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Out for Blood

Paul Ness runs Hopkins Hospital's Blood Bank, one of the nation's largest.
Two summers ago, attendings on the transfusion service held their breath each morning when they checked the OR schedule. That season, blood supplies were particularly anemic. The last thing they wanted to see was a big procedure that uses a boatload of blood, like a liver transplant, along with a patient with a rare blood type, like O negative or B negative. In the Blood Bank, when supplies are short, that kind of combination spells trouble.

With its medically complex patient population, The Johns Hopkins Hospital is by far the biggest user of blood in the region, if not the entire nation. It’s certainly at the top of the top 10, right up there with other big medical centers like Duke, Mayo and Mass General, says Paul Ness, medical director of the Blood Bank and director of Transfusion Medicine. Every year, Hopkins Hospital uses 45,000 units of red cells alone. That translates into 45,000 individual donors.

Blood supplies are lowest in the summer, on holiday weekends, and at Christmas and New Year’s—not because of an increase in trauma, but simply because fewer people are available to give, says Ness. He estimates that at least a third of the time, the hospital’s blood supply is lower than it should be. The ongoing shortage, combined with ever-pressing needs, has led the hospital to develop ways to manage its blood supply as efficiently as possible.

The latest example involves new technology at HATS (Hematopoietic and Transfusion Support Services). At the HATS donor center, specific blood components—red cells, platelets and plasma—are withdrawn and the remaining, unused components returned to the donor through a procedure called apheresis. “Apheresis is a better use of resources, and it’s increasingly common,” says Karen King, HATS medical director. “Transfusion medicine has moved to more specific therapy, known as component therapy, in which patients are given just what they need and nothing else.”

Tech Denise Caraballa with longtime donor George Rew at HATS blood donor center in JHOC, where new technology is making it possible to donate more.
The new automated technology will enable some donors to give, at one sitting, two units of red cells, the most commonly transfused blood component. (At blood centers or drives, donors give one unit of whole blood, which is then separated into components.) Most donors will be able to give one unit of red cells, plus a platelet product. Each day, on average, the hospital uses 123 units of red cells. HATS hopes to collect 10 units of red cells a day initially and then build upward.

HATS also plans to cultivate a donor base among employees, who are often especially sensitive to the need for blood. Potential donors will be carefully screened. Those with all blood types are encouraged to donate. With automated donation, collections can be targeted; donors can be matched to current Blood Bank needs.

All HATS collections go to the Blood Bank, where they are tested before being distributed exclusively to patients at Hopkins Hospital, along with products obtained from the Red Cross and other suppliers. HATS will continue to collect platelets—15,000 of these products are used each year, mostly to support cancer patients. “What we’re trying to do is collect some blood here at Hopkins that can supplement the supply we get from the Red Cross,” says Ness.

Already in place at Hopkins are programs that help stem the demand for blood. Chief among them is autologous donation, in which patients donate their own blood before elective surgery. “We’re one of the biggest users of autologous blood where it’s appropriate,” Ness says, adding that much of the planned surgery in urology and orthopedics is done with autologous blood. “Giving your own blood is probably the safest thing to do because even though the blood supply is incredibly safe in terms of infectious disease, there is still the rare breakthrough infection that comes across. And your own blood is yours immunologically. There’s no way you can make an antibody to it.”

As an institution, Hopkins has been aggressive in studying transfusion alternatives. Surgeons sometimes salvage the blood in the operative field, wash it, then return it to the patient. Ness, who is a past president of the American Association of Blood Banks (AABB) and current editor of Transfusion, the top journal in transfusion medicine, has teamed up with other investigators in Transfusion Medicine and Anesthesia to conduct clinical studies of hemodilution, a process in which blood is collected prior to surgery, replaced with a plasma expander, then returned to the patient. Others have evaluated blood substitutes and used techniques that expand blood volumes, with drugs like erythropoietin, for those who want to avoid transfusions.

Programs like these can ease Blood Bank pressures, including the daily grind of triaging cases that Ness finds so “draining.” “Let’s say you have a patient on the transplant list, waiting for a liver, and it comes in. You almost have the feeling that you’re going to haveto tell the transplant surgeons that you don’t know if you have enough blood to help them get it in. That really would be incredible. You can imagine the anxiety of the family waiting, or how the family giving that donor organ must feel.”

So far that hasn’t happened. But with supplies chronically low and demand soaring—one day it might.

—Anne Bennett Swingle

For more information on HATS’ automated donation, call 410-955-TIME.



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