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Neil Blumberg

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Neil Blumberg last won the day on February 27

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    Hematologist/Transfusion Medicine Physician

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  1. Another expensive but possibly effective approach would be to use one of the complement activation inhibitors, such as eculizamab, that is used to treat paroxysmal nocturnal hemoglobinuria, a disease with inadequate inactivation of complement components.
  2. Another strategy, which works for ABO incompatible kidney transplants in some cases, is a combination of immunosuppressive drug therapy, IVIgG and plasma exchange. If it works for ABO, one would guess that it could work for Inb (or anything else, for that matter). One also guesses that the antibody might be wholly or largely IgM if it only causes HTR and not HDN. If that were the case, plasma exchange could be particularly effective.
  3. I agree that blood bank refrigerators in the OR (or anywhere else) are accidents waiting for a place to happen. We use a temperature monitored and controlled cooler system so that the blood for the patient in the OR is sitting right next to the anesthesiologist. Have had no mistransfusion accidents in the OR in the close to 40 years I've been here. In the hospital where I trained there was an OR refrigerator and we had mistransfusions every few months. Case closed.
  4. Nurses are supposed to know how to give intramuscular injections to heavier patients. That said, it can be given intravenously or sub-cutaneously with equal benefit, although few outpatient practices give intravenous injections. With very heavy patients, a longer needle works.
  5. Most transfusion practices in neonatalogy, including this one, are not evidence based, but rather empirical expert opinion. The use of reconstituted whole blood is more historical than anything else. A unit or two of recently collected (perhaps 7-14 days) whole blood would probably be as rational. One might check the potassium before using to make sure it isn't super high. That is the rationale for washing a red cell. It removes potassium from hemolysis during collection and storage, and makes the red cells more likely to absorb potassium once transfused. It's definitely more useful if the baby is hyperkalemic to begin with. Otherwise, whole blood would be fine. The reason for using plasma is fear of hypocoagulability, which is probably mostly mumbo jumbo for small exchanges, but might be more of an issue for larger exchanges (2 or more blood volumes). There is no real proof that any of these approaches is superior or inferior. Calculating the hematocrit is a case of weighing the red cells and measuring their hematocrit and then diluting accordingly with plasma or albumin solution (5%). You don't want a hematocrit higher than 40 in the exchange as normal neonates do not have high hematocrits and oxygen delivery is actually worse at hematocrits much above 30 in experimental models. In this case, more is not better as far as anyone knows. Once again, this is expert opinion not evidence based.
  6. If you have access to a medical school or teaching hospital library, it will likely be available there at one of their computer stations.
  7. One might add that use of transfusion in acute chest syndrome has almost no evidence base and may indeed do more harm than good. In transfusion, less is usually better than more.
  8. " I know we will be getting another order for an Erythrocytapheresis" That's not to say that is good clinical judgment. There is not a shred of evidence that 30% is better than 35%, and to expose the patient to the risk of another 6-8 units of red cells and an invasive procedure is, in my opinion a serious misreading of the benefits and risks of transfusion in this setting. Not to mention that the same goal (30%) could be achieved by simple transfusion of AA red cells. But neither apheresis exchange nor transfusion is indicated for clinical benefit.
  9. One unit of hemoglobin AS blood will contribute perhaps 5% to the S level in a patient with hemoglobin SS whose overall post-apheresis hemoglobin level is 10 g/dl. Not enough to make a real difference. A lot of work for pretty much nothing in my view. But we do it anyway. Probably would be less work to test donor units if the %S doesn't drop quite as far as expected. Hemoglobin S in AS red cells does not behave the way it does in SS red cells, so this has absolutely no clinical implications. The hemoglobin S goal for most treatment is 30% or less. 5% is not going to make any difference in treatment plans. Just an alternative view from the usual :).
  10. There is no such thing as never in science and medicine. But while leukoreduced transfusions may on rare occasions be associated with a CMV seroconversion, the same is true of CMV seronegative, since it is possible to have a donor who is viremic but not yet seropositive. There are those who believe CMV is almost never transmitted by transfusion, but that these seroconversions are by the usual route of individual to individual environmental transmission. I am close to that point of view. We have not used CMV seronegative, as pointed out above, for the last 20 years plus. We have a 70 bed+ neonatal intensive care unit, do about 80-100 allogeneic transplants of stem cells, heart transplants, etc. CMV seronegative is totally unnecessary and provides little or no benefit to patients. Leukoreduction is much more important overall and provides enough CMV safety on its own, in my view, to beat a dead horse here :).
  11. This is something that only works when there is expert physician to physician communication. Your medical director needs to undertake this project. There are substantial data from randomized trials and observational cohort studies that leukoreduction abrogates CMV seroconversion. These are the studies we used twenty plus years ago to convince our practitioners that leukoreduction was not only good enough, but almost certainly superior in overall clinical outcomes to CMV seronegative non-leukoreduced transfusions. Of course no patient should be receiving non-leukoreduced transfusions at this late date, but in the USA not all transfusion medicine physicians are convinced of this, in my opinion, strongly justified clinical practice.
  12. We do the same thing, for historical reasons. Probably totally unnecessary :). The amount of S hemoglobin in one unit of donor blood is not clinically significant in patient management.
  13. No guidelines, just clinical common sense. There are absolutely no data to support the need for excluding heterozygous donors, nor the need for heterozygous recipients to receive only AA blood. Heterozygous patients are physiologically normal except for some data to suggest that under extreme conditions of dehydration, altitude they are slightly more susceptible to complications that occur even among hemoglobin AA patients.
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