Zbigniew M Szczepiorkowski

Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire, United States

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Publications (75)347.83 Total impact

  • [show abstract] [hide abstract]
    ABSTRACT: Background Our hospital transfusion policy was recently revised to recommend single-unit red blood cell transfusion (RBC TXN) for nonbleeding inpatients when the hemoglobin (Hb) level is not more than 7 g/dL. Our computerized provider order entry system was reconfigured to provide real-time decision support using prospective computerized order auditing based on the most recent Hb level and to remove the single-click ordering option for 2-unit RBC TXNs to enhance compliance. This study was undertaken to assess the impact of these changes on hospital transfusion practice.Study Design and Methods This study analyzed the total number of transfusion events, proportion of single and 2-unit transfusions and the Hb transfusion trigger in the preimplementation period (October 2011-March 2012) compared to the postimplementation period (October 2012-March 2013).ResultsIn the postimplementation period the total number of RBC units transfused/1000 patient-days decreased from 60.8 to 44.2 (p < 0.0001). The proportion of 2-unit TXNs decreased from 47% to 15% (p < 0.0001). We also observed significant decreases in pretransfusion Hb triggers.Conclusion Implementation of restrictive transfusion policy supported by prospective computerized order auditing has resulted in significantly decreased RBC utilization at our institution.
    Transfusion 04/2014; · 3.53 Impact Factor
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    ABSTRACT: The American Society for Apheresis (ASFA) conducted a 1 day consensus conference on Thrombotic Thrombocytopenic Purpura (TTP) during its annual meeting in Atlanta, GA, on April 10, 2012. The authors of this article, a subcommittee of ASFA's Clinical Applications Committee, developed several questions with regard to definitions, classification, pathophysiology, diagnosis, management, and future research in TTP. These questions were provided to the seven invited speakers who are the experts in the field of TTP. Two moderators conducted the proceedings of the conference which was attended by more than 100 participants. After each presentation, there was an open discussion that included moderator-selected written questions submitted by the audience. A medical writer-generated transcript of the proceedings as well as each presentation was made available to the authors. Each summary was reviewed and approved by the respective speaker before submission of this article. The subcommittee also developed seven key questions for blinded, electronic polling conducted by the moderators to generate a consensus amongst the speakers. This article includes these presentation summaries as well as results of the electronic poll. J. Clin. Apheresis, 2013. © 2013 Wiley Periodicals, Inc.
    Journal of Clinical Apheresis 10/2013; · 2.27 Impact Factor
  • Clinical Infectious Diseases 10/2013; · 9.37 Impact Factor
  • [show abstract] [hide abstract]
    ABSTRACT: The American Society for Apheresis (ASFA) JCA Special Issue Writing Committee is charged with reviewing, updating and categorizating indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approach in the grading and categorization of indications. This Sixth Edition of the ASFA Special Issue has further improved the process of using evidence-based medicine in the recommendations by consistently applying the category and GRADE system definitions, but eliminating the "level of evidence" criteria (from the University HealthCare Consortium) utilized in prior editions given redundancy between GRADE and University HealthCare Consortium systems. The general layout and concept of a fact sheet that was utilized in the Fourth and Fifth Editions, has been largely maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. This article consists of 78 fact sheets (increased from 2010) for therapeutic indications in ASFA categories I through IV, with many diseases categorized having multiple clinical presentations/situations which are individually graded and categorized. J. Clin. Apheresis 28:145-284, 2013. © 2013 Wiley Periodicals, Inc.
    Journal of Clinical Apheresis 07/2013; 28(3):145-284. · 2.27 Impact Factor
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    ABSTRACT: Transfusion of plasma and red blood cell (RBC) units in a balanced ratio approximating 1:1 has been shown in retrospective studies to be associated with improved outcomes for trauma patients. Our low-volume rural trauma center uses a trauma-activated transfusion algorithm. Plasma is thawed upon activation to avoid wastage. However, the time required for plasma thawing has made achievement of a 1:1 ratio early in resuscitation challenging. In this study, the time required for plasma thawing is characterized, and a potential solution is proposed. A retrospective chart study of 38 moderately and massively transfused (≥6 U in the first 24 hours) trauma patients admitted from January 2008 to March 2012 was performed. We evaluated the time required to dispense plasma and the number of RBCs dispensed before plasma in these patients. The average time between the dispense of RBCs and plasma was 26 minutes (median, 28; range, 0-48 minutes). The average number of RBCs dispensed before plasma was 8 U (median, 7 U; range, 0-24 U). Nearly one third of massively transfused patients had 10 RBCs or greater dispensed before plasma was available. There exists the potential for delayed plasma availability owing to time required for thawing, which may compromise the ability to provide balanced plasma to RBC transfusion to trauma patients. Maintenance of a thawed Group AB plasma inventory may not be operationally feasible for rural centers with low trauma volumes. Use of a thawed Group A plasma inventory is a potential alternative to ensure rapid plasma availability. Therapeutic study, level V.
    The journal of trauma and acute care surgery. 06/2013; 74(6):1425-31.
  • Larry J Dumont, Zbigniew M Szczepiorkowski
    New England Journal of Medicine 05/2013; 368(19):1848-9. · 51.66 Impact Factor
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    ABSTRACT: BACKGROUND: Clinical trials are investigating the potential benefit resulting from a reduced maximum storage interval for red blood cells (RBCs). The key drivers that determine RBC age at the time of issue vary among individual hospitals. Although progressive reduction in the maximum storage period of RBCs would be expected to result in smaller hospital inventories and reduced blood availability, the magnitude of the effect is unknown. STUDY DESIGN AND METHODS: Data on current hospital blood inventories were collected from 11 hospitals and three blood centers in five nations. A general predictive model for the age of RBCs at the time of issue was developed based on considerations of demand for RBCs in the hospital. RESULTS: Age of RBCs at issue is sensitive to the following factors: ABO group, storage age at the time of receipt by the hospital, the restock interval, inventory reserve, mean demand, and variation in demand. CONCLUSIONS: A simple model, based on hospital demand, may serve as the basis for examining factors affecting the storage age of RBCs in hospital inventories. The model suggests that the age of RBCs at the time of their issue to the patient depends on factors external to the hospital transfusion service. Any substantial change in the expiration date of stored RBCs will need to address the broad variation in demand for RBCs while attempting to balance considerations of availability and blood wastage.
    Transfusion 04/2013; · 3.53 Impact Factor
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    ABSTRACT: Wide acceptance of the colony-forming unit (CFU) assay as a reliable potency test for stem cell products is hindered by poor inter-laboratory reproducibility. The goal of this study was to ascertain current laboratory practices for performing the CFU assay with an eye towards identifying practices that could be standardized to improve overall reproducibility. A survey to evaluate current laboratory practices for performing CFU assays was designed and internationally distributed. There were 105 respondents to the survey, of whom 68% performed CFU assays. Most survey recipients specified that an automated rather than a manual cell count was performed on pre-diluted aliquots of stem cell products. Viability testing methods employed various stains, and when multiple sites used the same viability stain, the methods differed. Cell phenotype used to prepare working cell suspensions for inoculating the CFU assay differed among sites. Most respondents scored CFU assays at 14-16 days of incubation, but culture plates were read with various microscopes. Of 57 respondents, 42% had not performed a validation study or established assay linearity. Only 63% of laboratories had criteria for determining if a plate was overgrown with colonies. Survey results revealed inconsistent inter-laboratory practices for performing the CFU assay. The relatively low number of centers with validated CFU assays raises concerns about assay accuracy and emphasizes a need to establish central standards. The survey results shed light on numerous steps of the methodology that could be targeted for standardization across laboratories.
    Cytotherapy 03/2013; 15(3):255-62. · 3.06 Impact Factor
  • Amy M Schell, Melissa Petras, Zbigniew M Szczepiorkowski, Deborah L Ornstein
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    ABSTRACT: We report a case of refractory heparin-induced thrombocytopenia with thrombosis (HITT) with prolonged thrombocytopenia and multiple thrombotic complications that failed to improvedespite aggressive treatment. A 60year old female with a prior history of venous thromboemoblism was admitted with an acute pulmonary embolism, and developed HITT after several days on heparin therapy. She suffered multiple complications including bilateral venous limb gangrene, acute renal failure, and refractory thrombocytopenia, leading us to use multimodality therapy including therapeutic plasma exchange (TPE) and rituximab immunosuppression. The patient had transient improvements in her thrombocytopenia with TPE, and rituximab was added in an attempt to reduce antibody production. She eventually required bilateral limb amputation, and only after removal of the gangrenous limbs did her platelet count show sustained improvement. We discuss the possible contribution of infection to her prolonged course.
    Transfusion and Apheresis Science 02/2013; · 1.23 Impact Factor
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    ABSTRACT: BACKGROUND: The platelet (PLT) Pan Genera Detection test (PGD) is a rapid bacterial detection system used to screen PLTs for bacterial contamination. We report a single center 46-month experience with secondary screening of apheresis PLTs by PGD testing. STUDY DESIGN AND METHODS: Existing testing records of apheresis PLTs screened by PGD from July 2008 to April 2012 were reviewed. All PLT units were initially screened by routine postcollection culture methods. Secondary screening using PGD was performed for indated PLTs on PLT storage Day 4 and for outdated PLTs on Day 8. RESULTS: A total of 8535 apheresis PLTs were available in inventory during the study period. Of these, 5030 (58.9%) were dispensed and transfused before PGD testing and 3505 (41.1%) underwent PGD testing on Day 4. Twenty-five units tested on Day 4 were PGD initial reactive (0.71%). All were confirmed to be false positive by repeat PGD testing in triplicate (n = 20) or by confirmatory culture (n = 5). An additional 364 units that were PGD nonreactive on Day 4 were approved for transfusion on Day 6 or Day 7 due to urgent clinical need. A total of 371 outdated units underwent repeat PGD testing before discard on Day 8; all were nonreactive. CONCLUSION: Secondary PGD testing of culture-screened apheresis PLTs results in low yield in a medium-sized transfusion service. Use of PGD testing on Day 4 may allow for extension of the apheresis PLT shelf life to Day 7 for hospitals that face supply constraints.
    Transfusion 01/2013; · 3.53 Impact Factor
  • Zbigniew M Szczepiorkowski, Nancy M Dunbar
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    ABSTRACT: Transfusion of blood and blood components has been a routine practice for more than half a century. The rationale supporting this practice is that replacement of blood loss should be beneficial for the patient. This assumption has constituted the underpinning of transfusion medicine for many decades. Only over the past 20 years, we have seen a more concerted effort to answer very basic questions regarding the value of transfusion therapy. An assessment of the value of transfusion based on well-designed and appropriately powered randomized, controlled trials is the first step in optimizing transfusion practices. Systematic reviews provide the second step by building the knowledge base necessary to assess the impact of transfusion practice on patient outcomes. The third step is the development of clinical practice guidelines, and this occurs when systematic reviews are interpreted by individuals with expertise in transfusion medicine. Such guidelines are typically supported by professional organizations and/or health authorities. Implementation of clinical practice guidelines can be challenging, especially in an area as heterogeneous as transfusion medicine. However, clinical practice guidelines are necessary for the practice of evidence-based medicine, which optimizes patient care and improves patient outcomes. This review focuses on clinical practice guidelines for transfusion of three blood components: RBCs, platelets and plasma. In addition, we provide the approach used to implement clinical practice guidelines at our own institution.
    Hematology 01/2013; 2013:638-44. · 1.49 Impact Factor
  • Transfusion 11/2012; 52(11):2284. · 3.53 Impact Factor
  • Litchia L Weber, Nancy M Dunbar, Larry J Dumont, Zbigniew M Szczepiorkowski
    Transfusion 11/2012; 52(11):2494-5. · 3.53 Impact Factor
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    ABSTRACT: The number of circulating lymphocytes on day 15 after transplantation correlates with improved survival in patients with myeloma, but the lymphocyte subset responsible is unknown. NKG2D is a natural killer (NK) cell activating receptor that mediates non-MHC restricted and TCR-independent cell lysis. Our preliminary results indicate that CD3(+)CD8(+) T cells expressing NKG2D may be a critical lymphocyte population. A phase II trial examined the feasibility of infusing ex vivo-expanded cells enriched for NKG2D(+)CD3(+)CD8(+) T cells at weeks 1, 2, 4, and 8 after an autologous transplantation. In addition, low-dose IL-2 (6 × 10(5) IU/m(2)/day) was administered for 4 weeks, beginning on the day of transplantation. Twenty-three patients were accrued and 19 patients are evaluable. There were no treatment-related deaths. All patients completed their course of IL-2 and demonstrated normal engraftment. When compared with patients with myeloma who underwent transplantation not receiving posttransplantation immune therapy, the treated patients demonstrated an increase in the number of circulating NKG2D(+)CD3(+)CD8(+) T cells/μL (P < .004), CD3(+)CD8(+) T cells/μL (P < .04), CD3(+)CD8(+)CD56(+) T cells/μL (P < .004), and NKG2D(+)CD3(-)CD56(+) T cells/μL (P < .003). Myeloma cell-directed cytotoxicity by the circulating mononuclear cells increased after transplantation (P < .002). When compared to posttransplantation IL-2 therapy alone in this patient population, the addition of cells enriched for NKG2D(+)CD3(+)CD8(+) T cells increased tumor-specific immunity, as demonstrated by enhanced lysis of autologous myeloma cells (P = .02). We postulate that this regimen that increased the number and function of the NKG2D(+)CD3(+)CD8(+) T cells after transplantation may improve clinical outcomes by eliminating residual malignant cells in vivo.
    Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation 09/2012; · 3.15 Impact Factor
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    ABSTRACT: BACKGROUND: Platelets (PLTs) stored in additive solutions (PASs) may reduce the risk of several plasma-associated adverse transfusion reactions such as allergic reactions and potentially transfusion-associated lung injury. The objective of this study was to determine the in vitro characteristics and the in vivo radiolabeled recovery and survival of apheresis PLTs (APs) stored in a new PAS and compare the latter to Food and Drug Administration (FDA) criteria. STUDY DESIGN AND METHODS: Hyperconcentrated APs were collected from healthy subjects in a paired crossover study comparing PAS (35% plasma) and 100% plasma-stored APs (Part 1) up to 7 days and, in Part 2, to determine the in vivo recovery and survival of PAS stored AP at 5 days compared to fresh PLT controls. In vitro and in vivo assays were performed following standard methods. RESULTS: Sixty-six and 25 evaluable subjects successfully completed Parts 1 and 2, respectively. pH for PAS AP was maintained above 6.6 for 5 days of storage. P-selectin values were consistent with published values for commonly transfused PLT products. The PAS in vivo PLT recovery (54.3 ± 8.1%) was 86.7% of the fresh control, and survival (6.4 ± 1.3 days) was 78.0% of the fresh control, both meeting the FDA performance criteria. CONCLUSION: APs stored in PAS with 35% plasma carryover maintained pH over 5 days of storage and met current FDA criteria for radiolabeled recovery and survival. The use of PAS for storage of single-donor PLTs in clinical practice represents an acceptable transfusion product that reduces the volume of plasma associated with PLT transfusion.
    Transfusion 08/2012; · 3.53 Impact Factor
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    [show abstract] [hide abstract]
    ABSTRACT: The number of circulating lymphocytes on Day 15 following transplant correlates with improved
    Biology of Blood and Marrow Transplantation 08/2012; · 3.94 Impact Factor
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    ABSTRACT: BACKGROUND: Availability of platelets (PLTs) is severely limited by shelf life in some settings. Our objective was to determine and compare to Food and Drug Administration (FDA) criteria the PLT recovery and survival of autologous PLTs cryopreserved at -65°C or less in 6% dimethyl sulfoxide (DMSO) reconstituted with a no-wash method (cryopreserved PLTs [CPPs]) compared to autologous fresh PLTs. STUDY DESIGN AND METHODS: This was a randomized, Phase I study analyzing PLT viability and in vitro function in consenting healthy subjects. Apheresis PLTs (APs) were collected in plasma. APs were suspended in 6% DMSO, concentrated, and placed at not more than -65°C for 7 to 13 days. Frozen CPPs were thawed at 37°C and resuspended into 25 mL of 0.9% NaCl. Control PLTs (fresh autologous) and CPPs were labeled with (111) In or (51) Cr, and recovery and survival after reinfusion were determined using standard methods. A panel of in vitro assays was completed on APs and CPPs. RESULTS: After frozen storage, CPPs retained 82% of AP yield and showed increased PLT associated P-selectin and reduced responses to agonists. CPP 24-hour recovery (41.6 ± 9.7%) was lower than for fresh PLTs (68.4 ± 8.2%; p < 0.0001) and did not meet the current FDA criterion. CPPs had diminished survival compared to fresh PLTs (7.0 ± 2.1 days vs. 8.4 ± 1.2 days, respectively; p = 0.018), but did meet and exceed the FDA criterion for survival. CONCLUSION: While 24-hour recovery does not meet FDA criteria for liquid-stored PLTs, the CPP survival of circulating PLTs was surprisingly high and exceeded the FDA criteria. These data support proceeding with additional studies to evaluate the clinical effectiveness of CPPs.
    Transfusion 06/2012; · 3.53 Impact Factor
  • Melissa L Petras, Miriam K Leach, Zbigniew M Szczepiorkowski, Nancy M Dunbar
    Transfusion 06/2012; 52(6):1380-2. · 3.53 Impact Factor
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    ABSTRACT: Streptococcus pneumoniae-associated hemolytic uremic syndrome (pHUS) is an atypical form of HUS associated with microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. Although less common than diarrhea-associated HUS, incidence appears to be increasing. We report a case of a child with pHUS who underwent a course of therapeutic plasma exchange (TPE) and had complete recovery. This report adds to the existing literature supporting TPE in cases of pHUS.
    Journal of Clinical Apheresis 02/2012; 27(4):212-4. · 2.27 Impact Factor
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    ABSTRACT: One of the most frequent causes of transfusion-associated morbidity or mortality is the transfusion of the wrong blood to the wrong patient. This problem persists in spite of the incorporation of numerous procedures into the pretransfusion checking process in an effort to improve patient safety. A qualitative study was undertaken to understand this process from the perspective of those who administer blood products and to identify concerns and suggestions to improve safety. Twelve focus group discussions and seven individual interviews were conducted at six hospitals in five countries (n = 72 individuals). Health care professionals from a variety of clinical areas participated. Data analysis identified common themes using the constant comparison method. Five major themes emerged from the analysis: the pretransfusion checking process, training, policy, error, and monitoring. Findings include the following: staff were aware and appreciative of the seriousness of errors and were receptive to continuous monitoring, the focus was on checking the bag label with the paperwork rather than the bag label with the patient at the bedside, training methods varied with most perceived to have minimal effectiveness, and access to policies was challenging and keeping up to date was difficult. Other factors that could contribute to errors included high volume of workload distractions and interruptions and familiarity or lack of familiarity with patients. Multiple factors can contribute to errors during the pretransfusion checking limiting the effectiveness of any individual intervention designed to improve safety. Areas of further research to improve safety of blood administration were identified.
    Transfusion 01/2012; 52(8):1687-95. · 3.53 Impact Factor

Publication Stats

1k Citations
347.83 Total Impact Points


  • 2006–2014
    • Dartmouth–Hitchcock Medical Center
      • Department of Surgery
      Lebanon, New Hampshire, United States
  • 2013
    • University of Texas Southwestern Medical Center
      • Department of Pathology
      Dallas, Texas, United States
  • 1995–2013
    • Massachusetts General Hospital
      • • Department of Medicine
      • • Department of Pathology
      Boston, Massachusetts, United States
  • 2010
    • NHS Blood and Transplant
      Watford, England, United Kingdom
  • 2008
    • Universität Heidelberg
      • Institute of Transfusion Medicine and Immunology
      Heidelberg, Baden-Wuerttemberg, Germany
  • 2007
    • Emory University
      • Department of Pathology and Laboratory Medicine
      Atlanta, GA, United States