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Hemorrhagic shock is the primary cause of avoidable mortality in combatants. Data from the recent US army war experience show clearly that in cases of massive transfusion the transfusion policy strongly impacts mortality. Namely, for massive bleeding the ratio between red blood cells and clotting factors should be close to the composition of whole blood [2].
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Plasma is thus essential for massive transfusions. But FFP use is impractical in uncertain environments such as a battlefield. During military operations, refrigerated transportation and storage are logistical problems. Thawing of FFP takes a long time, with an important loss of plasma in austere environments. For example, Mabry and colleagues [3] report that, during the Mogadishu urban battle, the available FFP was stored in bags that fractured one-third of the time upon thawing.
We thank Daban and colleagues for their insightful observations and agree with the comments on the challenges to using AB FFP in trauma. Products such as freeze-dried plasma or lyophilized plasma are appealing for trauma resuscitation since they have many of the characteristics of an ideal resuscitation fluid for bleeding/coagulopathic patients. Such an ideal fluid would be easy to prepare and rapid to administer, contain all clotting factors, not require blood typing and matching, be free of infectious and immunological risks and have a long shelf life. Concerning volume, it is unclear whether the benefit of early and aggressive FFP transfusion in massive traumatic bleeding is related to either clotting factor or volume replacement with reduced crystalloid exposure. Since most trauma patients are hypovolemic, large volumes are often advantageous, but in circumstances where circulatory overload is a concern, the use of small volume clotting factor concentrates, including freeze dried plasma, would be superior.
Despite screening blood donations with advanced technologies and improved donor screening, the risk of transfusion-transmitted infections persists. This risk is mainly due to blood donations collected during the window period. A precise estimate of the transfusion risk of viral infection will help to determine the effect of new and current safety measures and to prioritize and allocate limited resources. Therefore, we estimated the risk of transfusion-transmitted viral infection in blood donations collected in Korea from 2000 to 2010.
Blood donations collected at 16 blood centers were tested for HIV, HCV, and HBV to estimate the residual risk of transfusion-transmitted viral infection. The residual risk was calculated in two-year periods using the incidence/window model. The incidence rates for HIV/HCV and the confirmed positive rate for HIV/HCV in first-time and repeat donors were compared.
The residual risk of HCV declined over the last decade due to improved screening reagents, implementation of the nucleic acid amplification test, and tight application of strict donor selection procedures. Current residual risk estimates for HIV and HCV in Korea are extremely low, but the risk for HBV is still high; therefore, urgent measures should focus on decreasing the residual risk of HBV. Despite the introduction of more sensitive assays in blood screening, several other factors may influence the actual residual risk of transfusion-transmitted infection. A continuous monitoring of residual risk of transfusion-transmitted infection is crucial in managing blood safety.
The realization that human immunodeficiency virus (HIV) can be transmitted through transfusion mobilized huge public concern for blood safety in the 1980s. Testing donations with advanced technologies and excluding donors at high risk of infection have reduced the risk of infectious donations entering the blood supply. The risk of transfusion-transmitted infection persists, however, mainly due to blood donations collected during the window period.
A precise estimate of the transfusion risk of viral infection will help to monitor transfusion safety, to assess the value of new screening interventions, to analyze the effects of current safety measures, and to assist in developing public health policy. Furthermore, an accurate estimate of residual risk can help inform evidence-based decisions in terms of prioritizing limited resources for hepatitis B virus (HBV), which is more prevalent in Korea than in countries such as the United States, Canada, the UK, and some other European nations.
Current estimates of the residual risks of transfusion-transmitted infection with HIV, hepatitis C virus (HCV), and HBV in Korea are drawn from old studies that only examined donors for short periods of time [1]. Therefore, we estimated the risk of HIV, HCV, and HBV in blood donations collected in Korea between 2000 and 2010. This information may be useful in adapting the national policy for blood transfusion, as well as in deciding among interventions targeted at blood safety.
Estimates of the residual risk of transfusion-transmitted viral infection were based on the incidence/window model [2]. All donations collected between January 2000 and December 2010 at the Korean Red Cross Blood Center were included in this study. Data included the number of blood donations, the number of donors who donated blood at least twice during each two-year period, the sum of intervals (in days) between the first and last donation for each donor, the number of donors that made a negative blood donation followed by a positive donation (seroconvertors), the sum of intervals (in days) between the positive and negative donations for seroconvertors, the number of confirmed positive donations, the screening assays, the methods used to confirm donations, and donation history.
A residual risk of transfusion-transmitted infection persists despite the adoption of stricter donor selection criteria and continuous improvements in the performance of screening assays. This risk is mainly linked to donations in the window following a recent, undetected infection. The residual risk of transmitting HIV, HCV, or HBV during a blood transfusion was estimated between 2000 and 2010. An incidence/window period model was used to estimate the residual risk. A mathematical model to quantify viral nucleic acid concentrations was developed in the early 2000s, when most developed countries began nucleic acid testing (NAT) for donations [11]. NAT for HIV and HCV in Korea was commenced in February 2005. 10 HIV and 19 HCV NAT yield donations were identified between 2005 and 2010 among 14,246,270 donations. Since the average yield per year was extremely low, the method of Schreiber was used in this study even though it may over-estimate the incidence density.
Korea has a moderate to high risk of HBV [28]. HBsAg-positive rate reached 4.6% in Korean residents aged 10 and older in 1998, and the prevalence dropped gradually to 2.9% in 2010 [29]. However, the prevalence of HBV is still substantially higher than those in other developed countries. Since introducing the hepatitis B virus vaccine in 1985, the prevalence of immunized residents aged 30 and older has reached 58.0%. One study showed that the positive rate of anti-HBs was approximately 80% in young patients [30]. The universal vaccination of HBV since 1995 will contribute to the reduction of residual risk of HBV in Korea. Thus, the actual transmission of HBV from a transfusion is likely lower than the estimated residual risk.
The residual risk of HCV declined over the last decade due to improved screening reagents, implementation of the nucleic acid amplification test, and tight application of strict donor selection procedures. Current residual risk estimates for HIV and HCV in Korea are extremely low, but the risk for HBV is still high; therefore, urgent measures should focus on decreasing the residual risk of HBV. Despite the introduction of more sensitive assays in blood screening, several other factors may influence the actual residual risk of transfusion-transmitted infection. A continuous monitoring of residual risk of transfusion transmitted infection is required to manage blood safety.
Foetal/neonatal alloimmune thrombocytopaenia (NAIT) results from maternal alloimmunisation against foetal platelet antigens inherited from the father and different from those present in the mother, and usually presents as a severe isolated thrombocytopaenia in otherwise healthy newborns. The incidence has been estimated at 1/800 to 1/1 000 live births. NAIT has been considered to be the platelet counterpart of Rh Haemolytic Disease of the Newborn (RHD). Unlike RHD, NAIT can occur during a first pregnancy. The spectrum of the disease may range from sub-clinical moderate thrombocytopaenia to life-threatening bleeding in the neonatal period. Mildly affected infants may be asymptomatic. In those with severe thrombocytopaenia, the most common presentations are petechiae, purpura or cephalohaematoma at birth, associated with major risk of intracranial haemorrhage (up to 20% of reported cases), which leads to death or neurological sequelae. Alloimmune thrombocytopaenia is more often unexpected and is usually diagnosed after birth. Once suspected, the diagnosis is confirmed by demonstration of maternal antiplatelet alloantibodies directed against a paternal antigen inherited by the foetus/neonate. Post-natal management involves transfusion of platelets devoid of this antigen, and should not be delayed by biological confirmation of the diagnosis (once the diagnosis is suspected), especially in case of severe thrombocytopaenia. Prompt diagnosis and treatment are essential to reduce the chances of death and disability due to haemorrhage. Due to the high rate of recurrence and increased severity of the foetal thrombocytopaenia in successive pregnancies, antenatal therapy should be offered. However, management of high-risk pregnancies is still a matter of discussion.
These cases require close monitoring until an adequate platelet count is reached. Usually, platelet transfusion is not necessary, as the platelet count increases rapidly. Alternatively, in case of severe drop in the platelet count, the management described above should be considered. In some cases, intravenous IgG (1g/kg/day for 2 days) may be used to raise the platelet count. 041b061a72