JOINT PROGRAM IN TRANSFUSION MEDICINE



JOINT PROGRAM

IN

TRANSFUSION MEDICINE

HOUSESTAFF MANUAL

(Revised 10/2009)

CONTENTS

1. Overview of BWH/CHB/DFCI Transfusion Service

1.2 Weekly schedule

1.3 Policy for Resident/Fellow Supervision

4. Fellowship Duty Hours Policy

5. Resident/Fellow Responsibilities: Apheresis Service

6. Educational Objectives

7. Curriculum

8. Handoff Policy

2. BWH Blood Bank

2.1 Pretransfusion compatibility testing

2.2Antibody identification

2.3 Component usage guidelines

2.3.1 RBCs

2.3.2 Platelets

2.3.3 FFP

2.3.4 Cryoprecipitate

2.3.5 Clotting Factor Concentrates

2.3.6 Granulocytes

2.3.7 SOPs for administration of Blood Products

4. Transfusion reactions

5. RhIg administration

3. BWH Blood Donor Center

3.1 Therapeutic apheresis

3.1.1 Indications

3.1.2 Venous access

3.1.3 Adverse reactions

3.2 Whole blood donation

3.2.1 Allogeneic donors

3.2.2 Autologous donors

3.2.3 Adverse reactions

4. DFCI Kraft Family Blood Donor Center

4.1 Apheresis platelet donation

4.2 Peripheral blood stem cell collection

5. Children's Hospital, Boston

1. OVERVIEW OF THE BWH/DFCI/CHB TRANSFUSION SERVICE

2. WEEKLY SCHEDULE

|MONDAY |TUESDAY |WEDNESDAY |THURSDAY |FRIDAY |

| |0900 Serology | |0800 Gross-Micro |0815 CHB Heme conf |

| | | | | |

| |1300 BWH Heme Conf |1200 Fellows Conf |1200 BMT Grand Rounds | |

| | | |1300 CP Conf | |

|1500 Work Rounds|1500 Work Rounds |1500 Work Rounds |1500 Work Rounds |1500 Work Rounds |

| | | | | |

1.3 JPTM POLICY FOR RESIDENT AND FELLOW SUPERVISION

Consults

Rotating residents and fellows are responsible for the initial evaluation of consults, including transfusion reactions, serologic workups, and therapeutic apheresis procedures. All formal consults will be discussed with and signed off by the supervising attending physician.

Other clinical issues

Residents and fellows evaluate a variety of clinical issues e.g. questions regarding blood donation, blood component utilization, management of apheresis patients, etc. Critical patient issues should be presented in a timely fashion to the on-call attending. Residents/fellows can never be criticized for calling the attending.

Attending physician backup

Attending physician backup will be available at all times. If a resident/fellow is unable to reach the on-call attending during an emergency, one of the off-service JPTM attending physicians should be called for backup.

Kraft Family Blood Donor Center: medical coverage

In addition to the blood bank attending, medical backup is available through the “Doc of the Day” (rotating DFCI attending MD) as well as the DFCI code team.

1.4 DUTY HOURS POLICY*

HARVARD MEDICAL SCHOOL FELLOWSHIP PROGRAM

IN TRANSFUSION MEDICINE

• Transfusion Medicine Fellow duty hours are herein defined as time spent at the worksite performing clinical and/or academic activities required by the resident’s GME training program, including:

o Patient care activities, both inpatient and ambulatory, whether scheduled or not (i.e., includes time spent in the hospital when a resident is called in from home)

o Administrative activities that are related to patient care.

o In-hospital “on-call”, regardless of what the resident activities are during such periods scheduled- academic activities (i.e., conferences and other didactics).

• The Joint Program in Transfusion Medicine endorses the duty hour and on-call limits defined by the ACGME (paraphrased below in italics).

o Fellows must not be assigned duty hours in excess of 80 hours per week, averaged over a four-week period.

o Fellows must be provided with at least one day off in seven. Note: A day off is defined as a continuous 24 hour period free from assigned educational and clinical responsibilities, including offsite beeper call, rounds and conferences. JPTM attending physicians will take “first call” from Sunday at 8:00 am until Monday at 8:00 am as needed to ensure that the one day off in seven is provided.

o Fellows must not be assigned in-house call any more often then every third night, averaged over a four-week period. Note: This excludes beeper call from home and/or academic preparatory work that is or could be done offsite.

o Fellows should have at least 10 hours off between regularly scheduled on-site duty shifts (including after in-house call).

o Fellows must not be scheduled to work in excess of 24 consecutive hours. This applies to onsite work.

o If a fellow experiences an unexpected illness or if they are concerned that fatigue is impairing their performance or a colleague’s performance, they must promptly notify their attending, who will arrange for alternative coverage.

* also applies to Transfusion Medicine residents. (Last Updated: June 7, 2005)

• Backup coverage:

In the instance of an emergency procedure occurring in the evening prior to a normal weekday shift, the resident or fellow responsible for the procedure must assess the likelihood that he or she will violate the ACGME duty hours guidelines, above. If, in the resident or fellow's judgment, such a violation will occur, the resident or fellow must (1) inform his or her attending physician and (2) transfer coverage of the beeper to the appropriate backup MD (defined below) the next morning at 8 am at the latest. The "relief" resident or fellow must take over all patient care duties at 8:00 AM, and the "relieved" resident or fellow will be excused from duty until at least 10 hours following his or her departure from the hospital, though small deviations from this 10-hour minimum are allowable under ACGME rules, and may be preferable to short-duration pager transfers.

• Backup MD:

If there are two fully-trained residents on the service, the off-call resident is expected to provide coverage. If there is one fully-trained resident on the service, the fellow is expected to provide coverage. If the fellow is on-call and there is a fully-trained resident on the service, the resident is expected to provide coverage. If no covering resident or fellow is available, the attending will be expected to cover or to work with the CP chief resident to identify a qualified backup MD.

1.5 APHERESIS SERVICE: RESIDENT/FELLOW RESPONSIBILITIES

Outpatient Responsibilities:

BWH: Photopheresis and plasmapheresis patients in the blood donor center (732-7524)

All morning patients should be seen and examined by 10:00am.

All afternoon patients should be seen and examined by 2pm.

If a new patient is scheduled to arrive and need to be consented before starting the procedure, one of the team should plan to be in the blood donor center within 10 minutes of the patient arriving so the procedure is not delayed.

DFCI: All stem cell harvest patients should be seen and examined by 11:00am at the Kraft Donor Center (632-6260).

CHB: Call to the in the morning or check the weekly calendar in the pheresis unit (355-6270) to determine if there are Children's Hospital, Boston outpatients to be seen.

Inpatient Responsibilities:

BWH: If you do not know the time of the scheduled procedure for an inpatient, check with the nurses in the donor center (732-7524) to determine the time for the procedure and whether the patient will need to be seen, evaluated and orders written before the nurses can start the procedure. In general, all NEW or potentially UNSTABLE patients need to be seen and examined prior to start of the procedure.

CHB: Check with the nurses to determine the time of the scheduled procedure. Same as above.

9 EDUCATIONAL OBJECTIVES

|[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |

|Beth Israel Deaconess |Brigham and Women's |children’s hospital, |Dana Farber Cancer |Massachusetts General |Harvard Medical School |

|Medical Center |Hospital |boston |Institute |Hospital | |

| | | | | | |

| | | | | | |

HARVARD MEDICAL SCHOOL

FELLOWSHIP PROGRAM IN TRANSFUSION MEDICINE

EDUCATIONAL OBJECTIVES AND APPROACHES

Updated 7/1/06

The HMS Fellowship Program in Transfusion Medicine emphasizes the achievement of key competencies by its clinical fellows. Objectives and approaches are summarized below for the six major areas of importance:

I. PATIENT CARE

Objectives –

• To gain diagnostic competence and the ability to provide appropriate and effective pathology services and clinical consultation.

• To learn to collaborate with other professionals, include those in other disciplines, in providing patient-focused care.

• To learn the principles of compassionate and cost-effective patient care.

Approach -

• Fellows gather essential and accurate clinical information about the patients on whom they perform consultations regarding therapeutic apheresis, transfusion reactions, serologic workups, hemostasis, or other transfusion-related issues.

• Fellows make informed decisions regarding the diagnostic workup of blood bank serologic specimens based on patients' clinical history, up-to-date scientific evidence gleaned from journal articles, internet-based searches, textbooks, and clinical judgment.

• Fellows use available information technology (hospital and laboratory information systems, electronic bibliographic searches and journals) to support workup and diagnosis, and to help educate clinicians by providing relevant literature references.

• Fellows demonstrate competence in the performance of tasks considered essential for transfusion medicine practice, including:

– Providing guidance to the various clinical services on laboratory testing and blood product usage, including coagulation factors.

– Planning and medical oversight of therapeutic apheresis procedures.

– Performing transfusion reaction investigations with appropriate follow up to the clinical services.

– Evaluating and managing blood and peripheral blood stem cell donors.

II. MEDICAL KNOWLEDGE

Objectives –

• To gather and consolidate knowledge about established and evolving basic biological and clinical sciences and clinicopathologic correlations, and the application of this information to patient care and to pathology.

• To gain analytical and problem-solving skills and their application in pathology.

Approach -

• Fellows demonstrate an investigatory and analytical thinking approach to clinical situations dependent on the blood bank/transfusion service including:

– Performing thoughtful and accurate serologic and transfusion reaction workups.

– Suggesting appropriate additional testing (e.g. advanced serologic testing serology, HLA testing, etc.) if applicable.

– Formulating comprehensive and cohesive differential diagnoses and developing treatment plans for patients in whom therapeutic apheresis is being considered.

– Designing and carrying out focused research projects, such as clinicopathologic studies, or case reports with literature review.

• Fellows know and apply the basic and clinically supportive sciences which are appropriate to the specialty of transfusion medicine, including:

– Demonstration of knowledge of hematology, immunology and infectious disease and as they apply to transfusion medicine.

– Demonstration of familiarity with all aspects of blood component manufacturing, testing, storage and provision.

– Demonstration of familiarity with blood group serology and blood bank testing methods.

– Demonstration of detailed knowledge of appropriate transfusion medicine practices as applied to specific clinical areas such as surgery, hematology/oncology, hematopoietic stem cell transplantation, pediatrics, obstetrics, etc.

– Demonstration of understanding the principles of therapeutic apheresis, and the rationale for using apheresis in a variety of disease states.

III. PRACTICE-BASED LEARNING AND IMPROVEMENT

Objectives –

• To gain the ability to evaluate and improve a diagnostic and consultative practice based on scientific evidence.

• To locate, appraise and use scientific data to improve patient care.

• To apply knowledge of rigorous scientific principles, study design and statistical methods to evaluate published clinical studies and do clinicopathologic investigation.

• To learn to use information technology to manage information and conduct personal continuing education.

• To facilitate the learning of students, residents, colleagues and other health care professionals.

Approach -

• Fellows show the ability to analyze practice experience and perform practice-based improvement activities using a systematic methodology, including:

– Active participation in weekly didactic conferences and operational meetings (e.g. BWH/DFCI Biological Therapies Committee).

– Participation in quality monitoring efforts e.g. assisting with quarterly transfusion appropriateness audits.

• Fellows show ability to locate, appraise, and assimilate evidence from scientific studies related to patients' health care problems, including using literature search and review to find relevant scientific references to aid in performing laboratory and clinical consultations.

• Fellows are able to apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness, including:

– Active participation in weekly conferences with critical discussion of study designs and statistical methods of presented articles.

– Design and conduct independent clinical, translational or basic research studies.

• Fellows demonstrate competency in the use of information technology to manage information, access on-line medical information, and support their own education, including:

– Accessing of patient clinical information and previous laboratory results via the hospital's Laboratory Information System.

– Performance of computer bibliographic searches.

• Fellows actively participate in the teaching of medical students and other health care professionals, including:

– Teaching students on elective rotations in Pathology and in Medical school courses as laboratory instructors.

– Teaching students and fellows from other disciplines during in-hospital clinical conferences.

– Teaching laboratory and donor center staff.

IV. INTERPERSONAL AND COMMUNICATION SKILLS

Objectives –

• To acquire and use interpersonal and communication skills that result in effective information exchange and collaboration with other health care professionals and patients (and their families).

• To create and maintain an effective, ethically sound and respectful relationship with peers, other health care professionals, and patients (and their families).

• To use effective listening skills.

• To work effectively with other professional and non-professional staff.

Approach -

• Fellows demonstrate effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning and writing skills. This includes:

– Following instructions from attending physicians during performance of consultations and management of therapeutic apheresis patients and donors.

– Demonstrating interest in case material during teaching rounds by asking relevant questions, and responding articulately to questions from transfusion medicine attendings.

– Eliciting relevant clinical information from and providing appropriate diagnostic information and clinical advice to clinicians via telephone conversations.

– Generating concise, accurate, and complete consultations in the clinical laboratories.

– Demonstrating effective oral and written communication skills in didactic talks and research projects.

• Fellows should work effectively with others as a member or leader of health care team or other professional group, including participation with other members of the Dept. of Pathology and Laboratory Medicine and other departments on various hospital committees.

V. PROFESSIONALISM

Objectives –

• To maintain a commitment to excellence in carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity in the workplace.

• To maintain respect, compassion and integrity; responsiveness to patients that supercedes self-interest; accountability to patients, colleagues, and the profession and discipline of pathology; and a commitment to on-going professional development.

• To develop and maintain a commitment to confidentiality of patient information, informed consent and ethical business practices.

• To learn the highest principles relating to conflict of interest and commitment.

• To develop the maximum sensitivity to colleague and patient ethnicity, age, gender and disabilities.

Approach -

• Fellows must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population, including:

– Showing respect, compassion, and integrity during interactions with patients.

– Showing responsiveness and accountability to the needs of patients and their families and clinicians that supersedes self-interest, including contributions to the timely completion of reports, and discussion of results with clinicians.

– Demonstrating commitment to excellence and ongoing professional development, such as completing directed and independent reading from pathology textbooks and journal articles, designing and completing research projects, undertaking literature searches on various transfusion medicine topics, providing high-quality presentations at conferences, and attending in-house and off -site pathology lectures and conferences.

– Demonstrating a commitment to ethical principles pertaining to confidentiality of donor and patient information.

– Demonstrating commitment to ethical principles pertaining to business practices, including helping to ensure accurate billing for services.

– Demonstrating adherence to the highest principles of mutual respect of colleagues and support personnel.

VI. SYSTEMS-BASED PRACTICE

Objectives –

• To develop an awareness of and responsiveness to the larger context and system of health care and the ability to access and effectively use resources to provide value-added pathology services.

• To understand how pathology services affects other health care professionals, organizations and systems.

• To develop an understanding of the principles of cost-effective health care and resource allocation that enhances (and does not compromise) quality of service and patient care.

Approach -

• Fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. This includes:

– Gaining an appreciation for transfusion medicine as a public health practice, and participating in policy discussions and decision-making.

– Demonstrating knowledge of methods for controlling health care costs and allocation of resources.

– Practicing cost-effective health care and resource (e.g. blood product) allocation that does not compromise the quality of care.

Demonstrating knowledge of how to partner with health care managers and health care providers to assess, coordinate, and improve health care, and knowledge of how these activities can affect system performance.

|[pic] |[pic] |[pic] |[pic] |[pic] |[pic] |

|Beth Israel Deaconess |Brigham and Women's |children’s hospital, |Dana Farber Cancer |Massachusetts General |Harvard Medical School |

|Medical Center |Hospital |boston |Institute |Hospital | |

1.7 CURRICULUM

CORE CURRICULUM

HARVARD MEDICAL SCHOOL

FELLOWSHIP PROGRAM IN TRANSFUSION MEDICINE

Updated 9/1/05

Upon completion of clinical training, fellows are expected to demonstrate understanding of the following aspects of Transfusion Medicine, organized by Competency:

PATIENT CARE

5 Blood Donation

1. Criteria for acceptability of individuals for blood donation

2. Process of donor interview, arm inspection and physical examination

3. Presentation and management of complications of blood donation

4. Clinical significance of product storage lesions

6 Blood Group Serology/Biochemistry

5. Clinically significant vs. insignificant red cell alloantibodies

a) Serologic specificity

b) Isotype

c) Thermal amplitude

6. Direct Antiglobulin Test in evaluating:

a) transfusion reaction

b) hemolytic disease of the newborn

c) autoimmune hemolytic anemia

d) drug induced hemolytic anemia

7 Blood Transfusion Practices

7. Clinical indications and dose/response for transfusion of:

a) Packed Red Blood Cells

b) Fresh Frozen Plasma

c) Cryoprecipitate

d) Platelets

e) Granulocytes

f) Coagulation factors

1) FVIII

2) FIX

3) Prothrombin Complex Concentrates (FEIBA, Autoplex)

4) rFVIIa (NovoSeven)

5) Humate P for von Willebrand Disease

g) RhIg

h) Other plasma derivatives e.g. albumin, IVIg, etc.

8. Product administration

a) infusion rate

b) time to expiration after pooling or preparation

9. CMV-safe blood products: indications and methods

10. Leukoreduction: indications and methods

11. Irradiated blood products: indications and methods

12. Compatibility testing requirements

a) ABO/Rh

b) Antibody screen

c) Abbreviated v. full crossmatch

13. Emergency transfusion protocols

14. Massive transfusion

a) metabolic abnormalities

b) dilutional coagulopathy

c) hypothermia

15. Autoimmune hemolytic anemia (AIHA)

a) Classes

1) Warm AIHA

2) Cold AIHA

3) Paroxysmal Cold Hemoglobinuria

4) Atypical AIHA

a) DAT-negative AIHA

b) Combined warm + cold AIHA

b) Pathophysiology

c) Clinical presentation

d) Laboratory evaluation

e) Selection of blood for transfusion

16. Inventory management during shortages

8 Adverse Effects of Blood Transfusion

17. Noninfectious complications of transfusion: presentation, pathophysiology, differential diagnosis, laboratory workup, management and prevention of:

a) Immune-mediated transfusion reactions

1) Hemolytic reactions

a) Acute

b) Delayed

2) Febrile Nonhemolytic Transfusion Reaction

3) Allergic

4) Urticarial

5) Anaphylactic

6) Transfusion-Related Acute Lung Injury (TRALI)

7) Transfusion-associated graft-versus-host disease

8) Post-transfusion purpura

b) Non-immune mediated transfusion reactions

1) Volume overload

2) Hypotensive reaction

3) Citrate toxicity

4) Hyperkalemia

5) Hypothermia

6) Nonimmune hemolysis (hypotonic solutions, pumps, etc.)

18. Infectious complications of transfusion: disease associations, significance, Incidence, per unit risk, pathophysiology, signs/symptoms, prevention, donor screening, management of:

a) Viral infections

1) Hepatitis B Virus

2) Hepatitis C Virus

3) HIV I/II

4) HTLV I/II

5) West Nile Virus

6) CMV

7) EBV

b) Bacterial infections

c) Parasitic infections

1) Syphilis

2) Malaria

3) Babesia

4) Chagas Disease

d) Prion diseases

1) Creutzfeldt-Jakob Disease

2) Variant Creutzfeldt-Jakob Disease

A. Apheresis: indications, anticoagulation, timing of procedures, replacement fluids, venous access, recognition and management of adverse events for:

1. Component collection

a) Platelets

b) Red cells

c) Granulocytes

d) Plasma

2. Therapeutic Apheresis procedures

a) Plasma Exchange

b) Red Cell Exchange

c) Leukoreduction

d) Red Cell Depletion

e) LDL apheresis (Liposorber)

f) Photopheresis

3. Peripheral Blood Stem Cell collections

MEDICAL KNOWLEDGE

B. Blood Donation

1. Laboratory tests performed on donated blood.

2. Methodology, and sensitivity/specificity of infectious disease markers

3. Donor deferral criteria

4. Deferred donor registry

C. Blood Component Manufacturing and Storage

1. Preparation of blood components from whole blood

2. Products that may be collected using hemapheresis procedures

3. Blood product anticoagulant/preservatives

4. Storage conditions/expiration dates for each blood component.

5. Preparation of components which require pooling/thawing

6. Special processing techniques of leukoreduction/washing/volume reduction/irradiation

7. Metabolic changes that occur during storage

8. Plasma derivatives that are prepared commercially

D. Blood Transfusion Practice

1. Transfusion “triggers”

a) Red cell

b) Platelet

c) Plasma

2. Refractoriness to platelet transfusion

3. Blood conservation strategies

4. Pediatric transfusion practice

5. Neonatal transfusion practice

6. Surgical transfusion support

E. Blood Group Serology/Biochemistry

1. Immunologic principles

a) Immunoglobulin structure and genetic basis for antibody diversity

b) Red cell alloantibodies vs. red cell autoantibodies

c) Primary and secondary immune responses to red cell antigens

d) “Naturally occurring” antibodies vs those requiring prior immunization

e) Mechanisms of red cell sensitization

f) Mechanisms of red cell destruction

1) Complement activation

2) Intravascular vs extravascular immune hemolysis

2. Red cell blood group antigens: biochemistry, genetic inheritance, immunogenicity, clinical significance, common phenotypes of:

a) Carbohydrate blood group antigens

1) ABH

2) Lewis

3) P

4) I/i

b) Protein blood group antigens

1) Rh

2) Kell

3) Duffy

4) Kidd

5) MNS

c) High frequency antigens

d) Low frequency antigens

3. Disease associations with the “null” phenotypes for ABO, Rh, Kell

4. Serologic Testing

a) Parameters affecting in vitro detection of antigen-antibody reactions

b) Testing formats

1) Tube

2) Gel

3) Solid phase

c) Indications, reagents, methods and interpretation of:

1) ABO/RhD typing

2) Weak D testing

3) Antibody screen

4) Antibody panel identification

5) Crossmatching Tests

a) Abbreviated

b) Full

6) Enhancement techniques

a) Enzymes

b) LISS, PEG

7) Adsorption techniques

a) Autologous

b) Heterologous

8) Elution techniques

9) Neutralizaton techniques

a)

10) Direct Antiglobulin Test (DAT)

11) Donath-Landsteiner Test

12) Hemolytic Disease of the Newborn

a) Rosette Test

b) Kleihauer-Betke Test

c) Antibody Titration Studies

13) Electronic crossmatching

a) Information system requirements

b) Procedural requirements

c) Advantages/disadvantages

5. Hematopoietic Stem Cell Transplantation

a) Diseases treated with stem cell transplantation

b) Stem cell biology

1) Bone marrow-derived stem cells

2) Peripheral blood stem cells

3) Cord blood stem cells

c) Mobilization of stem cell donors

d) Stem Cell Collection

e) Stem Cell Processing

f) Thawing and Infusion

g) Engraftment

h) Transfusion support of stem cell transplantation patients

1) Product support

2) ABO mismatched transplants

3) TA-GVHD

4) CMV

6. HLA

a) Genetics

b) Structure of the HLA complex, Biochemistry

c) Clinical relevance to transfusion medicine e.g. management of platelet refractoriness

d) Testing methods

7. Therapeutic Apheresis

a) Principles

b) Indications/rationale for use in:

1) Hematologic diseases, e.g.:

a) TTP

b) Acute leukemia/hyperleukocytosis

c) Hyperviscosity syndromes

d) Sickle Cell Disease

2) Neurologic diseases, e.g.:

a) Cryoglobulinemia

b) Myasthenia Gravis

c) Guillain-Barre Syndrome

PRACTICE-BASED LEARNING & IMPROVEMENT

F. Application of current Transfusion Medicine literature to clinical decisions

G. Mastery of available information technology resources

H. Education of students, residents, techs

IV. INTERPERSONAL AND COMMUNICATION SKILLS

A. Development of therapeutic relationships with patients

B. Foster effective working relationships with MDs and technical staff

C. Provide effective consultation to physicians from other services

V. PROFESSIONALISM

3 Competent, conscientious, ethically sound practice

A. Sensitivity to culture, gender, age issues

VI. SYSTEMS-BASED PRACTICE

Prospective, concurrent and retrospective auditing of blood product transfusion

B. Hospital Transfusion Committees

B. Development of hospital transfusion policies

C. Roles of regulatory agencies whose oversight directly impacts Transfusion Service operation

1. FDA

2. AABB

3. JCAHO

4. FACT

5. DPH

D. Informed Consent for Transfusion

E. Crossmatch/Transfusion ratio

F. MSBOS ( Maximum surgical blood ordering schedule)

G. “Lookback”

H. Blood product inventory management

I. Budgeting

J. Blood bank information systems

8. JOINT PROGRAM IN TRANSFUSION MEDICINE

POLICY FOR HANDOFFS AMONG RESIDENTS,

FELLOWS AND PHYSICAN ASSISTANTS

• Each handoff must be an interactive communication between the outgoing and incoming caregiver that should include both a written and verbal component. For Transfusion Medicine, this specifically applies to:

o Any inpatient at BWH or CHB undergoing therapeutic apheresis

o Any inpatient or outpatient at CHB/BWH/DFCI actively receiving consultation by the Transfusion Service

o Any significant laboratory issues at CHB/BWH/DFCI

• Each handoff should be performed as a face-to-face interaction whenever possible. If a face-to-face handoff is not feasible then it should occur via telephone. Email or voicemail by itself is not an acceptable manner of handing off.

• Handoffs should occur in a quiet, private place to minimize the possibility that information will be lost or overheard by those other than the intended recipients.

• Hand offs must include up to date information regarding the patient’s care including - patient name, date of birth, MRN,bed location, admitting diagnosis, attending physician, current condition, recent and anticipated changes in condition or treatment and plan of care.

• Interruptions during hand offs must be limited to minimize the possibility that information would fail to be conveyed.

• Hand offs require a verification of the received information including a read back or repeat back of critical components when appropriate.

• The receiver of the hand off information must have an opportunity to review relevant patient historical data, which may include previous care, treatment and services, and to ask all relevant questions.

2. BWH BLOOD BANK

One of the goals of the resident or fellow taking 1st call for the blood bank is to try to ensure that transfused patients receive blood products appropriate to their clinical condition. You may be paged by the blood bank if a patient receives an order for a blood product that falls outside of the norm (e.g., a request for FFP in a patient with a normal PT.) Sometimes these “unusual” requests are perfectly legitimate, sometimes they are not. Your role is to contact the clinical service, investigate the situation, and make a judgement as to whether the request is medically sound. If a request for a product is truly not indicated, try to offer an appropriate alternative. This may mean recommending not transfusing at all; often the correct maneuver is to recommend transfusing something other than what was ordered. (e.g., a bleeding patient with a platelet count of 25,000 and a normal PT/PTT needs platelets, not plasma.) You should not refuse blood products; you should try to provide guidance to the primary service with the goal of transfusing the patient appropriately. Many of these discussions will arise in the setting of patients who are on the operating table, actively bleeding. Under these stressful circumstances, the surgeons and/or anesthesiologists may begin ordering lots of blood products in an apparently haphazard fashion. Find out what is happening from the anesthesiologist. It may be appropriate to ask him or her to follow the patient’s labs to help guide transfusion decisions (e.g., ask to check a fibrinogen level before the next dose of cryo is ordered).

2.1 Pretransfusion compatibility testing

Recommended reading: Technical Manual 13th Ed. pp. 375-388

When a new blood order is received for a patient, the blood bank initiates a serologic workup that may take from 45 minutes-1 hour (the usual case) to several days (in cases of complicated/rare “unexpected” antibodies.) In emergency situations, type O blood can be released without serologic testing. The blood bank maintains “trauma coolers” stocked with 6 units of O+ and 2 units of O- PRBCs available for immediate pickup by ED personnel. Refer to the chart below for typical blood turnaround times.

BLOOD AVAILABILITY TIME TABLE

|Time you can wait to transfuse |RBC product available |Comments |

|(5 minutes |Group O, uncrossmatched |RBC antibodies found in ~1-3% of patients. |

| | |Serious hemolytic reactions rare. |

|15 minutes after sample arrives in BB |ABO group-specific, uncrossmatched |Risks as above. |

|60 minutes after sample arrives in BB |ABO group-specific, crossmatched |No unexpected alloantibody found. |

| | |“Immediate spin” crossmatch-compatible. |

|2 hours-several hours; rarely, longer |ABO group-specific, antigen-negative |Some antibody investigations may take |

| |crossmatched in a pt. with an “unexpected” |several hours. If blood is absolutely |

| |alloantibody. |required prior to completion of workup, do |

| | |not withhold transfusion. The clinical |

| | |team should confer with the blood bank |

| | |physician. |

Standard pretransfusion testing for red cell transfusions includes the following:

1. ABO type. Recipient red cells are tested using anti-A and anti-B (“forward typing”); recipient serum is tested against A1 and B cells (“reverse typing”).

2. Rh type. Recipient red cells are determined to be RhD positive or negative using anti-RhD.

3. Antibody screen. Recipient serum is screened for “unexpected” alloantibodies, using the indirect antiglobulin test following a 37oC incubation (indirect Coomb’s). Two commercially prepared, type O screening cells are used: I: Rh phenotype = R1R1; II: R2R2. The use of a third screening cell (rr) is optional. This combination of screening cells covers the five most important Rh group antigens, in addition to the other non-ABO antigens most commonly encountered in clinical practice e.g. Jka/Jkb.

4. Immediate spin crossmatch. Saline-suspended donor cells are mixed with recipient serum at room temperature, centrifuged immediately, and checked for (the absence of) agglutination. The immediate spin crossmatch serves merely as a final check on ABO compatibility between donor and recipient. An electronic crossmatch can be done instead of an immediate-spin crossmatch, provided a properly validated computer system is in place that will reliably prevent the release of ABO-mismatched units.

After completing the above testing, red cell units can be released provided that there are no ABO discrepancies or unexpected antibodies in the serum. When ABO testing is discrepant (e.g. a patient forward types as A but has anti-A in the serum) the discrepancy needs to be resolved. If transfusion cannot be delayed, type O cells should be given as an interim measure.

Further testing is also required for patients with a demonstrated alloantibody in the serum (e.g. anti-E) or patients with a history of an alloantibody. Note that over a 10-year period, some 50% of alloantibodies stimulated by pregnancy or transfusion will become undetectable in the serum. It is important to give antigen negative blood even when a previously detected alloantibody has faded, because a rapid anamnestic response/hemolytic reaction can occur upon re-exposure to the antigen.

2.2 Antibody identification

Recommended reading: Technical Manual 13th Ed. pp. 389-418.

When a positive antibody screen is obtained, a panel of commercially prepared, phenotyped red cells is tested against the patient’s serum using the indirect antiglobulin test. The antibody is identified based on the pattern of reactivity observed, using the “cross-out” technique. To demonstrate convincingly the presence of an alloantibody, it is necessary to identify three cells known to be positive for a given antigen that yield a positive agglutination reaction with the patient’s serum, and three cells known to be negative for the antigen that yield a negative reaction with the patient’s serum. Once a clinically significant alloantibody is identified, blood that is negative for the relevant antigen must be provided. In such cases, a crossmatch using an antiglobulin reagent (“Coomb’s crossmatch”)--rather than just an immediate spin crossmatch—is performed prior to the release of red cell units. The time required to identify one or more antigen-negative units depends primarily on the frequency of that antigen in the population. (For example, approximately 75% of red cell units are positive for Jka; the blood bank would have to screen 4 units on average to find one that is Jka-negative.) The chart on the next page lists the phenotypic frequencies of many clinically important red cell antigens.

You may be called by the blood bank in situations where the floor is requesting blood for a patient in whom an unexpected antibody has been detected. Your job is to facilitate communication between the blood bank and the primary physicians regarding the clinical significance of the antibody and how long it will take to find compatible units of red cells. In rare emergency situations, it may be necessary to give incompatible units of blood for patients that cannot wait for the completion of an antibody workup.

2.3 Component usage guidelines

2.3.1 Red Blood Cells

Red blood cell transfusions are indicated to increase the oxygen carrying capacity for patients in whom the oxygen supply does not meet the oxygen demand of the tissues. There is no single laboratory test (e.g. hematocrit) that can be used as a red cell transfusion “trigger;” the risks and benefits of red cell transfusion need to be considered case-by-case. The patient’s age and clinical condition needs to be taken into account, and the signs and symptoms of anemia (lightheadedness, weakness, pallor, tachycardia, dyspnea on exertion, etc.) should be searched for. A few general points:

1. RBC transfusion is almost never indicated with a Hgb > 10 g/dl, and is almost always indicated with a Hgb < 7 g/dl.

2. It is reasonable to transfuse patients with cardiac disease to a Hgb of 10 g/dl. Non-cardiac patients may do fine with hemoglobin levels of 7-9 g/dl, even in the critical care setting (NEJM 340;6: 409).

3. Sickle cell anemia patients should never be transfused to a Hct > 30%. The increased blood viscosity can actually worsen intravascular sickling and clinical symptoms.

4. RBC transfusion can often be avoided in patients with chronic anemia secondary to metabolic problems. For example, most patients with iron deficiency anemia should almost always be treated with iron supplementation rather than blood.

5. As a rule of thumb, one unit of packed red blood cells is expected to increase an average-sized patient’s Hgb by 1 g/dl and hematocrit by 3%.

2.3.2 Platelets

In patients with functional platelets, spontaneous bleeding does not generally occur with platelet counts above 10,000/(l. The BMT service in fact uses a platelet count < 10,000 as their “trigger” for prophylactic platelet transfusion. Remember that 1 unit of single donor platelets (SDP) is roughly equal to a pooled 6-pack of random donor platelets (RDP), and should contain at least 3 X 1011 platelets. An SDP (or a pool of RDPs) should bump the platelet count by 30,000-60,000 unless the patient is alloimmunized or is consuming platelets secondary to bleeding, sepsis, etc. A number of formulas have been developed to assess platelet recovery (e.g. the Corrected Count Increment); in practice these formulas are used in published studies but are not often utilized in everyday practice.

Platelet transfusion guidelines:

Platelet count Recommendation

< 10,000 Prophylaxis: transfuse 1 SDP or 6-pack of RDP

< 30,00-50,000 Transfuse if pt. is to have an moderately invasive

procedure (e.g. line placement) or in the presence of active bleeding. Note: platelet transfusions are generally not needed for bone marrow biopsies/aspirates, even at very low counts.

Comments

Patients undergoing cardiothoracic surgery represent a special case, because often they have been placed on bypass and their core body temperature is low, resulting in poor platelet function. These acutely post-op (or intra-op) patients may benefit from platelet transfusion even with a normal platelet count. Another scenario where platelet transfusion in the setting of a normal count may be appropriate is in bleeding patients who have recently received aspirin or other platelet inhibitors such as Plavix (Clopidogrel).

PLATELET REFRACTORINESS

Common causes of decreased responsiveness to platelet transfusion

Chemotherapy Multiple previous platelet transfusions (10+)

Platelet-poor units Sepsis

ABO incompatible Fever

Older platetlets splenomegaly

Amphotericin B heparin

DIC Active bleeding `

Risk factors for platelet refractoriness

Lymphocytotoxic antibodies (PRA+) heparin

Fever bleeding

Immune-mediated causes of refractoriness

Anti-HLA antibodies

Anti-platelet antibodies

ITP

Heparin-induced thrombocytopenia

Drug hapten effects (antibiotics, procainamide)

TRAP trial Follow-up study definition of platelet refractoriness:

Post-transfusion platelet count increment (11,000/(l

CAP Definition of platelet refractoriness:

CCI < 7500/(l from 2 or more sequential transfusions when measured 10-60 minutes after infusion is complete.

[Posttransfusion platelet count – pretransfusion platelet count]

CCI = --------------------------------------------------------------------------

(No. of platelets transfused x 1011) X (Body surface area)

Body surface area (m2) = 0.20247 x Height(m)0.725 x Weight(kg)0.425

It has been shown that using a raw platelet count increment instead of the CCI to evaluate platelet transfusion response dramatically increases the incidence of refractoriness (18->27%), indicating that platelet-poor units and large patients are frequent causes of apparent or pseudo-refractoriness. Therefore, if refractoriness is being seriously considered for a patient, a true CCI is necessary.

Protocol for management of refractoriness to platelets:

1. When consulted by a primary team about a patient’s poor response to platelet transfusion, ask about modifying factors as listed above that may influence response to platelets, in particular history of chemotherapy and number of previous transfusions. Place patient on restrictions for freshest-possible ABO-matched platelets, confirm that they’re already on leukoreduced restrictions. Ask for post-transfusion counts to determine platelet increments for the next 2 transfusions. If the patient doesn’t meet criteria for refractoriness ((11,000/(l), but is still consuming large numbers of platelets, it suggests a non-immune cause of poor responsiveness, and the clinical team should be counseled accordingly—i.e., “Your patient is not platelet refractory and therefore does not need HLA-matched or cross-matched platelets.”

2. If the patient meets the TRAP criteria for refractoriness, ask the team to send a specimen (red top or red/black top tubes for serum) to tissue typing for the FlowPRA test for anti-HLA (class I) antibodies. Specify that PRA single antigen specificities should be determined (the tissue typing lab will be made aware of the protocol we prefer they use so that when the team orders the test they can advise them as well). Also advise the team that the patient will be placed on HLA-matched platelets temporarily until the FlowPRA results are back. If the patient hasn’t been typed yet, ask the team to send blood (green top tube) to the tissue typing lab for class I HLA typing.

3. The tissue typing lab will transmit the HLA type to Dana Farber for HLA matching, and the results of this match will go to the BWH blood bank. The FlowPRA results will also go to the Brigham blood bank for Antigen Exclusion Matching. With these results, the BWH blood bank will first check its stock for category A or BU matches (a match with no incompatible class I antigens present in the donor). If an A or BU match isn’t available, the technologists will screen units for antigens of exclusion (Antigen Exclusion Matching).

4. If the FlowPRA is negative, discontinue HLA unit matching.

5. If the patient is refractory and has a threatening active bleed or a scheduled procedure, attempt to find directed donors from any recent transfusions the patient responded well to. If this doesn’t provide sufficient donors find HLA A or BU matches from our donor lists. If we cannot obtain donations from any HLA A or BU matches, or there isn’t time for directed donors, order crossmatched platelets from the American Red Cross.

6. If there is evidence of clinically significant immune-mediated platelet consumption and all the above attempts at providing compatible donor platelets have failed, you may wish to consult hematology regarding alternative interventions such as splenectomy, IVIG, or immunomodulators, which have shown some clinical value in isolated case reports. Remember that the FlowPRA, HLA, and platelet crossmatch will each take about a day and aren’t done on weekends, so think ahead.

References

1. Petz LD, Garratty G, Calhoun L, Clark BD, Terasaki PI, Gresens C, Gornbein JA, Landaw EM, Smith R, Cecka JM. Selecting donors of platelets for refractory patients on the basis of HLA antibody specificity. Transfusion. 2000 Dec;40(12):1446-56.

2. Heal JM, Blumberg N. Optimizing platelet transfusion therapy. Blood Rev. 2004 Sep;18(3):149-65.

Sacher RA, Kickler TS, Schiffer CA, Sherman LA, Bracey AW, Shulman IA; College of American Pathologists.Transfusion Medicine Resource Committee. Management of patients refractory to platelet transfusion. Arch Pathol Lab Med. 2003 Apr;127(4):409-14.

2.3.3 Fresh frozen plasma (FFP)

FFP contains all clotting factors at a concentration of 1 unit/ml. Each unit has a volume of ~250 cc, and is stored at –18 oC for 12 months.

Indications for FFP transfusion:

1. Therapy for multiple coagulation factor deficiencies as evidenced by prolonged PT and/or PTT in a patient who is bleeding or at risk of bleeding. Examples include patients with liver disease who are bleeding or at risk of bleeding due to planned invasive procedures, patients with DIC, or massively transfused patients who may develop dilutional coagulopathy. In patients with abnormal liver function, it is often impossible to completely correct the PT with FFP, due to (1) the short half-life of Factor VII and (2) limits on the volume of FFP possible to infuse into a patient.

2. Therapy for thrombotic thrombocytopenia purpura.

3. Immediate reversal of warfarin effect in situations where there is insufficient time to use vitamin K. Vitamin K should be used rather than FFP whenever possible. Remember that FFP has clotting factors at normal plasma concentrations (~1 U/ml), so that it may take 6 or more units of FFP to reverse a PT prolonged to 16-17 seconds. Vitamin K 5-10 mg p.o. will reverse coumadin within 24 hours and should not result in a coumadin-resistant state. 25-50 mg p.o. will result in coumadin resistance for approximately 4-5 days. This should not be of concern in the immediate postoperative period since heparin is used as an anticoagulant. 50 mg intravenous vitamin K will normalize the PT within 6 to 12 hours, however, the IV formulation carries an added risk of allergic reactions.

4. Correction of specific coagulation factor deficiency for which a purified product is unavailable (fibrinogen, antithrombin III, Factor II, V, VII, X, XI, protein C or S).

Inappropriate Use of FFP

1. FFP should not be used as a volume expander.

1. FFP should not be used to treat bleeding alone, or prolonged PT or PTT alone.

2. Standing orders for FFP are inappropriate.

Comments

FFP is indicated for bleeding patients with a PT or PTT prolonged to 1.5X control values. FFP may not be of significant benefit in patients with more modest prolongations of the PT/PTT.

Keep in mind that Factor VII has a very short plasma half-life (4-7 hours). For this reason, when FFP is used to try to acutely correct a prolonged PT in preparation for an invasive a procedure, it is best to give the FFP just before the procedure

The decision to transfuse FFP will necessarily rely on evidence of coagulopathy as documented by laboratory evaluation. In emergent situations, where laboratory results may not be available, samples for these tests should be submitted before FFP is given.

2.3.4 Cryoprecipitated AHF (“Cryo”)

Cryoprecipitate is produced by thawing fresh frozen plasma at 4oC and collecting the insoluble fraction. (The soluble fraction remaining is “cryo-poor plasma” aka “cryosupernatant”). Each unit (“bag”) of Cryo has a volume of 10-15 cc. Cryo contains the following: (1) Fibrinogen (150-250 mg/bag) (2) von Willebrand Factor (80 U/bag) (3) Factor VIII (80-120 U/bag) (4) Factor XIII (40-60 U/bag) (5) Fibronectin. Cryoprecipitate is not a concentrated form of FFP--it contains insignificant amounts of the other coagulation factors. Cryo is frequently ordered inappropriately for bleeding patients who actually need plasma, because the physicians want to correct a coagulopathy while giving less volume. Cryoprecipitate is indicated in the setting of a bleeding patient who has a fibrinogen level Clinical Practice Manual --> Blood

Policies

Children's

Children's internal home page -> Clinicial Site tab -> Nursing ->

Nursing Policy and Procedure Manual -> Chapter 3, Fluid Management ->

3.2 Blood Products

Website:



es%20and%20Standards/Nursing%20Patient%20Care%20Policy%20and%20Procedure

/03%20Fluid%20Management/03.2%20Blood%20Products/

2.4 Transfusion reactions

For any reported reaction to transfusion of a blood product the following steps should be taken by the floor:

1. The transfusion should be discontinued if suspicious signs/symptoms are noted (e.g. fever, chills, unexplained hypotension: see refs more complete discussion) and IV lines kept open for potential fluid resuscitation.

2. The following samples/items should be sent to the blood bank ASAP:

a. completed, signed transfusion reaction form ( normally attached to the product in question)

b. the product/bag itself which is suspected to have caused the reaction ( and any bag transfused before reaction in reasonable time frame. e.g. if two units of RBCs transfused and reaction is noted during the second, send both if available)

c. one clotted (red top) and one anticoagulated (purple top) post transfusion blood specimen, each properly labeled and accompanied by a Blood Bank requisition form

3. A freshly voided post transfusion reaction urine sample should be sent to chemistry for urinalysis to evaluate for hemoglobinuria.

4. Blood cultures on the recipient should be sent if a septic transfusion reaction is suspected (e.g. hypotension, high fever).

The following steps will be taken by the technologist in the blood bank:

1. Clerical check (check of all paperwork, computer, log book against product label, requisition form)

2. Visual examination of pre and post serum/plasma for hemolysis and icterus

3. Direct Antiglobulin Test on post transfusion specimen

• If the DAT is positive on the post-transfusion specimen, additional testing is done, including:

o ABO/Rh/Ab screen/repeat crossmatch

o If the DAT is positive using anti-IgG: an eluate/antibody ID is performed

4. Culture of remaining product, if the recipient had evidence of infection e.g. fever

Be aware that the blood bank will not release further blood products to any patient following a transfusion reaction without the approval of a blood bank physician. If the floor asks to transfuse a patient after a reaction has been called, the blood bank will page you. Determine the following:

1) What product was transfused? What product is now being requested?

2) What was the nature of the transfusion reaction? (Change in vital signs?)

3) What are the results of the transfusion reaction work-up? (is there laboratory evidence for hemolysis e.g. positive DAT?)

4) Has the patient had any previous transfusion reactions/does the patient have any anti-RBC antibodies?

Inform the blood bank whether it is acceptable to release more blood products based on the reaction history and workup. Let them know if you recommend any additional maneuvers: (e.g. premedication with Benadryl to prevent allergic reactions, etc.) A table of the most clinically important transfusion reactions is presented on the next page.

TRANSFUSION REACTIONS

|Reaction Type |Mechanism |Signs/Symptoms |Lab Diagnosis |Treatment |

|Acute Hemolytic |Pre-formed red cell |fever, hypotension, |clerical error? |Stop transfusion; |

|Transfusion |antibody |flank pain, chest pain, |DAT positive |Maintain IV access; |

|Reaction | |nausea/vomiting, chills, |hemoglobinemia, |Hydrate w/ NS +/- |

| | |shock, renal failure, |hemoglobinuria |diuretics. |

| | |DIC | | |

|Delayed Hemolytic |Primary or amnestic |Usually asymptomatic |(Hgb/Hct |Monitor CBC, renal |

|Transfusion Reaction |red cell antibody |Rarely, clinical picture |(bilirubin |status. |

| |response ~1-2 weeks |similar to acute |DAT positive | |

| |post-transfusion |hemolytic txn rxn. |(usually) | |

|Febrile Nonhemolytic |Antibody v. donor |Fever > 1oC |Blood bank |Stop transfusion; R/O |

|Transfusion Reaction |WBCs or |Chills/rigors |hemolytic workup |acute hemolytic rxn or |

| |Cytokine-mediated | |negative; culture |bacterial contamination. |

| | | |of unit negative |Premedicate w/ Tylenol; |

| | | | |Use leukopoor products. |

|Transfusion of |Product seeded by |Fever, shock, |Culture of product |Broad-spectrum |

|bacterially |donor skin flora, or |hemoglobinuria |and patient |antibiotics, fluids, |

|contaminated |donor bacteremic; |renal failure, DIC | |pressors |

|product |growth during storage | | | |

|Allergic Reaction |Allergy to donor |Hives, itching |N/A |If urticaria only sign, |

| |plasma protein |Occ. wheezing, (BP | |may re-start transfusion. |

| | | | |Premedicate w/ |

| | | | |Benadryl 25-50 mg iv. |

|Anaphylactic |Antibody to IgA |Hypotension/shock |(IgA levels |Epinephrine, fluid |

|Reaction | | |Anti-IgA Ab |resuscitation, intubation; |

| | | | |Prevent w/ washed blood |

| | | | |products. |

|Congestive heart |Volume overload, |Signs of congestive |(pO2 |Transfuse slowly; |

|failure |usually in pts. w/ |heart failure |pulmonary edema |Diuretics. |

| |heart dz getting PRBCs | |on CXR | |

|Transfusion Related |Ab to recipient WBCs |Acute respiratory |(pO2; pulm |Supportive care; usually |

|Acute Lung Injury |(usually anti-HLA) |distress, usually |edema on CXR; |resolves within 96 hrs |

|(TRALI) |(ARDS |within 6 hours of txn. |Work up donor for | |

| | | |anti-HLA Abs. | |

|Transfusion-related |Donor lymphocytes |Fever, rash, diarrhea, |CBC, (LFTs |Supportive care; |

|Graft-Versus-Host- |versus host; rarely |severe pancytopenia |skin biopsy |immunosuppression; |

|Disease (GVHD) |seen in immuno- | | |Prevent w/ irradiated |

| |competent pts who | | |blood products. |

| |share HLA w/ donor | | |Mortality rate is high. |

|Hypotensive reaction |Charged filters/artificial surfaces |Hypotension |N/A |BP support; D/C |

| |activate bradykinins; pts. on ACE | | |ACE inhibitor |

| |inhibitors can’t clear them. | | | |

|Post-Transfusion |Ab-mediated platelet |Severe pancytopenia |CBC, PlA typing |Plasma exchange or |

|Purpura (PTP) |destruction; usually |~ 1 week after | |IVIG |

| |in multiparous |transfusion. | | |

| |women who are PlA1 | | | |

| |negative. | | | |

[pic]

2.5 RhIg administration

Because of inventory limitations, RhD-negative recipients may sometimes be issued RhD-positive platelet units. (This is never done for RhD-negative women of childbearing age.) Notify the house officer taking care of the patient that that because platelet units contain a small volume of RBCs, the patient may become sensitized to the RhD antigen. To try to prevent sensitization, our policy is to recommend administering Rh Immune globulin (RhIg). The RhIg dose in this situation is 1 vial (300mcg). The route varies by brand: Rhogam is only given IM; WinRho is only given IV; Rhophylac is given either IM OR IV. RhIg is ordered on the floor and sent up by the blood bank. The rationale for trying to prevent RhD sensitization in patients who are not women of childbearing age is that the presence of anti-D in the serum might slow down a future blood bank serologic workup in a situation where the patient may need blood emergently. Note that the BMT service has a policy of giving RhIg to all Rh- patients who receive Rh+ blood products.

Occasionally you will be asked to help dose RhIg in the setting of an Rh(D) negative woman with a fetal-maternal bleed. One vial of RhIg contains 300 (g RhD and is sufficient to suppress the immune response to 15 ml Rh positive packed red cells or 30 ml whole blood. The Kleihauer-Betke (K-B) test can be used to quantitate the amount of a fetal-maternal bleed. This test is based on the fact that in the presence of acid, fetal red cells will maintain normal staining characteristics whereas adult red cells will appear as “ghosts.” The number of fetal red cells present in the sample is determined by manual counting and is expressed as a percentage of the total red cells.

To calculate the number of vials of Rhogam required, the following rule-of-thumb is used:

# vials RhIg required = 50 X %fetal red cells ( round-off +1 vial

30 ml/vial

The “50” assumes that all women have a 5 liter blood volume. The percent fetal red cells is provided by the K-B test result. One vial of RhIg covers a 30 ml bleed, and 1 extra vial is provided “for good measure.”

3. BWH BLOOD DONOR CENTER/APHERESIS UNIT

3.1 Therapeutic apheresis

During apheresis, blood is centrifuged and separated into components by density. Depending on the procedure, platelets, red cells, white cells or plasma is collected, and the remaining components are returned to the patient. Photopheresis is a special category of apheresis procedures, where the buffy coat is collected from a patient, the collected white cells are inactivated with psoralen and UV irradiation, and then returned to the patient.

3.1.1 Indications

Apheresis has been attempted as a therapy for a large number of diseases. Both the American Association of Blood Banks (AABB) and the American Society for Apheresis (ASFA) have published guidelines reflecting the current thinking regarding the efficacy of apheresis for various clinical entities. Diseases are assigned to one of four categories based on available studies in the literature (AABB Technical Manual 13th ed. pp. 136-7):

Category I: standard acceptable therapy

Category II: sufficient evidence to suggest efficacy usually as adjunctive therapy

Category III: inconclusive evidence of efficacy or uncertain risk/benefit ratio

Category IV: lack of efficacy in controlled trials

Indications for emergency therapeutic pheresis include:

TTP: This is a potentially fatal disease that can have a rapidly progressive course, so plasma exchange should be initiated as soon as possible. Follow the platelet count, Hgb/Hct, LDH, and creatinine daily. (The presence of schistocytes on the peripheral smear is critical for the initial diagnosis of TTP, but other parameters, particularly the platelet count, are more useful for monitoring the patient.) In contrast to most conditions, plasma is always used as the replacement fluid for TTP. Our standard therapeutic approach for a newly-diagnosed patient with TTP is to perform daily plasma exchanges until the platelet count stays in the normal range for ~3 days, then stop and observe the patient’s counts. Cryosupernatant (“cryo-poor FFP”) is used for replacement in patients who fail to respond after ~5 plasma exchanges.

Myasthenia Gravis: Common indications for plasma exchange include:

(1) shortness of breath (risk of respiratory failure) (2) difficulty swallowing (risk of aspiration) and (3) preparation for thymectomy. Plasma exchange is frequently used to try to prevent a patient from requiring intubation, or to hasten a patient’s removal from the ventilator. Key respiratory parameters to follow are negative inspiratory force (NIF) and forced vital capacity (FVC). Patients are typically pheresed ~every other day for 5 days, using 5% albumin in normal saline (NS) as a replacement fluid. Because coagulation factor levels are lowered when using albumin replacement, the PT/PTT should be monitored. If the PT prolongs more than a few seconds, or if any other additional bleeding risk is present, FFP should be considered. (A typical maneuver is to use 5% albumin/NS for the beginning of the procedure, and then to use FFP for the last liter of replacement.)

Sickle Cell Disease: The efficacy of red cell exchange has been best established for: (1) evolving stroke (2) sickle chest syndrome and (3) refractory priapism. Hematocrit and

%Hgb S goals (usually Hct = 30%; Hgb S = 30%) are decided in conjunction with Hematology. In most cases, the patient is assumed to have a starting Hgb S of 100%. Generally, these patients are not transfused to hematocrits above 30%, as higher hematocrits can impair blood flow and actually worsen the clinical condition. The replacement product of choice is prestorage leukoreduced PRBCs (theoretically less likely to cause transfusion reactions). These patients should be premedicated with Benadryl (25 mg IVP) and Tylenol (650 mg po) prior to the procedure to reduce the chance/severity of an allergic reaction, and to try to prevent having to halt the procedure because of a febrile reaction. (Hemolytic transfusion reactions can present with fever.) Order a post-procedure CBC and Hgb analysis.

Guillain-Barré: As with myasthenia gravis, the primary indication for plasma exchange is to prevent patients from having to be intubated, or to shorten their course on the ventilator. Patients who are in imminent danger of respiratory failure are treated on an emergent basis.

Leukoreduction: Patients with acute leukemia may present with symptoms of hyperviscosity secondary to leukostasis in the cerebral or pulmonary vascular beds. Usually this is seen in patients with extremely high blast counts (> 100,000/(l.) Leukapheresis may be requested to acutely lower the white count prior to the initiation of chemotherapy.

Goodpasture’s Disease: Acute removal of the pathologic anti-basement membrane antibody is done to preserve lung and kidney function. In patients with hemoptysis, FFP is a good choice for replacement.

Posttransfusion purpura (PTP): This is a rare antibody-mediated thrombocytopenia typically seen in multiparous women ~1 week after receiving a blood product. Thrombocytopenia can be very severe ( ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download