The Observatory and Fast Facts

Nov. 25, 2019
Blood transfusions

Further restricting blood transfusion guidelines could save lives and money. Blood transfusion guidelines may require further evaluation with an eye to reducing transfusions for patients with stable blood pressure, according to Divyajot Sadana, MD, from the Cleveland Clinic, who presented the study findings at the CHEST Annual Meeting 2019 in New Orleans, LA.

The Joint Commission on Accreditation of Healthcare Organizations has identified blood transfusion as an overused procedure, and the American Association of Blood Banks (AABB) advises limiting transfusion to patients who are at risk of shock, cardiovascular failure, circulatory collapse and decreased blood flow, or who have a hemoglobin value of less than seven g/dL.

The researchers evaluated the necessity and outcome of transfusions by reviewing charts of the 888 patients who accounted for the 1,009 admissions to the medical intensive care unit (MICU) and required at least one blood transfusion from January 2015 to December 2015.

Although the Cleveland Clinic MICU closely adheres to blood conservation, a proportion of patients with stable blood pressures who received blood transfusions might have benefited from closer scrutiny. The researchers found that 13 percent of transfusions were prescribed in deference to transfusion guidelines and could have been potentially avoided.

“We identified a specific group of patients for whom blood transfusion can be safely avoided,” explained  Sadana. “Closer inspection, greater scrutiny and a vigorous investment in a restrictive transfusion practice could have significant implications on both financial and patient outcomes.”

Michelle Cao, MD, member of the American College of Chest Physicians Scientific Presentations and Awards Committee and Clinical Associate Professor at Stanford University, CA, commented on the study: “Clinical practice guidelines are developed after an extensive review of the evidence in order to optimize clinical care and to standardize medical care. This study, although a retrospective outlook, shines light into the transfusion practices of intensive care providers in a typical tertiary hospital. Beyond the investigators’ findings, it is worth taking a deeper dive into the rationale or conditions that contributed to medical professionals not adhering to recommended practice guidelines. Their decision-making has prognostic implications on morbidity, mortality and economic burden.”

Blood collection safety

Final guidance document on bacterial safety standards for platelet collection and transfusion. Cerus Corporation applauds the publication of the FDA’s final guidance document titled, “Bacterial Risk Control Strategies for Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion; Guidance for Industry.” The FDA has formally recognized the risk of transfusion-transmitted bacterial infections and the need for additional safety measures, including the use of pathogen-reduction technology, to protect patients.

“This is an important day for patients that require platelet transfusions,” said Dr. Richard Benjamin, Cerus’ chief medical officer. “It is estimated that approximately one in every 1,500 platelet units contain bacteria despite current testing protocols, thereby putting these often immunocompromised patients at risk of sepsis, including the possibility of death. The publication of the final FDA guidance document and the implementation of its recommendations will enhance the safety for platelet transfusions.”

The FDA’s guidance document outlines approaches that blood centers and hospitals will need to implement over a period of 18 months to reduce the risk of transfusion-transmitted bacterial sepsis. One approach that offers comprehensive protection against not only bacteria, but also emerging viruses like Zika, is pathogen reduction. Cerus’ INTERCEPT Blood System is currently the only FDA-approved pathogen-reduction technology to treat platelet components. The INTERCEPT system uses amotosalen, a well characterized photochemical compound that specifically binds to DNA and RNA of bacteria, viruses and other pathogens, rendering them inactive. Many of the nation’s largest blood centers and academic hospitals, including the American Red Cross, have deployed the INTERCEPT system in advance of this final FDA guidance document.

Blood infections

Young infants with fever may be more likely to develop infections. Infants with a high fever may be at increased risk for infections, according to research from Penn State College of Medicine, PA.

In a new study, researchers determined that for an infant less than eight weeks old, having a fever was associated with a doubled risk for developing serious bacterial infections, including meningitis and infections of the blood or urinary tract. Based on the findings, the researchers encourage parents of infants younger than eight weeks old to seek immediate care if their child develops a fever (a temperature higher than 100.4 degrees Fahrenheit).

Dr. Joshua Davis, an emergency medicine resident at Penn State Health Milton S. Hershey Medical Center, said that identifying criteria that can increase an infant’s risk for infection is crucial.

According to Davis, the study findings, published in The Journal of Emergency Medicine, are an exception to the traditional teaching in medical education that the height of a fever doesn’t necessarily correspond to the likelihood of infection. This exception to the rule only applies to infants younger than two months old.

In working with his colleague Erik Lehman, a statistician at the Milton S. Hershey Medical Center, Davis discovered that as a temperature rises in infants younger than 60 days old, their risk for serious bacterial infection increases.

For the study, Davis used data from the Pediatric Emergency Care Applied Research Network study on infants with fevers. He studied 4,821 eligible infants with a single, recorded fever who had at least one blood culture completed. The infants included had no record of prematurity, sepsis, or recent antibiotic use.

The researchers evaluated three characteristics of the fevers—height, duration and location of where the temperature was taken —to see if any were associated with increased risk for infants developing a serious infection. Approximately 70 percent of the temperatures collected were taken at a health care facility instead of at home.

Duration and location were not associated with risk for infection, but there was a statistically significant relationship between height of the fever and risk of infection. According to Davis, serious bacterial infections occurred in 20.4 percent of infants with a fever, compared to 9.1 percent of infants with a lower temperature.

According to Davis, understanding the criteria that put infants at risk for severe infections might someday reduce the extensive panel of tests that infants with a fever undergo when visiting an emergency room. Spinal taps and bloodwork are just a few of the procedures that are done to assess for bacterial infection, and these may be painful or invasive to small infants.

Chemicals in blood

Hygiene products are associated with the presence of chemicals in women’s blood. Women who use a vaginal douche could be at a higher risk of exposure to potentially dangerous chemicals, according to a University of Michigan (U-M) study that looked at the correlation between the use of female hygiene products and the levels of volatile organic compounds in women’s blood.

The study found a significant association between vaginal douching and higher blood concentrations of 1,4-dichlorobenzene (DCB), a volatile organic compound (VOC). Because black women in the study reported significantly more use of vaginal douching, researchers believe they could be at higher risk of exposure to the chemicals and their negative effects.

According to the study, women who used a vaginal douche two or more times per month had concentrations 81 percent higher than those that never used a douche. Women who used douches occasionally (once a month) had 18 percent higher concentrations of the chemical.

VOCs are chemicals that are used in a wide range of products including deodorants, nail polish and paints. Some of these chemicals have been associated with respiratory symptoms, cancers and neurological disorders, as well as adverse effects in reproductive systems.

While additional studies are needed, women would be better off heeding the recommendation from the American Society for Obstetricians and Gynecologists (ACOG) not to use certain products, said Ning Ding, a doctoral candidate in epidemiology at U-M’s School of Public Health and lead author of the study.

“While they are more concerned about disrupting the balance of bacteria in the genital area or interrupt the pH level, they have not focused on the toxicity of those endocrine-disrupting chemicals, which is really important and needs to be highlighted,” said Ding, pointing out that 20-40 percent of women use this kind of product in the U.S. “I would recommend women not douche.”

The study, published online in the Journal of Women’s Health, uses data from a representative sample of 2,432 women aged 20-49 from the National Health and Nutrition Examination Survey 2001-2004. Participants were asked about their use of feminine products including tampons, sanitary napkins (pads), vaginal douches, sprays, powders and wipes/towelettes.

Researchers used regression models to estimate percentage changes in concentration of  VOCs in blood to establish whether a dose-response relationship existed. Among the chemicals analyzed were seven VOCs: bromoform, bromodichloromethane, benzene, chloroform, dibromochloromethane, DCB and ethylbenzene.

In addition to the relationship between douching and DCB levels, researchers found that the use of feminine powder in the past month was significantly associated with higher concentrations of ethylbenzene.