‘National plan required for blood transfusion amidst increased demand’

• Official calls for disaster management plan and emergency preparedness protocols
• Attention needed on transport aspect at Blood Bank/Blood Transfusion Service 

BY Ruwan Laknath Jayakody 

In light of Sri Lanka experiencing national level disasters in the form of the Easter Sunday terrorist attacks in 2019 and the ongoing Covid-19 epidemic situation, there is a need to establish a disaster management plan and pre-organised protocols as far as the blood transfusion services are concerned for the purpose of emergency preparedness to deal with the increased demand for blood products. 

Towards achieving this end, it is important to gather information from past experiences, published guidelines, checklists and research data, and to conduct awareness and training programmes, along with the regular review of such protocols. 

These points were mentioned in a letter to the Editors of the Sri Lanka Journal of Medicine titled “Managing transfusion service in disasters” which was authored by E.M.S.K. Senavirathna who is attached to the National Blood Transfusion Service, and which was published in the said Journal’s 30th Volume’s First Issue on 1 July 2021. 

During mass casualty events that occur due to natural disasters or human activity, as noted in the “Disaster operations handbook” by J. Blietz, B. FitzGerald, G. Ramsey, R. Sylvester and W. Trivisonno, a considerable number of casualties could be admitted to the trauma units in health care facilities, thus posing challenges to providers of health care services. In particular, the majority of trauma patients require blood components for their survival as the use of blood is essential for a patient who is bleeding, as blood cannot be replaced by, as pointed out in M.F. Murphy, D.H. Pamphilon and N.M. Heddle’s “Practical transfusion medicine”, any pharmacological agent, and nor can they be synthetically produced. Furthermore, Senavirathna explained that in the case of patients presenting with multiple injuries, they frequently experience major haemorrhage, thus requiring massive blood transfusion in which all blood products, and not just the replacement of red blood cells, are of vital essence. This is due to the fact that simple volume replacement with fluids does not improve the tissue oxygenation in the case of significant haemorrhage, Senevirathna elaborated. 

Therefore, Senavirathna further explained that managing a disaster is critical for transfusion services as blood components are scarce resources that have a limited supply due to not being able to be artificially produced and also because blood products have a limited shelf life and therefore maintaining an extra stock could result in increased wastage owing to expiration. The aspects that a transfusion service is responsible for, includes, as pointed out by Senevirathna, ensuring the availability, quality, safety and accessibility of blood products. For this purpose, an action plan to work together with the national emergency preparedness and response plan is required. 

Case scenario 

The suicide bombings on 21 April 2019 Easter Sunday, targeting several churches and hotels caused deaths and injuries in the triple digit range. The injured victims were brought to hospitals including the Accident and Emergency Department of the National Hospital, the Lady Ridgeway Hospital for Children, and the Batticaloa Teaching Hospital, A significant number of blood products were issued by the respective blood banks (as per the Statistics Report of the National Blood Transfusion Service, the blood bank of the Accident and Emergency Department of the National Hospital, issued 131 units of red cells, 70 units of fresh frozen plasma {FFP which is a blood product made from the liquid portion of blood and is used to treat conditions in which there are low blood clotting factors or low levels of other blood proteins}, and 62 units of platelets {forms clots and stops bleeding} while the blood bank issued 22 red cell units to the Batticaloa Teaching Hospital). 

During the said man-made disaster, even though blood products were redistributed from unaffected areas and there were voluntary blood donors at the blood bank, there were human resources and equipment related limitations which hindered the process. This was specifically the case when it came to handling blood donors. Since blood bank staff was mainly involved in the process of the provision of blood, the large crowds that came to donate blood could not be managed by the blood bank. The situation took an about turn as owing to the curfews and other regulations imposed and enforced by the Government in the weeks following the attacks, the number of donations experienced a drastic reduction, thus resulting in critical blood stock levels, which in turn required public awareness programmes so as to improve the blood stocks. 

At a health care institute, where those casualties are managed, professionals face many problems. In order for health care professionals to manage large numbers of casualties in natural (earthquakes, floods, tsunamis, landslides) or man-made (motor traffic accidents, bomb attacks) disaster situations, proper planning in every related discipline is required. 

Massive haemorrhage is defined by B.J. Hunt, S. Allard, D. Keeling, D. Norfolk, S.J. Stanworth and K. Pendry in “A practical guideline for the haematological (blood) management of major haemorrhage” as the loss of one blood volume in 24 hours or the loss of 50% of the blood volume in three hours or blood loss at a rate of 150 mililitres per minute. D. Harmening’s “Modern blood banking and transfusion practices” mentions that during massive transfusion, there is coagulopathy (a condition where the blood’s ability to clot is impaired and is also caused when the dilution of coagulation factors with volume replacement during fluid resuscitation leads to coagulation factor deficiency, a condition which is aggravated if the patient is treated only with red cells) secondary to tissue injury, hypoperfusion (reduced amount of blood flow), dilution and the consumption of clotting factors and platelets, adding that the combination of coagulopathy, hypothermia (when the body loses heat faster than it can produce heat, thus causing dangerously low body temperature), and acidosis (too much acid in the body fluids) negatively impacts the patient’s outcome. Hypocalcaemia (low level of calcium in the blood) is another related complication, Senevirathna notes. 

In the case of red cell transfusion, which is important for tissue perfusion (the passage of fluid through the circulatory system or lymphatic system to an organ or tissue), red cell transfusion should not be delayed. If the situation is extremely urgent as far as the need for immediate blood transfusion is concerned and the patient’s blood group is not known, Hunt et al., explain that it is acceptable to issue Group O (universal donors) un-cross matched red cells. However, finding out the blood group of the patient can be done within a few minutes and should be done as soon as possible so as to reduce the issuing of Group O red cells, Senevirathna adds. “In such emergency situations, female patients of reproductive age must be provided with Group O Rhesus (Rh) D negative red cells so as to avoid Rh D sensitisation. ABO Group specific red cells can be given when the patient’s blood group is identified. According to S. Robinson, A. Harris, S. Atkinson, C. Atterbury, P. Bolton-Maggs, C. Elliott, T. Hawkins, E. Hazra, C. Howell, H. New, T. Shackleton, K. Shreeve and C. Taylor’s ‘The administration of blood components: a British Society for Haematology guideline’, the rapid rate of administration of red cells than the normal rate is usually practiced in such an emergency situation. Hunt et al., further explain with regard to platelets that the count should be maintained above the critical level of 50 into/multiplied by 109/litres (l) in the case of massive haemorrhage and that therefore, platelet transfusion can be considered if the count is 75 into/multiplied by 109/l. The transfusion of FFP is essential in massive blood transfusion,” Senavirathna further added.

Therefore, Senavirathna emphasised that early communication with all clinical specialties is essential in such situations, and that in this regard, permanent local protocols for the management of massive haemorrhage should be made available in all hospitals while all relevant staff must be educated about the protocols through the conduct of periodical drills along with the performance of regular reviews to assess deficits and to update such accordingly.

Senevirathna also elaborated on the importance of positive patient identification in the transfusion practice as the transfusion of incompatible blood causes transfusion reactions, which could even prove fatal. This is a major challenge in mass casualty incidents, where most of the time, the patients’ identification cannot be achieved with their names. For this purpose, Senevirathna recommended the use of a clearly visible identification number. C. Milkins, J. Berryman, C. Cantwell, C. Elliott, R. Haggas, J. Jones, M. Rowley, M. Williams and N. Win noted in “Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories” that in an unconscious patient, the minimum patient identifiers include the unique number and gender. Moreover, E.J. Dann, L. Bonstein, L. Arbov, A. Kornberg and N. Rahimi-Levene’s “Blood bank protocols for large scale civilian casualty events: experience from terrorist bombing in Israel” recommends large sized printed numbers, wrist bands and barcodes for positive patient identification.

Dann et al.’s study noted that the majority of the approximately one third of hospitalised patients had received blood transfusions, during the first two hours with 10.2% of such undergoing massive transfusion. 

S.M. Glasgow, S. Allard, H. Doughty, P. Spreadborough and E. Watkins’s showed in “Blood and bombs: the demand and use of blood following the London bombings of 7 July 2005 – a retrospective review” that keeping only red cell concentrates would not be helpful in a mass casualty incident and that therefore having available, adequate amounts of all blood products is essential in managing bleeding trauma patients. Towards this end, Senevirathna emphasised further that if any blood bank cannot store such a considerable amount, there should be a centre nearby to get down the required quantities of blood products from, provided that the transport facilities are made available promptly. 

On the other hand, M.J. Lozada, S. Cai, M. Li, S.L. Davidson, J. Nix and G. Ramsey’s “The Las Vegas mass shooting: An analysis of blood component administration and blood bank donations” noted that putting out a call for blood donors is not urgently required as in their case, 17% of the blood collected on that day had been discarded. In short, Senevirathna proposed that strengthening routine blood collection as opposed to urgent blood collection through emergency donor calling is what is necessary, especially in view of the preparations to face future disaster situations. 

Also, K.E. Nollet, H. Ohto, H. Yasuda and A. Hasegawa’s “The great East Japan earthquake of 11 March 2011, from the vantage point of blood banking and transfusion medicine” emphasised the importance of coordinating among blood centres, and in particular, the nationally coordinated redistribution of blood components through preparedness and central coordination. Furthermore, H. Doughty, S. Glasgow and E. Kristoffersen’s “Mass casualty events: blood transfusion emergency preparedness across the continuum of care” and S. Glasgow, C. Vasilakis, Z. Perkins, S. Brundage, N. Tai and K. Brohi’s “Managing the surge in demand for blood following mass casualty events: early automatic restocking may preserve red cell supply” highlighted that having an automated computer based system to improve blood stock management would aid in redistribution to trauma centres alongside such centres having a computer simulation model to assist in making decisions regarding prioritisation. Inter centre coordination too has been observed by A. Simonetti, H. Ezzeldin, M. Walderhaug, S.A. Anderson and R.A. Forshee in “Planning for emergency preparedness and medical countermeasures”. 

Concerning the establishment of related protocols, A.N. Gschwender and L. Gillard noted in “Disaster preparedness in the blood bank” that a disaster plan should include aspects pertaining to the determining of the demand of the blood products, a communication plan, human resource management and donor recruitment.

The periodic review of guidelines and the system, which is a vital aspect in this regard, has allowed to, in the case of V. Caramello, O. Camerini, F. Ricceri, P. Ottone, G. Mascaro, R. Chianese, M. Bodas, J. Bierens and F.D. Corte’s “Blood bank preparedness for mass casualty incidents and disasters: a pilot study in the Piedmont region, Italy”, apply a checklist of the American Association of Blood Bank (AABB) which includes risk assessment, communication and coordination, blood inventory management, transportation facilities, the management of blood donors, safety and security, staff management, documentation, computerisation and the handling of the media, in the evaluation of disaster preparedness. 

In conclusion, Senevirathna observed that the issuing of a significantly higher number of blood units is not always possible without having a proper action plan in place and also that no hospital can work alone in the context of a mass casualty event, and that therefore, it is important to work with other institutes (as also noted in P. Melmer, M. Carlin, C.A. Castater, D. Koganti, S.D. Hurst, B.M. Tracy, A.A. Grant, K. Williams, R.N. Smith, C.J. Dente and J.D. Sciaretta’s “Mass casualty shootings and emergency preparedness: a multidisciplinary approach for an unpredictable event”). 

Although Sri Lanka has a nationally coordinated island-wide blood transfusion service, and communication has made blood redistribution easy, it was noted that the availability of sufficient transport facilities and the proper coordination of their service are aspects that should be looked into urgently.