Thirty-day typing and screening for patients undergoing elective surgery: experience at a large cancer center.

BACKGROUND: Preoperative testing in patients scheduled to undergo surgery often includes determining the ABO group and Rh type and screening for atypical alloantibodies in blood samples. AABB recommends obtaining blood samples within 3 days of transfusion. This was extended to 30 days to minimize the number of phlebotomies, avoid delays in providing blood during surgery, and decrease the laboratory workload. This study was conducted to show that extending the expiration date of the preoperative blood sample for blood typing and screening to 30 days will serve our purpose and provide better patient care. STUDY DESIGN AND METHODS: Data were collected for all patients undergoing elective surgery with perioperative blood samples submitted to our blood bank over 31 months. Each patient completed a questionnaire to determine whether his or her samples qualified for a 30-day preoperative clot. The questionnaires were validated upon preoperative screening. A transfusion medicine physician made the final determination regarding whether the samples qualified for 30-day typing and screening. These blood samples were used for cross-matching to find compatible blood during surgery. RESULTS: A total of 12,310 preoperative blood samples were received with a request for typing and screening, 4,370 (35.5%) of which qualified for a 30-day expiration date. No significant problems were encountered with these blood samples. CONCLUSION: Extension of the preoperative clot expiration date from 3 to 30 days has improved service to our patients and their physicians and indirectly reduced the laboratory workload.

Transfusion of RhD-incompatible blood components in RhD-negative blood marrow transplant recipients.

BACKGROUND: Transfusion-dependent bone marrow transplant recipients are routinely transfused with ABO group and RhD-compatible blood components. However, because of the scarcity of RhD-negative blood components, particularly platelets, a policy was developed to transfuse RhD-positive blood components to RhD-negative patients during periods of shortage. METHODS: We reviewed the records of 78 RhD-negative patients with hematologic malignancies who received RhD-negative bone marrow and/or peripheral blood stem cells, from June 1995 to August 2000. The patients transfused with RhD-incompatible blood components were screened periodically for evidence of the development of red blood cell (RBC) alloimmunization. RESULTS: Three of 78 patients (4%) developed anti-D antibodies after receiving RhD-incompatible platelet transfusions. One of the patients developed evidence of anti-RhD antibodies after receiving 42 units of RhD-positive random donor platelets; the second patient developed such evidence after receiving 6 apheresis platelets and 2 infusions of intravenous immunoglobulin G (positive for anti-RhD). The third patient received 206 RhD-positive random donor platelets and 5 apheresis units. All patients were discharged from the hospital. The overall immunization rate was 4%. Six patients received Rh-incompatible packed RBCs and showed no evidence of neither anti-RhD nor any other anti-RBC antibodies. All 78 patients had received RhD-incompatible platelets throughout their engraftment period. CONCLUSION: Transfusion of RhD-positive blood components to Rh-negative patients with hematologic cancers, who have received RhD-negative bone marrow and/or peripheral blood stem cells, are at low risk of developing RhD antibodies. These findings allow for a flexible strategy of blood component therapy support for this special patient population during periods of shortage.

Underreporting of minor transfusion reactions in cancer patients.

BACKGROUND: Minor adverse reactions following transfusion of blood components to cancer patients are not uncommon. Reporting these minor reactions to the transfusion service needs a careful evaluation. The objectives of this study were to closely monitor the transfusion reactions that occurred and had not been reported to the transfusion service and to evaluate the process by which the medical and nursing staff recognized and managed these reactions. METHODS: We prepared a questionnaire with the nursing staff of a selected inpatient unit that addressed important questions, such as signs and symptoms during the transfusion, premedications given, process for physician notification, recommended action, and blood component implicated. Charts of the patients were reviewed, and the process was monitored for a 6-month period. RESULTS: A total of 58 cases were completed and analyzed. Platelet concentrates were transfused in 43 cases (74.1%), packed red blood cells in 9 cases (15.6%), and fresh frozen plasma in 6 cases (10.3%). Minor adverse reactions that were documented included chills in 11 cases (19.0%), low-grade fever in 11 cases (19.0%), hives and itching in 24 cases (41.4%), nausea and vomiting in 1 case (1.7%), and headaches and nonspecific mild pains in 11 cases (19.0%). Transfusions had been resumed in 27 cases (46.6%) and stopped completely in 13 cases (22.4%). Twenty-seven of 58 (46.6%) were first-time events. CONCLUSION: We conclude that underreporting of minor transfusion reactions, such as a febrile nonhemolytic transfusion reaction and allergic reactions, exists. To ensure safety to our cancer patients who are transfusion-dependent, we suggest that careful evaluation of any suspected transfusion reaction event should be referred to the transfusion medicine physicians who will evaluate each case and discuss it with the attending physician. This process will prevent detrimental, acute transfusion reactions.

Intraarterial platelet infusion for patients with intractable gastrointestinal hemorrhage and severe refractory thrombocytopenia.

Transarterial therapies used for the treatment of acute nonvariceal gastrointestinal (GI) hemorrhage have traditionally included vasopressin infusion and embolization. However, for patients with diffuse or multifocal hemorrhage and severe refractory thrombocytopenia, these options are suboptimal because platelet counts and coagulation parameters may not be adequate to allow for the formation of a stable clot. Herein two such patients treated with direct intraarterial (IA) infusion of platelets into the vascular territory supplying the hemorrhage are described. In both patients, after IA platelet infusion, blood product requirements were immediately reduced, bleeding from the GI tract resolved by clinical and laboratory criteria, and no significant bowel ischemia was seen.

West Nile encephalitis in 2 hematopoietic stem cell transplant recipients: case series and literature review.

Most human cases of West Nile virus infection are acquired via bites from an infected mosquito. In some cases, infection may also be transmitted by infected blood products or transplanted organs. There have been recent publications suggesting that chemotherapy and immunosuppression may increase a person's risks of developing central nervous system disease if the person is infected with the West Nile virus. Because patients undergoing hematopoietic stem cell transplantation not only are immunocompromised, but also receive multiple blood products, they are at a particularly high risk for acquiring symptomatic disease if exposed to the West Nile Virus. We describe here 2 patients who underwent hematopoietic transplantation at our institution and subsequently developed fatal West Nile virus infections.

Transjugular liver biopsy in patients with hematologic malignancy and severe thrombocytopenia.

PURPOSE: The purposes of this study are to report experience with transjugular liver biopsy (TJLB) in patients with hematologic malignancy and severe thrombocytopenia and to determine the incidence of hemorrhage-related complications in patients with prebiopsy and pretransfusion platelet counts of 30 x 10(9) /L or lower to propose a threshold platelet count above which TJLB can be safely performed without transfusion. MATERIALS AND METHODS: Medical records and laboratory reports of 50 patients with severe thrombocytopenia who had undergone 51 TJLB procedures and prebiopsy platelet transfusions between August 1999 and September 2001 were retrospectively reviewed. Biopsy success and procedural complications were recorded. RESULTS: TJLB was technically successful in 49 of 51 procedures (96%). The mean prebiopsy, pretransfusion platelet count was 17 x 10(9)/L (range, 3-30 x 10(9)/L) and a mean of 11 U (range, 6-32 U) of platelets per patient were transfused. The overall mean postbiopsy platelet count was 38 x 10(9)/L (range, 5-105 x 10(9)/L), but it remained 30 x 10(9)/L or lower in 24 TJLB procedures. No hemorrhage-related complications were encountered, but ventricular fibrillation occurred in one patient during the procedure. CONCLUSION: A threshold platelet count for safe TJLB resides below 30 x 10(9)/L. A prospective study is necessary to better define a lower threshold above which TJLB can be performed without platelet transfusion.

Safety and efficacy of transfusions of autologous cryopreserved platelets derived from recombinant human thrombopoietin to support chemotherapy-associated severe thrombocytopenia: a randomised cross-over study.

BACKGROUND: The increasing demand for platelet products, and concern over the transfusion-associated risks of alloimmunisation and infections, have motivated a search for improved methods aimed at keeping exposure to donor antigens to a minimum. Transfusion of thrombopoietin-derived autologous platelets might provide an alternative strategy. We aimed to compare the safety and efficacy of this strategy with that of transfusion with fresh allogeneic platelets in patients with severe chemotherapy-induced thrombocytopenia. METHODS: 20 patients with gynaecological malignancies were treated with two doses of 1.2 microg/kg recombinant human thrombopoietin. From day 12, we aimed to collect 50 units of platelets from these patients by plateletpheresis. Harvested platelets were cryopreserved in ThromboSol and 2% dimethyl sulfoxide (DMSO) for use in subsequent autologous transfusions. Patients then received carboplatin for up to six cycles. Patients were randomly assigned to group A (n=10), which received allogeneic fresh platelets at the first instance of severe thrombocytopenia (platelet count <15,000/microL) and then autologous cryopreserved platelets at the next, or to group B (n=10), which received first autologous and then allogeneic platelets. In subsequent cycles, all patients received autologous platelets while available. The primary endpoint was platelet count increment corrected for the number of platelets transfused and the patients' body-surface area. Analysis was by intention to treat. FINDINGS: Treatment with recombinant human thrombopoietin significantly increased platelet count (median 2.3-fold [range 1.5-3.3], p<0.0001) in all but one patient in group A. The median number of platelets collected per patient was 53 units (14-66) in two collections (one to three). There was no significant difference in the corrected platelet count increments (CCIs) between the 19 paired transfusions of cryopreserved autologous platelets and fresh allogeneic platelets (median 1-h CCI 15.7 vs 19.8, p=0.398; median 24-h CCI 13.0 vs 18.1, p=0.398). 14 of the 19 patients had a good response (1-h CCI >7.5) to their first transfusion of allogeneic platelets. By contrast, all patients had a good response to their first transfusion of autologous platelets (p=0.063). Moreover, no significant decrease in the CCIs (p=0.405) was seen over six cycles after autologous platelet transfusions (n=63). No transfusion reactions or any serious adverse event was recorded during autologous platelet transfusions. INTERPRETATION: Recombinant human thrombopoietin facilitated collection of multiple units of platelets, which could be cryopreserved and reinfused to counteract severe thrombocytopenia during multicycle chemotherapy. Transfusion of autologous cryopreserved platelets derived from recombinant human thrombopoietin can provide a viable strategy to minimise the risks of allogeneic platelet transfusions and provide a long-lasting supply of platelet support.