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World J. Surg. Vol. 4, No. 5, September, 1980

Transfusion 1978. A Symposium presented at the 31st Annual Meeting of the American Association of Blood Banks. Chicago, American Association of Blood Banks, 1978, pp. 71-79

Invited Commentary Charles Huggins, M.D. Massachusetts General Hospital, Boston,Massachusetts, U.S.A. Worthington describes very nicely the complex inner workings of a l~lood bank in an active general hospital. Although most surgeons devote about as much thought to how blood gets to their patients as to how hot and cold water arrive at the scrub sink, it is clear that a great deal of time-consuming laboratory processing is involved in delivery of all forms of blood and blood components. This is a particular problem if the patient happens to have unexpected blood group antibodies. Worthington also makes it clear that if every blood bank kept on hand enough blood and blood components to meet any eventuality, half of these units would become outdated before they could be used. Blood banks have established mechanisms to meet sudden, unexpected demands for blood and blood components without having to keep them stocked on hand at all times, but most mechanisms take some time. From the surgeon's standpoint the most important message of the above is: Get a properly identified sample of blood from your patient to the blood bank as early as possible to permit them to identify complicated antibody problems and arrange for unusual amounts, or types of blood and components. This gives the blood bank the best possible chance to help you and your patient. All blood looks the same. Unless extreme care is taken at all times, it is possible, particularly when managing patients with exsanguinating hemorrhage, to give a patient blood intended for someone else. If a patient receives blood intended for another patient there is approximately a 1/3 chance that the 2 patients will be compatible. There is a 1/3 chance of a relatively minor incompatibility (e.g., O blood to an A patient), and a 1/3 chance of a frequently lethal incompatibility (e.g., A blood to a B patient) reaction. Transfusion of improperly identified blood by all odds is the most common cause of immediate fatal transfusion reactions. One of the most dangerous items of equipment in any hospital is a blood refrigerator in an operating room that contains blood for several different patients. It is inevitable in this circumstance that a patient will suffer a fatal transfusion reaction. It is only a matter of when this reaction will occur. In the

15. Mollison, P.L.: Red cell antigens and antibodies and their interactions. In Blood Transfusion in Clinical Medicine, 6th edition, Oxford, Blackwell Scientific Publications, 1979, p. 204 state of Massachusetts 2 patients have died in the past 2 years as the result of wrongly identified transfusions of blood taken from a refrigerator that held blood for several patients. Insulated boxes with a static refrigerant to keep the contents cold are available from a variety of sources. Use of this type of system permits storage of several units of blood for the same patient in the operating room in case it is needed rapidly. If the contents of the box are checked by the blood bank technician, the operating room nurse, and the anesthesiologist, the possibility of a fatal transfusion reaction due to improperly identified blood are greatly reduced. At the Massachusetts General Hospital we are considerably more liberal than Worthington in the use of fresh frozen plasma. In the isovolemic blood loss and replacement situation we have 3 different practices for the man weighing 70 kg: 1. For loss and replacement of 1500 ml of blood we prefer to use red cells (fresh or freshly frozen) and noncolloid-containlng solutions such as lactated Ringer's. 2. For loss and replacement of between 1500 and 5000 ml we use, consecutively, a unit of red cells (fresh or freshly frozen), 250 ml of 5% albumin in saline, and 250 ml of lactated Ringer's solution. 3. For blood loss and replacement beyond 5000 ml, where dilutional coagulopathy is likely to occur, we like to use, from the start, a unit of red cells (fresh or freshly frozen), a unit of fresh frozen plasma, and 250 ml of lactated Ringer's solution. One unit of platelet concentrate is generally given for each 500 ml of blood lost after the first 5000 ml. Experience has shown that it is easier to prevent dilutional coagulopathy than it is to treat it once it has occurred. We have not seen severe hypotension associated with fresh frozen plasma requiring the use of epinephrine as described by Worthington. We do not use human plasma protein fraction, sometimes called Plasmanate or PPF. Hypotension has been clearly documented with this biological product and patients have been reported to become sensitized to the human leukocyte antigens by way of soluble H L A antigen in the PPF. Five percent albumin-saline solution has not been associated with either of the foregoing disadvantages, and the price is essentially the same as that of PPF. Give your blood bank as much time and information as possible, and they will be able to help you. An occasional "thank you for a job well done" also helps to improve relations with the blood bank technologists.