1 / 23

Ariana Beck, M.D. PGY3

Ariana Beck, M.D. PGY3. Blood Bank Interesting Case Conference. Interesting Case #1 Patient JW. Interesting Case Conference: Pt JW. 54 year old man with a history of a recurrent parafalcine meningioma who underwent resection with a bone flap at the Nashville VA 1/25/2015

dewald
Download Presentation

Ariana Beck, M.D. PGY3

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Ariana Beck, M.D. PGY3 Blood Bank Interesting Case Conference

  2. Interesting Case #1 Patient JW

  3. Interesting Case Conference: Pt JW • 54 year old man with a history of a recurrent parafalcine meningioma who underwent resection with a bone flap at the Nashville VA 1/25/2015 • He was subsequently discharged to rehab at the Murfreesboro VA 2/6 but developed wound drainage and edema around 2/17-2/18 • He represented to the Nashville VA 2/20/2015 • MRI showed a fluid collection consistent with empyema and hematoma and he was transferred to VUMC • In addition, he was throbocytopenic (plt 77k/uL)

  4. Interesting Case Conference: Pt JW Type and screen negative (3/2) Type and screen negative (2/24) Type and screen negative(2/20) • He underwent washout surgery 2/20 • A type and screen was sent • At that time, an antibody screen was negative • The patient’s blood type is O negative

  5. Interesting Case Conference: Pt JW Type and screen negative (3/2) Type and screen negative (2/24) Type and screen negative(2/20) • A type and screen performed 3/6 was positive with an anti-D identified on follow up panels (DAT –ive for IgG)

  6. Interesting Case Conference: Pt JW Investigation:

  7. Interesting Case Conference • Further investigation: • VA transfusion history • Per VA BB tech all RBC units were Rh- • He did, however receive 2-3 units of Rh+ platelets (circled)

  8. Interesting Case Conference • What happened? • Did the patient really develop an anti-D alloantibody in response to the platelet transfusions? Only apheresis platelets are used at Vandy and the VA • Is this a passive anti-D? • No record of IVIG or RhIG administration • The VA does not have RhIG in stock • Recall that ABHantigens (but not Rh) are present on the surface of platelets • A small, but nonetheless immunogenic dose of RBCs may be present in platelet products • Whole blood-derived platelets carry a higher risk of alloimmunization due to the greater amount of RBCs in the product compared to apheresis platelets • Per FDA standards a single apheresis platelet product must have less than 2 mL of RBC in an apheresis  • In reality, more like less than 0.001 ml of RBCs • In contrast, each whole blood derived platelet concentrate contains a few tenths of a milliliter of RBCs • One study reports quality control data showing the mean RBC content in apheresis and whole blood derived platelets was 0.00043ml and 0.036 ml respectively • There is evidence that the minimum RBC volume necessary to elicit a primary anti-D immune response is ~0.03 ml • The AABB mandates that transfusion services must have a policy for RhIG prophylaxis for D- patients exposed to D+ RBCs [1,2]

  9. Interesting Case Conference [1] • Older studies (before 2000) have shown the incidence of D alloimmunization in D- recipients after receiving D+ platelet transfusions as up to 19% • A more recent study performed in Spain showed an anti-D alloimmunization rate of ~3.8% (315 total patients) • However, 88% of these transfusions were whole blood derived platelets • Smaller studies looking at alloimmunization rates due to apheresis platelets have shown no alloimmunization

  10. Interesting Case Conference • 14 year retrospective study performed at Beth Israel Deaconess Medical Center looking at the rate of anti-D formation after D-incompatible platelet transfusions in patients who did not receive RhIG or D+ RBCs. • January 1997- December 2011 [1]

  11. Interesting Case Conference [1] • 626 total D- patients who received D+ aphersis, leukoreduced platelets were identified • 45 excluded for RhIG administration • 50 excluded for receiving D+ RBC • 16 excluded for receiving a stem cell transplant from a D+ donor • 8 excluded for “unresolved Rh” at admission • 23 excluded for prior anti-D • Of the eligible patients, 130 had antibody screens performed at least 4 weeks after the platelet transfusion • 52% were men, 48% were women • 57% were immunocompetent • None of these (130) patients developed an anti-D

  12. Interesting Case Conference • Retrospective study looking at D- patients who received D+ platelet transfusions from 11 centers in 4 countries • 2010, 2011, 2012 • Eligible patients were D-, with no known anti-D, no prior D+ blood component exposure, and had an antibody screen performed at least 28 days after the transfusion • Patients who received RhIG, D+ RBCs, etc were excluded [2]

  13. Interesting Case Conference: Pt JW [2] • The overall frequency of primary D alloimmunization was 7/485 or ~1.4% (95% CI: 0.25-2.97%) • Of those 7, 4 received only apheresis platelets • 3 were immunocompetent, 3 were immunosuppressed, and the status of 1 was unknown • In this study the D alloimmunization rate was 4/288 in patients who exclusively received apheresis platelets (~1.4%) • There were no significant differences between the primary anti-D formers and those who did not form a primary anti-D in any of the analyzed parameters • Gender, age, ABO group, main diagnosis, iatrogenic immunosuppression, pregnancy history, location, previous RBC transfusions, previous platelet transfusion or platelet product (whole blood derived, apheresis, both) • I would have like to have seen the data divided by type of platelet transfused to specifically look at immunosuppressed/ immunocompetent patients who received only apheresis platelets

  14. Interesting Case Conference: Pt JW [2] • What happened? • Not significantly immunosuppressed • Should we have done anything differently? • Should we have given RhIG • What about at the VA • Was this an anamnestic or primary response? • Typically it should take ~28 days to produce a primary anti-D immune response • Could have developed an anti-D in response to Rh+ platelets given at the VA 1/31/2015 • Is this a real anti-D or passive • No record of IVIG or RhIG

  15. Interesting Case #2 Patient JA

  16. Interesting Case Conference: Pt JA • 32 year old man with a history of a sickle cell disease who presented 3/12 with altered mental status • Just prior to presentation, he had a seizure and fell • Sustained vertebral fractures • He has no history of respiratory compromise or acute chest syndrome • Smokes ~1 pack per week x 16 years • He has a history of infected left hip hardware that has required surgical revision and an antibiotic spacer • During this admission, multiple blood cultures have grown MSSA • His left hip hardware and right port were the likely sources • Right subclavian port was removed by general surgery

  17. Interesting Case Conference: Pt JA What should we do? • We were consulted 3/24 to perform a red blood cell exchange prior to the patient undergoing orthopedic surgery • Orthopedic surgery initially cancelled due to high HgS of 63.5% • HgS dropped to 48.1% after 2 simple transfusion • His hemoglobin at that time was 11.4 g/ dL, HCT 34% • Operative history includes bilateral total hip arthroplasties (OSH) with revision of the left hip femoral component in 2014 (VUMC) as well as a splenectomy in 2001 (VUMC) • Per the patient, he has never undergone exchange transfusion • In addition, he does not want a femoral line

  18. Interesting Case Conference: Pt JA • Orthopedic procedures are common in sickle cell patients • Multicenter study looking at perioperative complications among sickle cell patients using different transfusion strategies [3]

  19. Interesting Case Conference: Pt JA [3] Patients undergoing elective orthopedic surgery were randomized into 2 groups • 1- Aggressive transfusion: decrease hemoglobin S to <30% and to increase hemoglobin to 10 g/dL • Method of transfusion up to principle investigator of site • 73% underwent exchange transfusion • 2- Transfusion to increase hemoglobin to 10 g/dL • 10% underwent exchange transfusion • Patient who declined randomization or were transfused within 3 months were eligible for group 3: not transfused in the preoperative period or group 4: transfused but not randomized

  20. Interesting Case Conference: Pt JA [3] • 118 patients underwent 138 procedures • 74 patients randomized into groups 1 and 2 • The remaining patients were in the non-randomized groups • All patients received sickle-negative blood • 68% of the surgeries were hip related • Results: • Group 3 had lower Hg than the other groups (9.0 g/dL vs 10.3-10.9 g/dL) • The HgS% was also different across all groups: 38% group 1, 58% group 2, 89% group 3, 25% group 4 • Sickle cell related event were associated with 17% of procedures • These events did not significantly differ between randomized groups • There was a statistically significant difference in acute chest syndrome rate across the groups: 21% group 1, 8% group 2, 21% group 3, 3% group 4 (P= 0.04) • Authors concluded that there is no advantage to aggressive pre-op transfusion • They conclude that a conservative transfusion regimen in which hemoglobin is brought to between 9-11 g/dLpreop was as effective as an aggressive transfusion regimen in which the hemoglobin S level was lowered to ~30%

  21. National NIH Published Guidelines [4]

  22. Interesting Case Conference: Pt JA • Excellent example of good communication with clinical team • Patient doing well post op Follow up

  23. Interesting Case ConferenceReferences [1] O'Brien KL, HaspelRL, Uhl L. Anti-D alloimmunization after D-incompatible platelet transfusions: a 14-year single-institution retrospective review. Transfusion. 2014 Mar;54(3):650-4. PubMed PMID: 23829356. [2] Cid J, Lozano M, Ziman A, West KA, O'Brien KL, Murphy MF, Wendel S, Vázquez A, Ortín X, Hervig TA, Delaney M, Flegel WA, Yazer MH; Biomedical Excellence for Safer Transfusion collaborative. Low frequency of anti-D alloimmunization following D+ platelet transfusion: the Anti-D Alloimmunization after D-incompatible Platelet Transfusions (ADAPT) study. Br J Haematol. 2015 Feb;168(4):598-603. PubMed PMID: 25283094. [3] Vichinsky EP, Neumayr LD, Haberkern C, Earles AN, Eckman J, Koshy M, Black DM. The perioperative complication rate of orthopedic surgery in sickle cell disease: report of the National Sickle Cell Surgery Study Group. Am J Hematol. 1999 Nov;62(3):129-38. PubMed PMID: 10539878. [4]http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/sickle-cell-disease-report.pdf

More Related