The Coronavirus Emergency and the US Blood Supply: College of American Pathologists Transfusion, Apheresis and Cellular Therapy Committee

Most US hospital transfusion services have been notified recently by their blood suppliers about major concerns for the national blood supply during the coronavirus disease 2019 (COVID-19) pandemic. With large segments of our society shutting down, most blood drives are being cancelled and many donors are unable to travel to blood centers to donate. Elective surgeries are being widely postponed, but many emergency surgeries and lifesaving procedures will still continue.

As we face the possibility of a severe blood shortage at the same time hospitals are preparing for large numbers of COVID-19 patients, the CAP Transfusion, Apheresis and Cellular Therapy (TACT) Committee offers the following considerations for hospital transfusion services.

Laboratory Measures

• Closely communicate with your blood suppliers and monitor your blood inventory carefully.
• Expand prospective review of blood component orders for compliance with criteria.
• Avoid unnecessary use of group O RBCs, and especially O D-negative RBCs. Convert emergency uncrossmatched-transfusion patients to type-specific blood components as soon as possible after blood type confirmation.
• Reduce blood wastage as much as possible in your transfusion service and in your clinical areas.
• Update your surgical crossmatching protocol to reduce over-crossmatching.

Transfusion Practice Measures

• Promote adherence to transfusion guidelines from your transfusion committee, your blood provider or from published sources such as AABB.
• For stable anemic patients, encourage transfusion of one RBC unit at a time, then reassessment of further need.
• Consider the potential need to issue partial platelet doses to stretch platelet supplies.
• Encourage good perioperative blood management practices, including preoperative anemia and coagulopathy correction, perioperative RBC salvage, and expanded hemostasis testing for transfusion decision support (stat labs or viscoelastometry).
• Plan for the possibility of needing to adopt more restrictive transfusion criteria to conserve your blood supply if necessary. For example, the March 2020 Canadian Blood Services plan for critical blood shortages includes reviewing all RBC requests when the hemoglobin level is >6 g/dl and eliminating prophylactic platelet transfusions in non-bleeding hematology-oncology patients (1).
• Communicate with clinicians and hospital medical leadership about planning for a severe blood shortage and which types of patients would have the highest transfusion priority. This process may include the hospital transfusion committee.
• For hospitals performing extracorporeal membrane oxygenation (ECMO) for respiratory failure, consult with the ECMO service about their COVID-19 plans, patient capacity and anticipated transfusion needs.

Pharmacologic Hemostasis

• Promote urgent warfarin reversal with prothrombin complex concentrate instead of plasma.
• Consider the option of replacing cryoprecipitate, if supplies become depleted, with fibrinogen concentrates. The two licensed US products, RiaSTAP® (CSL Behring) and Fibryga® (Octapharma), are approved only for rare congenital low-fibrinogen conditions, and treatment of acquired hypofibrinogenemia would be off-label.

Blood Supply

• If feasible, facilitate blood drives at your hospitals. Consider the need for ongoing donations as the supply decreases, including future blood drives in addition to those already scheduled. Mobile blood collection sites should not pose concerns for SARS-CoV-2 transmission. Blood collection facilities are modifying their procedures to include appropriate distancing and other safety precautions.

Transfusion Safety and Potential Transfusion Therapy

• With regard to SARS-CoV-2 and transfusion safety, the Food and Drug Administration stated on 11 Mar 2020 that respiratory viruses, in general, are not known to be transmitted by blood transfusion, and there have been no reported cases of transfusion-transmitted coronavirus (2).
• Transfusion of convalescent plasma containing antiviral antibodies from subjects who have recovered from COVID-19 is being considered for clinical trials as an adjunctive treatment for COVID-19 patients.

Conclusion

The wide-ranging impacts of the COVID-19 epidemic on blood supply and demand are rapidly evolving. As further developments warrant, we will periodically update blood bank information on the CAP COVID-19 web page.

CAP Transfusion, Apheresis, and Cellular Therapy Committee
Glenn Ramsey, MD, FCAP, Chair (gramsey@nm.org), Monica B. Pagano, MD, FCAP, Vice-Chair, Joanne L. Becker, MD, FCAP, Mary Berg, MD, FCAP, Julie L. Cruz, MD, FCAP, Kristina A. Davis, MD, FCAP, Robert DeSimone, MD, FCAP, Nicole Draper, MD, FCAP, Jay P. Hudgins, DO, FCAP, Matthew S. Karafin, MD, FCAP, Nicole L. LePage, MD, Ryan Metcalf, MD, FCAP, Tammon A. Nash, MD, FCAP, Yara A. Park, MD, FCAP, Meredith A. Reyes, MD, FCAP, Susan N. Rossman, MD, PhD, FCAP, Joseph Schwartz, MD, MPH, Zbigniew M. Szczepiorkowski, MD, PhD, FCAP, Lynne Uhl, MD, FCAP

References

1. National Advisory Committee on Blood and Blood Products. The national plan for management of shortages of labile blood components. Canadian Blood Services, 16 Mar 2020. Available at: https://www.nacblood.ca/resources/shortages-plan/index.html 
2. Information for Blood Establishments Regarding the Novel Coronavirus Outbreak. Food and Drug Administration, 11 Mar 2020. Available at: https://www.nacblood.ca/resources/shortages-plan/20200320 The National Plan for Management of Shortage of Labile Blood.pdf