O NO YOU DIDN T! AN ABO-MISMATCHED PLATELET TRANSFUSION

Transcription

1 O NO YOU DIDN T! AN ABO-MISMATCHED PLATELET TRANSFUSION L A U R I E W O L F M L S ( A S C P ) S B B U N I V E R S I T Y O F K A N S A S H O S P I T A L

2 PATIENT OVERVIEW y/o male with a history of NHL presents to the outpatient cancer clinic complaining of significant fatigue, overall weakness and hematuria NHL diagnosis in Subsequent autologous BMT Multiple transfusions

3 PATIENT OVERVIEW Lab Values Hemoglobin 5.9 C ( gm/dl) Urinalysis Color RED Turbidity TRACE (CLEAR) Urine Bili POS (NEG) Ictotest POS Urine Blood 2+ (NEG) Patient admitted from the Cancer Center to the hospital for possible HTR

4 WHAT ON EARTH HAPPENED?! Transfusion related? 10/28/11 1 RBC and 1 PLT 10/29/11 1 RBC 10/31/11 1 PLT 11/1/11 1 RBC 11/2/11 1 RBC 11/3/11 1 PLT Transplant related? Possible allo instead of auto? Drugs? Clerical error?

5 POST TRANSFUSION WORKUP

6 TRANSFUSION REACTION WORKUP 11/4/2011 SPECIMEN

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8 PRE TRANSFUSION WORKUP

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11 TRANSFUSION REACTION: A COMPARISON Pre transfusion No clerical errors Icterus and no visible hemolysis A positive / ABSC negative DAT positive Anti-A in eluate and plasma Post transfusion No clerical errors Icterus and no visible hemolysis A positive / ABSC negative DAT positive Anti-A in eluate and plasma

12 TRANSFUSION TIMELINE Date Hgb ( gm/dl) Product Rec d PLT RBC Blood Type O POS A POS Issued Time RBC A POS PLT O POS RBC A POS RBC A POS PLT O POS RBC A POS RBC O POS * RBC O POS * Haptoglobin 4 ( mg/dl)

13 TRANSFUSION TIMELINE RBC A POS / RBC A POS PLT Vol: 234 ml 10/ / RBC A POS 5.9 PLT Vol: 229 ml 11/ RBC A POS 11/ / / RBC PLT A POS Vol: 262 ml 11/ RBC O POS 11/ RBC O POS 11/ HGB

14 ABO-MISMATCHED PLATELET TRANSFUSIONS: Platelet Product Review ABO antigens on surface of platelet Donor plasma containing naturally occurring anti-a, anti-b, anti-a,b Compatibility Issues Major ABO-incompatibility Decreased donor platelet survival due to recipient s isohemagglutinins Minor ABO-incompatibility Decreased recipient RBC survival due to passively acquired donor s isohemagglutinins

15 ABO-MISMATCHED PLATELET TRANSFUSIONS Acute Hemolytic Transfusion Reactions Rare but potentially severe hemolysis Hemoglobinuria/hematuria HGB resulting in RBC transfusions Fatalities reported Unusually high titers of anti-a in group O platelet donors Large amounts of incompatible plasma in SDPs Incidence ranges (institutional reporting) from 1 in 2000 to 1 in 46,176 platelet transfusions 1 Estimated risk of 1 in 9000 due to 40% of platelet transfusions in the US are incompatible 1

16 ABO-MISMATCHED PLATELET TRANSFUSIONS Platelet Product Management 10-40% of platelet transfusions in US facilities are incompatible with patient s RBCs 1 5 day platelets Short outdates Decrease wastage Relative low risk

17 TO TITER OR NOT TO TITER? THAT IS THE QUESTION Policies and Practices No standardization in US regarding management of ABO-mismatched platelet transfusions AABB and CAP require policies for transfusion services but vague requirements Some blood centers titer, some don t Cost/benefit ratio Titer group O platelet donors What method shall be used? Tube or gel? Or both? What is considered a high titer or dangerous donor? Cutoff? Potentially eliminate a platelet donor in an already scarce supply?

18 TO TITER OR NOT TO TITER? THAT IS THE QUESTION European Policy Proactive approach in preventing HTRs Mandate passed in the 1990 s stating that each donation testing laboratory should have in place a testing and issuing policy which would strive to avoid the transfusion of blood from high-titer anti-a and/or anti-b donors to non-group O recipients 1 Universally, blood centers screen donors for high titers Automated method: titer of 100 Tube method: titer of 128 University Health System Consortium Academic healthcare organizations from across the country Data-driven comparison of systems Approximately half titer Cutoff for critical titers range from one tube titer of 1:50 to 1:500 Most immediate spin, saline tube methods Most are then labeled as critical Some products are even plasma reduced depending upon the age of patient

19 UHC SURVEY: NOVEMBER 2011 TRANSFUSION POLICIES FOR OUT OF GROUP PLATELET TRANSFUSIONS Location University of Virginia Health System Do you transfuse ABO plasma incompatible (out of group) platelet apheresis? Yes If so, do you perform anti- A/anti-B titers to eliminate high titer products that may cause passive alloimmune hemolysis? Yes Are titers performed on all platelet types or restricted to group O? All platelet types except AB What titer do you use to determine acceptability for transfusion? 200 The 200 titer came from the Vietnam era. They would do titers of 200 to determine if they could give out of group whole blood to wounded soldiers. We have been doing the titers for over 20 years and have never had a problem. Comments Rush University Medical Center Try to give ABO compatible, but will give incompatible if nothing else is available. Except for Infants up to 4 months who either get AB 1 st, ABO compatible if AB not available; and plasma removed if ABO incompatible. If patient develops a pos DAT due to A or B antibody and the antibody is detectable in the patient plasma, then only ABO compatible are given or plasma removed from ABO incompatible. No No NA

20 UHC SURVEY: NOVEMBER 2011 TRANSFUSION POLICIES FOR OUT OF GROUP PLATELET TRANSFUSIONS UCSD Transfusion Services Yes Yes any reaction of a 1:100 dilution of plasma in saline with A1 & B cells; IS RT; no incubation. This occurs about 1/30 samples and varies by blood type. all O, A, B University of Arkansas for Medical Sciences We do transfuse ABO plasma incompatible platelet apheresis. We do not perform anti-a/anti-b titers We transfuse approximately 13,000 platelet apheresis per year and see very few problems related to ABO mismatch platelet transfusions, the majority of those few problems are positive DAT s on some of our multiply transfused patients that would require an eluate. UWHospital and Clinics Madison, WI We do transfuse ABO plasma incompatible platelet apheresis units but limit it to 1 per 24 hrs. We do not perform any anti-a or anti-b titers on these units.

21 UHC SURVEY: NOVEMBER 2011 TRANSFUSION POLICIES FOR OUT OF GROUP PLATELET TRANSFUSIONS Fletcher Allen Health Care (Burlington, VT): Yes Yes All platelet types as needed or with possible intention to transfuse out of 1:50 with saline at immediate spin group, but not all (tube method), but for patients under platelets received into 6 years of age, we require both 1:50 Blood Bank. So not titer as well as plasma reduction of restricted to group O. the platelets. In emergencies for We have seen some pediatric patients we will waive the high titer anti-a centrifugation step but still require among our group B the 1:50 titer if possible, or avoid platelets. There is group O platelets if they cannot wait one report in the for the titer to be completed. literature of a high titer non-o platelet associated hemolytic reaction. University Hospital, NJMS/UMDNJ, Newark, NJ Yes Yes Incompatible plasma We use platelets if titer of either A or B is less than 64. Loyola University Medical Center, Maywood, IL Yes Yes Do not perform titers unless requested NA

22 UHC SURVEY: NOVEMBER 2011 TRANSFUSION POLICIES FOR OUT OF GROUP PLATELET TRANSFUSIONS Parkland Health & Hospital System Yes Yes Group O only We do a single tube at a titer of 1:500. If the tube is positive, we will put a sticker on the product and only use the platelet for a type O patient. If the tube is negative, will put a sticker on the product and use for any patient. These titers are ordered on the product in our computer system and maintained electronically. DeGowin Blood Center University of Iowa Hospitals & Clinics At the University of Iowa, we transfuse ABO plasma incompatible apheresis platelets to adults when we don't have compatible units. We don't do titers. For patients less than 1 year of age, we give type specific or ABO plasma compatible. If we don't have compatible units, the Pathologist evaluates the benefit versus the risk. Again, we don't do titers. No NA NA

23 UHC SURVEY: NOVEMBER 2011 TRANSFUSION POLICIES FOR OUT OF GROUP PLATELET TRANSFUSIONS Stritch School of Medicine, Loyola University Medical Center Yes, frequently in adult patients, usually without any clinical or likely even serological consequences. Prophylacticall y, for children/infants, we endeavor to maintain use of compatible or ABO-identical platelets (the risk of isoagglutinin hemolysis is enhanced in patients who have a small blood volumes) as much as possible. [But even in children, I'd clinically correlate the decision in emergent situations.] We do not perform anti-a / anti-b titers. Passive alloimmune hemolysis is a risk, but a very small risk, although it is reported in the literature and is a consideration. In over 25 years, I have seen only one case of mild hemolysis in an A-pos adult who had a reaction associated transfusion of a Group O apheresis platelet with a weakly-positive DAT due to anti-a,b. This was a hemolytic transfusion reaction and the patient did spike a fever with chills, but the transfusion was halted. There are no regulations or Standards which require such titering. In Hospital Blood Banks that transfuse 1000's of platelets annually, I wonder how many Services have enough staff to do titers? Maybe in a more perfect world. Not performed on any. NA

24 UHC SURVEY: NOVEMBER 2011 TRANSFUSION POLICIES FOR OUT OF GROUP PLATELET TRANSFUSIONS UCLA Medical Center Denver Health Medical Center We only very rarely give a Group O pltph to a Group A, B or AB patient. And Because of the rarity, its usually a very extreme we do not currently emergency. Maybe once or perform titers on the twice a year. We would O pltpherses. warn any MDs of small but possible chance of hemolysis. We transfuse ABO incompatible Platelet Apheresis to Adults and Children over 12yr / 40lbs. No University of Kansas Hospital Yes, when type specific products are not available. We try to avoid use of a group O platelets on group A patients. No NA NA University of Chicago Medical Center Yes, we allow up to 500ml incompatible plasma per 24 hours (approximately 2 products) when we have to give ABO incompatible platelet apheresis products. We have also started using and drawing the PAS platelets which allows more products due to the PAS products reduced donor plasma. No NA NA

25 UHC SURVEY: NOVEMBER 2011 TRANSFUSION POLICIES FOR OUT OF GROUP PLATELET TRANSFUSIONS Wishard Health Services yes, but we limit to 2 ABO incompatible/24 hrs or maximum of 4/week. We do an intentional deviation from SOP for Massive transfusion protocols - they are given whatever we can get. :) No NA NA SUNY Downstate Medical Center Yes Yes, but only for neonates in an emergency. All types <100 Yes No NA NA Truman Medical Center Hospital Hill

26 CASE STUDY PLATELET TITERS Platelet Date Transfused Cells IgM + IgG Titer A A A A A A IgG Titer

27 8 7.5 TRANSFUSION TIMELINE: REVIEW HGB / PLT A 1 Total: 128 IgG: 64 A 2 Total: 64 IgG: 32 10/ / PLT A 1 Total: 32 IgG: 16 A 2 Total: 32 IgG: 4 11/ / / / PLT A 1 Total: 512 IgG: 128 A 2 Total: 256 IgG: 32 11/ / /5 1600

28 RESOLUTION Patient Admitted to hospital afternoon of Given group O RBCs to support decreased HGB One volume therapeutic plasma exchange HGB rebounded up to 8.2 mg/dl within a few days Donor Platelet #3 donor was deferred as a platelet donor

29 QUESTIONS What is your facility s policy? Should platelet products containing anti-a and/or anti-b be titered? Should the products be labeled as a dangerous donor or be deferred? What s the preferred method? What should the cutoff be?

30 REFERENCES 1. Josephson, C, Castillejo, M, Hillyer, C. ABO-mismatched platelet transfusions: Strategies to mitigate the patient exposure to naturally occurring hemolytic antibodies. Transfusion and Apheresis Science 42 (2010) Herman, Jay. Apheresis platelet transfusions: does ABO matter? Transfusion 2004; 44: Josephson, C, Mullis, N.C., Van Demark, C, Hillyer, C.D. Significant numbers of apheresis-derived group O platelet units have high-titer anti-a/a,b: implications for transfusion policy. Transfusion 2004; 44: Fung, M, Downes, K, Shulman, I. Transfusion of Platelets Containing ABO-Incompatible Plasma: A Survey of 3156 North American Laboratories. Arch Pathol Lab Med, Volume 131, June 2007,