a f o r a c l i n i c of up t o 1 0 0 0 p a t i e n t s .