Q&A with Robert A. DeSimone, MD
Transfusion Medicine Fellow
New York Blood Center, New York, NY
MedicalLab Management: What are the risks and benefits of accepting and reissuing returned blood cell concentrates?
Dr. DeSimone: Blood products are a precious resource in health care, and as transfusion medicine physicians, we have tremendous respect for our blood donors and their provision of this valuable resource to our hospitals and patients. To demonstrate this respect, one of the essential roles of transfusion medicine laboratory physicians and staff is working to limit blood product wastage.
Proper stewardship of blood products requires a combination of training and education methods used in concert with clinical-grade storage, transport control, and monitoring mechanisms. An initial transfusion medicine training step for our clinical colleagues is to instill the practices of strictly limiting blood product requests according to absolute indications, and making those requests only when the patient is ready to be transfused. That said, exceptions always arise, and there are occasions when blood products are requested only to be returned to the blood bank minutes later. While these events should be prevented to every possible degree, certain events are unavoidable (eg, the patient spiked a fever just as the blood product arrived at the bedside).
When a blood product is returned to the blood bank and that blood product was not issued in a validated, temperature-controlled environment, we must determine whether it is safe to reissue this product to a different patient. Blood products are precious and we try to limit wastage as much as possible, but above all, we must ensure that every blood product we issue is safe for transfusion.
For returned RBC units, our greatest concern involves the risk of bacterial proliferation, and we must question whether the unit warmed sufficiently to allow bacterial growth that might harm the transfusion recipient. Other in vitro parameters also affected by RBC warming include hemolysis markers, PaO2, PaCO2, pH, mechanical RBC fragility, deformability, and concentrations of glucose, lactate, sodium, potassium, ATP, and 2,3-DPG. This is why tight temperature control during transport is so essential. Unfortunately, no published studies have investigated how reissued RBC units directly impact actual patient outcomes.
MLM: What has been the historical procedure when considering acceptance of RBCs without temperature maintenance?
Dr. DeSimone: Historically, published studies demonstrated that RBC units are associated with a greater degree of hemolysis and septic transfusion reactions when stored in a non-refrigerated environment after 30 minutes. The 30-minute rule originated following a 1971 publication that showed that the surface and core temperature of whole blood units stored in acid citrate dextrose exceeded 10°C after 30 and 60 minutes, respectively.1
MLM: What are the weaknesses with the 30-minute rule?
Dr. DeSimone: From our two-year focus experience with clinically transported RBC units without temperature maintenance, the 30-minute rule has excellent value at predicting which RBC units will exceed the allowable transport temperature range of 1-10˚C after 30 minutes. In fact, units returned to the blood bank more than 30 minutes after issue will almost always be out of the appropriate temperature range.
However, the rule has poor predictive value for indicating which RBC units will be within appropriate temperature range if returned in less than 30 minutes. That is, units returned to the blood bank less than 30 minutes after issue may or may not be out of the appropriate temperature range for reissue.
MLM: What changes did you see in the amount of waste generated after implementing temperature monitoring of returned RBCs, and what impact did this have on transfusion reactions?
Dr. DeSimone: When we implemented temperature monitoring of returned RBC units, per current AABB Standards for Blood Banks and Transfusion Services requirements, we observed significantly more wastage (13%) but significantly less transfusion reactions for reissued units (only 1 transfusion reaction for reissued units over 1 year) compared to our previous practice using the 30-minute rule (5 transfusion reactions for reissued units over 1 year).
MLM: What method would you recommend the lab follow for accepting returned blood products?
Dr. DeSimone: Per current AABB standards, temperature monitoring is now required, and this can be practically conducted in two ways. The first is through the use of temperature-sensitive indicators, which are attached to every individual RBC unit and permanently change color when the allowable temperature has been exceeded. When the RBC unit is returned to the blood bank, a quick check of the indicator shows whether that unit was maintained at an appropriate temperature during transport.
Another method is to utilize a validated thermometer and measure the temperature of RBC units upon return. Either method is acceptable as long as it has been vigorously validated.
MLM: Please describe the catalyst for your recent study of the impact of returned RBC concentrates without temperature maintenance?
Dr. DeSimone: In order to comply with current AABB standards, we switched over to temperature monitoring, as is required of all AABB-accredited blood banks. We took this required change as an opportunity to examine temperature monitoring in a realistic clinical setting, and compare our processes before and after the change. Before our study,2 no one had quantified the increase in wastage or the clinical implications when taking a temperature-based inventory management approach, compared to the historical time-based rule.
MLM: What implications does your study have for blood bank practice?
Dr. DeSimone: Our small pilot study shows that RBC temperature monitoring, as advocated by the AABB, may be safer for patients receiving reissued units. It also shows that the 30-minute rule is not a strong predictor of appropriate RBC product temperature when units are returned within 30 minutes. Canada still uses a time-based approach and recently extended their 30-minute rule to a 60-minute rule based on in vitro data on bacterial proliferation. However, a closer study of long-term patient outcomes on a larger scale may be necessary before continuing with this approach.
- Pick P, Fabijanic J. Temperature changes in donor blood under different storage conditions. Transfusion. 1971;11(4):213-15.
- DeSimone RA, Lo DT, Nowak MD, Hsu YMS. Warming Kinetic and Clinical Impact of Returned RBC Concentrates without Temperature Maintenance. Study abstract. Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY.
Robert A. DeSimone, MD, completed his anatomic and clinical pathology residency training at New York-Presbyterian Hospital-Weill Cornell Medicine in New York, and is currently completing his fellowship in transfusion medicine at the New York Blood Center. At Cornell, he served as chief resident in clinical pathology and was recently recognized by the ASCP as a “40 Under Forty” honoree. He completed his BS in biological sciences and microbiology at Cornell University and his MD at Stony Brook University School of Medicine.