A colleague in Florida reports that his hospital's new Liver Transplant program is experiencing a significant wastage of RBC units. With four transplants completed to date, they have discarded 11 RBC's. Currently, they do not have a refrigerator in their OR, but they do supply the OR at the beginning of each transplant surgery with 10 units of RBCs and 10 units of FFP in an insulated 'cooler' in which is placed frozen ice packs. (Interestingly, the Transfusion Service is on the same floor and less than a one-minute walk from the surgical suites.) In spite of the proximity of their blood bank to the OR, the insulated cooler is kept in OR during the entire procedure and new units of FFP and RBC's are added to the cooler, as needed. When returned to the blood bank, the temperature of the blood products within the cooler exceeds 10C. Consequently, they must discard the unused blood products that have warmed up above 10C. The inquiring colleague would like to know how other Liver Transplant programs handle supplying blood products to the surgery suite to minimize wastage of RBC units.

The following comments have been received.

ADDENDA May 25, 2004

1. A colleague reports that at her hospital in Southern California, they treat liver transplants like they do their other surgery cases. They use validated coolers in which they place wet ice and the RBCs. The coolers are labeled with a 4-hour expiration, and the OR staff will bring the cooler back to the blood bank for recharging, if needed. All RBC put in the coolers have a Saf-T-Vue^® indicator applied. The responding colleague reports that generally this system works well. The main complaint is that a cooler with 6-10 units of RBC and a large bag of ice is pretty heavy. They used to have monitored refrigerators in several of the larger operating suites, but poor compliance (not taking the temperatures and placing non-blood items in the refrigerators) caused them to revert to coolers.

ADDENDA May 26, 2004

2. A transfusion medicine physician in Chicago reports that his hospital has three portable small blood refrigerators on wheels which they use for liver transplants and massive trauma cases. The inside dimensions are about 2 ft high x 1.5 ft wide x 1.5 ft deep, and they have an audible alarm and a temperature chart. One portable refrigerator is used per case and is loaded with the initial blood order, and then placed in the OR or just outside the room. Leftover units usually go to the ICU with the patient for several hours after the transplant.  He adds that they can also use these refrigerators for dedicated single-patient storage, to isolate highly biohazardous (eg, HIV+) autologous units issued to the OR.  They also convert their thawed FFP to 5-day thawed plasma, which reduces waste of the thawed plasma.

ADDENDA May 27, 2004

3. A Blood Bank Supervisor at an academic center in Arizona reports that her hospital has performed approximately 200 liver transplants. Initially they used calibrated coolers to store blood in the ORs, but found that the temperature was not sustained beyond 4 hours, just like the Florida hospital's experience. Consequently, they installed an under-the-counter blood refrigerator in an equipment room next to the liver transplant OR suite. This refrigerator is monitored by the blood bank staff. It is kept locked at all times, other than during a liver transplant case, to avoid the temptation by the OR staff to store blood products for other patients in it. The lab staff transports the liver transplant patient's blood to and from this dedicated refrigerator. (There is also a large O.R. blood refrigerator for use for all routine surgical cases that is monitored by the blood bank staff.)

ADDENDA June 1, 2004

4. The transfusion service medical director at the USC University Hospital in Los Angeles reports that his hospital uses a cooler system for most bood-utilizing surgeries, including liver transplantation. The coolers have a standardized ice pack that screws into the lid, and have been carefully QCed to maintain the blood temperature at desired levels for a fixed period of time. In addition, an irreversible "temperature dot" indicator is affixed to each unit to indicate whether the unit was ever warmed above 10 degrees C. The time that the cooler leaves the blood bank is monitored by the blood bank. The blood bank also takes responsibility for exchanging the ice packs at a certain time interval, if necessary, to ensure the temperature of the blood remains within acceptable limits. A full cooler means that blood is instantly available, which significantly reduces stress in the OR and the blood bank. Wastage has never been a problem. The system has proven to be safe and has been received enthusiastically by the surgical teams.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator