Quality Systems in Automated Plateletpheresis inHospital-Based Blood Transfusion Service in North

India

Rajendra Chaudhary,* Sudipta Sekhar Das, Prashant Agarwal, and Jai Shanker Shukla

Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

The issues of providing quality blood products and maintaining donor safety are primary aims of bloodtransfusion services. A comprehensive quality system should be in place to fulfill these aims, which can beattained through strict adherence to the established standard operating procedures (SOPs). The Drugs andCosmetics Act of India, which controls the licensing of blood transfusion services, does not provide clearguidelines regarding plateletpheresis procedure. We, therefore, established our own SOP and operationalflow chart for plateletpheresis that can be easily followed by other centers in India. A total of 100 plate-letpheresis procedures performed using two cell separators (CS3000 Baxter Healthcare, Round Lake, IL;MCS3p, Haemonetics Corporation, Braintree, MA) were evaluated following our established SOP. Themean platelet yield in CS3000 was 2.9 ± 0.84 · 1011 and in MCS3p it was 2.88 ± 0.75 · 1011 per unit.However, only 4–7% of SDPs showed WBC levels <5 · 106 due to lack of appropriate methods toquantitate residual WBC counts. Six of 100 donors complained of hypocalcemic symptoms. The operationalflow chart designed in this study was found to be simple and easy to adapt by blood transfusion services inthis country. J. Clin. Apheresis 20:81–85, 2005 � 2005 Wiley-Liss, Inc.

Key words: donor safety; standard operating procedure; quality control

INTRODUCTION

Providing of quality blood products to the patientsand the safety of the blood donors are the primeobjectives of blood transfusion services. To fulfill theseobjectives and to adhere to the current good manu-facturing practices (cGMP) and current good labora-tory practices (cGLP), a comprehensive quality systemand laboratory environment are essential [1]. Withincreased complexity of transfusion practices repre-senting everything from donor selection to the trans-fusion of blood products, the chances of clerical errorsand manufacturing errors have increased [2]. With anincreasing number of indications like leukemia,aplastic anemia, peripheral stem cell transplant, livertransplant, cardiovascular surgery, and infectiousdiseases, the demand for single donor platelets (SDP)has increased [3]. The transfusion specialists are notonly concerned with the collection of such productsbut also optimizing these in terms of balancing ofplatelet yield versus donor post-donation hematolog-ical changes [4,5]. The main aim is to obtain a high-quality platelet product simultaneously ensuring do-nor safety. All these constraints compelled theapheresis center to set their standard operating pro-cedures (SOPs), to train operators, make flow charts,and document the activities. The SOPs so written mustbe complete, clear, understandable, and duly followed

so as to establish the plateletpheresis procedures. Mostof the apheresis centers document their activities usingcomputerized work sheets to validate and checkquality of both the procedures and the products.

In India, because of economic constraints, SDPproducts are not in demand. However, ours being atertiary care hospital having transplantation andoncology units, the demand for SDP is increasing.The majority of blood donors in our center are firsttime donors whose serological status for transfusion-transmitted infections and ABO/Rh is unknown.Therefore, we have to develop our own protocols forquality system in plateletpheresis suited to the bloodtransfusion services in India.

MATERIALS AND METHODS

Study Population

A total of 100 plateletpheresis procedures wereevaluated, 50 each using two cell separators (CS3000,

*Correspondence to: Rajendra Chaudhary, MD, Dept of Trans-fusion Medicine, SGPGIMS, Lucknow 226 014, India. E-mail:rkcchaud@sgpgi.ac.in

Received 28 December 2004; Accepted 14 February 2005

Published Online in Wiley InterScience(www.interscience.wiley.com)DOI: 10.1002/jca.20056

Journal of Clinical Apheresis 20:81–85 (2005)

� 2005 Wiley-Liss, Inc.

Baxter Healthcare, Round Lake, IL, and MCS3p,Haemonetics Corporation, Braintree, MA) fromJanuary 2004 to November 2004 following the oper-ational protocol as depicted in Figure 1. Procedureswere performed by trained resident medical doctorsand nurses after written consent from the donor isobtained.

Cell Separators and Procedures

Plateletpheresis procedures were performed onMCS3p maintaining a maximum draw rate of 50 ml/min, anticoagulant (ACD-A) ratio of 12:1, andplatelet collection setting at 85% with the optics set tocollect maximum platelets. Return flow rate was 70 to90 ml/min and the end point was either a target vol-ume of 280 to 300 g platelets as displayed by themachine or a processing time of approximately 90min, whichever is earlier. Procedures were performedon CS3000 using TNX-6 separation chamber withinterface offset (IO) of 6. Blood flow rate for all col-lections was maintained at 40 to 50 ml/min withanticoagulant (ACD-A) ratio of 12:1. The end pointwas the target yield of 3 · 1011 platelets per unit.Leukoreduction techniques, either using in line or offline filters or by adjusting the IO, were not practicedfor any procedure. The collection efficiency (%) ofeach cell separator was calculated using the followingformula.

Sampling and Quality Control

Approximately 2 ml of sample was collected in theEDTA vial after thorough stripping of the segmentsattached to the bag. Analysis was done on an auto-mated cell counter (Micros 60, ABX Diagnostics,France) after thorough mixing of the sample in bloodmixer (Techno FAB, India). A Fuchs Rosenthalhemocytometer was used to quantitate residualWBCs.

Statistical Analysis

Data are presented as mean ± SD. All other sta-tistical comparisons were done using the two-tailed t-test. A P value of <0.001 was considered significant.

Methods

1. Donor selection:Weight ‡50 kgDonor questionnaire and examination by the residentdoctor• Normal pulse, BP, respiratory rate (rest for 30 minif abnormal)

• Good accessible venous access (single arm ordouble arm procedure)

• Hemoglobin ‡ 12.5 gm/dl (CuSO4 technique)• Platelet count ‡ 150 · 103/ul (standardized auto-mated analyzer)

• Serological marker testing (HIV, HBsAg, HCV,VDRL, malaria)

• ABO & Rh grouping (should be identical to therecipient), if not consult in-charge apheresis unit.

2. Donor activities:• Encourage donor toDrink some waterLoosen tight clothingLie on donor couch comfortably

3. Procedure and donor monitoring: by resident doctorPhysical inspection of apheresis kitInstallation of kitCheck for kink or wrong installDonor phlebotomyStart procedureDonormonitoring (pulse, respiration, any discomfort)Documentation

4. Post-donation activities:Donor evaluation and suggestion:

• Examination of vitals, e.g., BP, pulse, respiration.• Any discomfort, e.g., Perioral paraesthesia• Rest on the donor couch for 10 min• Refreshment• Compliments• Report any adverse reactions

Post-donation donor blood counts & documentation• Hemoglobin• Platelet counts

Documentation of displayed values of machine:• Blood volume processed (ml)• ACD volume (ml)• Platelet collection (g)• Duration of procedure (min)

Efficiency (%) ¼ platelet yield per SDPð�1011Þ � 100

½ðdonor pre donation PLTþ donor post donation PLT) / 2 ] �blood volume processed (ml)� conversion factorð109=LÞ

82 Chaudhary et al.

Quality control of product & documentation• Volume (ml)• Platelet yield (·1011)• WBC contamination (standardized automatedanalyzer and Fuchs-Rosenthal HemocytometerChamber, Germany)

• RBC contamination• Swirling• Serological marker testing (HIV, HbsAg, HCV,VDRL, Malaria)

Labeling of product:• Product name• Unit number

• Date of collection• Date of expiry• Name of the patient• Blood group• Signature of the resident doctor

Storage of product:• Flat surface for 30 min at 22�C initially, then• Agitator at 22�C till issue

Manipulation of product:Plasma depletion

• If ABO mismatched donor• Deplete autologous plasma and replace with ABplasma

Fig. 1. Operation flow chart of plateletpheresis.

Quality Systems in Plateletpheresis 83

• QC of product: loss of platelets, bacterial culture• Appropriate label on bag• Documentation

Irradiation• If indicated• Just before issue• Entry in irradiation protocol• Irradiation label on bag

Leukodepletion• As indicated• QC of product: loss of platelets, log reduction ofWBC

Issue of product:• Physical examination of bag just before transfusion• Review of the reaction form to confirm identifica-tion

• Entry in issue register

RESULTS

Following the protocol described in Figure 1, 100plateletpheresis procedures were performed on heal-thy donors. Table 1 shows cell separator–relatedmeasurements. Except for mean blood volume pro-cessed, which was significantly higher in CS3000 (3.8± 0.70 L) compared to MCS3p (2.93 ± 0.34 L), therewere no significant differences between the cell sepa-rators used with regard to other parameters. Thequality of the SDP products collected by the cellseparators is depicted in Table II. The platelet yieldvaried from 2.88 ± 0.75 · 1011 (mean) with MCS 3pcell separator to 2.9 ± 0.84 · 1011 (mean) withCS3000. WBC levels were <5 · 106/bag in 4% (MCS3p) to 7% (CS3000) of SDPs. There were 5 SDPs,which were ABO mismatched with the recipient and,

therefore, subjected to plasma depletion and additionof AB plasma as per the operational flow chart de-scribed.

Six of the 100 donors (6%) complained of circu-moral tingling sensations that could be well managedwith a glass of milk or calcium supplementation. Notransfusion-related side effects were reported with anyof the SDP.

DISCUSSION

Plateletpheresis is now becoming a routine proce-dure in most of the blood centers in developingcountries. The mandate of cGMP and cGLP neces-sitates reduction in errors by improved managementof the entire system so as to ensure donor safety and aquality product for the transfusion recipient. Differ-ent centers use different cell separators, each havingits own mechanism of operation needing validationand quality control to assure the production ofacceptable products. Therefore, it is incumbent uponevery center to establish its own Standard OperatingProcedures (SOP) as per the cell separators used andthe existing donor population. Such SOPs are to bestrictly followed to achieve the desired goal.

At our center, two cell separators (CS3000, Baxterand MCS3p, Haemonetics) are in use for the collec-tion of SDPs. We have established the SOP ofplateletpheresis as described in Materials and Meth-ods, taking into consideration the demographic pro-file of our donor population and quality of theproduct obtained. It may differ from those in thedeveloped countries due to differences in donordemographics. For instance, pre-screening for trans-fusion-transmitted infections and pre-procedure

Table I. Comparison of Cell Separator Related Parameters During Plateletpheresis

Parameters Units CS3000 [n = 50] mean ± SD MCS3p [n = 50] mean ± SD P value

Blood volume processed Lit 3.8 ± 0.7 2.9 ± 0.34 <0.001Apheresis time Min 82.5 ± 18.1 93.9 ± 18.5 NSCollection volume ml 200.6 ± 14.6 274.5 ± 37.9 NSACD volume ml 309 ± 56.4 274.5 ± 35.2 NS

NS: Not significant.

Table II. Quality Assessment of SDP Obtained Using Two Cell Separators

Parameter Unit CS3000 [n = 50] Mean ± SD (Range) MCS3p [n = 50] Mean ± SD (Range) P Value

Platelet count in bag ·1011 2.9 ± 0.84 (1.9–5.7) 2.88 ± 0.75 (2–4.98) NSLeukocytes in bag ·106 5.33 ± 9.5 (2–16.2) 6.07 ± 47.1 (2.2–18.9) NSRed cells in bag ·109 11.2 ± 8.6 (0 – 15.9) 13.7 ± 14.1 (0–22.1) NSEfficiency rate % 55.6 ± 14.3 (39.3–61.6) 60.4 ± 9.1 (57.2–63.6) NS‡ 3 · 1011 % 41.6 39.3 NS‡ 2 · 1011 % 96 100

NS = Not significant.

84 Chaudhary et al.

typing for ABO and Rh may not be done in devel-oped countries as a majority of their plateletpheresisdonors are repeat donors.

According to the American Association of BloodBanks 1999 [6], 75% of the SDPmust contain ‡3 · 1011

per unit while the Council of Europe 1992 [7] recom-mends platelet count ‡2 · 1011 per unit. These levelshave been determined to provide the desired hemo-static platelet doses to the recipient. No such guidelinesfor platelet yield in SDP are available in the Drugs andCosmeticsAct [8], which controls the licensing of bloodtransfusion services in India. So, it becomes difficult toensure uniformity in the quality of SDP in terms ofplatelet yield throughout the country. We found amean platelet yield of 2.9 ± 0.84 · 1011 in the CS3000compared to 2.88 ± 0.75 · 1011 with MCS3p, which isless than the standards of AABB. Approximately 40%of SDPs obtained by both machines met the AABBrequirement of ‡3 · 1011 per unit, while almost 100% ofSDPs met the European guidelines (Table II). There-fore, the guidelines established by the Council of Eur-ope may be suitable for India and other developingcountries tomonitor the quality of SDPs.However, theclinical outcome of such a transfusion practice needs tobe investigated. As there are no studies on this subjectfrom India, no comparisons of our results can be done.Approximately, 7% of SDP obtained by CS3000 and4% obtained by MCS3p contained WBC<5 · 106 perunit. However, it must be noted that the use of aNageotte hemocytometer is not possible due tounavailability in India. The Fuchs Rosenthal hemo-cytometer is intended for WBC counts in spinal fluidand does not hold the larger sample volume of theNageotte. The residual WBC counts may be higherthan might be expected based on literature values. Theefficacy of different cell separators with regards toleukodepletion varies considerably. The newer ma-chines like Amicus (Baxter) and COBE Spectra(Gambro) give a consistently leuko-depleted productwhile CS3000 and MCS have a 95% failure rate [9].However, better results can be achieved using on-linefilters or by adjusting the IO position as in CS3000 [3].The Drugs and Cosmetics Act of India provides nospecific guidelines regarding leuko-depletion. Theresults of this study will help to monitor the quality ofSDP and will ensure a clinically efficacious bloodproduct to the recipient.

Minor ABO mismatch between donor plasma andthe recipient’s red cell antigens can cause intravascu-lar hemolysis [10,11]. This has led to the practice of

issuing ABO-matched SDP to the patients in manycenters, including ours. In the absence of group-spe-cific donors, ‘‘O’’ group SDP can be issued providedsupernatant plasma is replaced with AB plasma, ashas been successfully done in 5 of our ABO minormismatched SDPs. However, there is a concern aboutplatelet loss during plasma depletion. This has beencalculated to be about 12% at our center.

In order to decrease the chances of errors andincrease donor safety and the quality of the endproduct, an efficient quality management systemshould be in place of which SOP and documentationsare essential parts. The record-keeping system,documentation, and SOP we prepared for SDP isproducing the desired results in the form of a better-quality product and maintaining donor safety. It can,thus, be adapted to other centers as there are nostandards available from the Drugs and CosmeticsAct of India for plateletpheresis.

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