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Kari Reichenau

Rh negative Patients that receive Rh positive blood

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We are trying to restructure our procedure to utilize Rh positive blood in emergent situations, or situations where there is no confirmation type performed.  In so doing, there comes into play the whole anti-D prophylaxis issue.  What would be the time frame to determine the amount of Anti-D to administer.  Immediately after receiving the dosage of positive blood, 24 hours post when the blood had equilibrated, two hours after, any help would be useful.

With the blood supply being at an all time low and the negative units of all blood types being effected, we were trying to establish guidelines for our generalist to utilize,

 

Thanks.

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The only use of Rh immune globulin that I have seen is for neutralizing the tiny amount of fetal RBCs that may enter the mother's bloodstream.   I also would be interested in how this could work for large amounts of D+ RBCs being transfused in an emergent situation, such as a massive transfusion.

Scott

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As a NON-CLINICIAN, as I understand it, in the case of a female of child-bearing potential (in the UK, 0 to 50), once the patient has settled, the first thing that would be attempted would be an exchange transfusion (probably a double exchange, if sufficient D Negative units can be located), and then an estimation would be made of the volume of the residual D Positive red cells, and then the anti-D immunoglobulin (almost certainly the IV type) would be estimated and given.  This would be followed-up after 72 hours, and more given as necessary, and then followed up again, and at 6 months.

If there was insufficient D Negative units after the patient has settled, we may try massive doses of anti-D immunoglobulin, but almost certainly not, as this will have the effect of clearing the D Positive red cells, but there would be nothing with which to replace them.  In such a situation, I think we would explain the situation to the patient (or their relatives if they were either too young to understand, were mentally incapable of understanding or were unconscious, and sit back and be thankful that we still have a live patient.

If the patient was either a male or a female of greater than 50 years of age, we wouldn't bother.

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I've never seen RhIg prevent immunization to transfusion of a unit of Rh+ blood.  Tried it a few times years ago.

I have seen the immune response suppressed by only transfusing Rh+ blood, but if you only give 1 or 2 I think the patient will become sensitized no matter how many you give.

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We have a policy to offer RhIg if we have given Rh Positive Random Donor Platelets to an Rh Neg female of childbearing potential. The amount of RBCs in a platelets is normally less than can be covered by a single dose of RhIg unless the platelets were particularly bloody in which case we don't accept them from our supplier. Luckily these days our supplier is doing a great job of supplying only Single Donor Platelets so bloody platelets are not an issue. Giving enough RhIg to cover a RBC transfusion would not be a reliable or economically feasible option since the RhIg we have on hand only covers 15mls pRBCs. So a one (1) standard unit of packed RBCs would take in excess of 18 doses. As Malcolm said giving the RhIg would have the added downside of clearing the Rh Pos RBCs you just gave so unless you have additional Rh Neg units available you are just putting yourself behind again.

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I'm sure Malcolm can give you the hard numbers and details but keep in mind that not every D- person responds the same when given D+ RBCs.  Some will develop anti-D with as little as 100 microliters of cells or less while others will never develop anti-D no matter how many units of D+ RBCs they receive.  Then everyone else is scattered around in between these 2 extremes.  Then throw in the males and women who are beyond child bearing and it becomes even more complicated.  I fall into the category believing that try to prevent the formation of anti-D after a transfusion event, especially one of multiple units is counter productive and an effort in futility.  :coffeecup: 

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11 minutes ago, John C. Staley said:

I'm sure Malcolm can give you the hard numbers and details but keep in mind that not every D- person responds the same when given D+ RBCs.  Some will develop anti-D with as little as 100 microliters of cells or less while others will never develop anti-D no matter how many units of D+ RBCs they receive.  Then everyone else is scattered around in between these 2 extremes.  Then throw in the males and women who are beyond child bearing and it becomes even more complicated.  I fall into the category believing that try to prevent the formation of anti-D after a transfusion event, especially one of multiple units is counter productive and an effort in futility.  :coffeecup: 

Roughly speaking, it is 15% hyper-responders, 70% normal responders and 15% non-responders (but those figures are rough).

I tend to agree with your last sentence John.  I was thinking more in terms of a single unit in an average sized adult.

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On the other hand, if those 15% are in another emergent situation in the future...

Scott

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True Scott, but these people don't exclusively make anti-D; they could make virtually any specificity, even if D Negative blood had been given.  For example, if they had made an anti-c, they would be in equally in the deep and nasty, if they have another emergent situation in the future, and are given rr units!

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Posted (edited)

See this large study https://www.ncbi.nlm.nih.gov/pubmed/3137672 regarding use of rh positive blood for untyped trauma recipients.

Abstract

The emergency blood needs of 449 patients were met by supplying 1,717 uncrossmatched units of either red blood cells (RBC) type specific Whole Blood or group O RBC. The RBC were all Rh positive, and 601 units were transfused to 262 untyped patients. None of the patients presented with anti-Rh antibodies. Only 20 patients who were Rh negative received group O Rh positive RBC, and most of these patients were male. There were no acute hemolytic reactions or sensitizations of young females. Group O Rh positive RBC is our first choice to support patients with trauma who cannot wait for type specific or crossmatched blood. Those who do survive the emergency conditions can be reverted to blood of their own type without problem. Acceptance of Rh positive emergency transfusions by physicians giving emergency care can prevent unbalanced shortages in a regional blood supply system.

Edited by Dansket
added abstract

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On ‎8‎/‎23‎/‎2019 at 6:27 PM, Dansket said:

See this large study https://www.ncbi.nlm.nih.gov/pubmed/3137672 regarding use of rh positive blood for untyped trauma recipients.

Abstract

The emergency blood needs of 449 patients were met by supplying 1,717 uncrossmatched units of either red blood cells (RBC) type specific Whole Blood or group O RBC. The RBC were all Rh positive, and 601 units were transfused to 262 untyped patients. None of the patients presented with anti-Rh antibodies. Only 20 patients who were Rh negative received group O Rh positive RBC, and most of these patients were male. There were no acute hemolytic reactions or sensitizations of young females. Group O Rh positive RBC is our first choice to support patients with trauma who cannot wait for type specific or crossmatched blood. Those who do survive the emergency conditions can be reverted to blood of their own type without problem. Acceptance of Rh positive emergency transfusions by physicians giving emergency care can prevent unbalanced shortages in a regional blood supply system.

My lab (for trauma I center) does just that: our MTP prep. work includes having sets of O+ aside for male traumas, and O= aside for female traumas. For these untyped pts in emergency situations, the Rh is essentially determined by their gender. For platelets, male/women BCBY do not require Rh= receipt. You're right @Kari Reichenau in saying that giving O= to everybody really burns the inventory...

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11 hours ago, Ward_X said:

My lab (for trauma I center) does just that: our MTP prep. work includes having sets of O+ aside for male traumas, and O= aside for female traumas. For these untyped pts in emergency situations, the Rh is essentially determined by their gender. For platelets, male/women BCBY do not require Rh= receipt. You're right @Kari Reichenau in saying that giving O= to everybody really burns the inventory...

We do the same for our traumas.  I think its a common practice.

Scott

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On ‎08‎/‎25‎/‎2019 at 8:51 PM, Ward_X said:

My lab (for trauma I center) does just that: our MTP prep. work includes having sets of O+ aside for male traumas, and O= aside for female traumas. For these untyped pts in emergency situations, the Rh is essentially determined by their gender. For platelets, male/women BCBY do not require Rh= receipt. You're right @Kari Reichenau in saying that giving O= to everybody really burns the inventory...

We give O= unxm only to females of child bearing potential (<50 yo).

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On ‎8‎/‎27‎/‎2019 at 5:15 AM, David Saikin said:

We give O= unxm only to females of child bearing potential (<50 yo).

This is what we have done for well over 10 years and have not seen any problems from it.   For those repeat Rh negative trauma patients, even Rh incompatible blood carries oxygen and transfusion reactions are seldom intravascular so are usually survivable.  Also, patients often have hemorrhaged out a lot of antibody as well as blood.  You can fill them back up with Rh neg after you ID the antibody.  We had to knowingly give e+ blood to a trauma once and she did fine other than having a positive DAT.  We only gave a few e+ units and got in some e negative to fill her back up with.  I think she got 2 units of each.

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In the technical manual (pg 514, 19th Ed) it talks about Rh Negative women getting Rhig within 72 hours of being transfused with Rh positive platelets. I wonder if that would be the same for blood?

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