Massive Transfusion Recipient

[Angela S.]

If there is a regulatory requirement for this situation, please let me know

How would your organization transfuse the following patient:

TS performed on day 1.   Patient is A- with a negative screen. 

Patient receives a massive transfusion in surgery. Due to inventory constraints, the patient received 12 A+ RBCs. 

TS on day 3. Patient is typing as A+ (No Mixed Field, just straight up A+), negative screen. 

 

If the floor ordered a unit of blood after the 2nd type and screen, what type of RBCs would your organization require you to transfuse?

[Cliff]

If you are accredited by AABB, you need a policy.

5.19.6 Massive Transfusion The BB/TS shall have a policy regarding compatibility testing when, within 24 hours, a patient has received an amount of blood approximating or greater than the total blood volume.

I'm sure The Joint Commission has something too.

[Angela S.]

We aren't AABB accredited anymore. 

I am wondering what other hospital's policies say. 

[helalami]

A Negative is the type of choice next.  The most recent type of A positive is from the transfused units. They will eventually go away.  Patient true type is A negative and should get A or O negative.  Patient might also develop Anti-D.  Diving A negative will help the cells survive longer.  If the patient is a female of reproductive age, it might be good to suggest giving  Rhogam to the medical Director. 

 

 

[jshepherd]

RhIg after giving 12 Rh pos units is futile. The patient will either make anti-D or not, too late to prevent at this point without exchange transfusion, which seems like overkill. We always say the female of childbearing age has to live in order to worry about anti-D in a future pregnancy, so we worry about that first.

Our policy is to revert to the patient's actual type after a massive situation. We would give A neg. Now, if the patient starts massively bleeding again, we would revert to A pos. Until the patient makes that anti-D of course. 

Even though you've already given Rh pos to this patient, you did it during a mass transfusion, which is physiologically different than tranfusing an Rh pos unit low and slow. 

[Malcolm Needs ☆]

5 minutes ago, jshepherd said:

RhIg after giving 12 Rh pos units is futile. The patient will either make anti-D or not, too late to prevent at this point without exchange transfusion, which seems like overkill. We always say the female of childbearing age has to live in order to worry about anti-D in a future pregnancy, so we worry about that first.

Our policy is to revert to the patient's actual type after a massive situation. We would give A neg. Now, if the patient starts massively bleeding again, we would revert to A pos. Until the patient makes that anti-D of course. 

Even though you've already given Rh pos to this patient, you did it during a mass transfusion, which is physiologically different than tranfusing an Rh pos unit low and slow. 

I agree entirely, EXCEPT, we should think of females of child bearing POTENTIAL, rather than child bearing AGE.  Think, for a moment, of a female who is group A, D Negative, who is, for example, 11 years old.  Sorry to be picky, but, so often, these female children do not get the anti-D immunoglobulin they should be given.

[John C. Staley]

First question, is the patient actively bleeding?  If not and they just want to "top them off" then A neg is the choice.  If they are and your A negs are very limited then stay with the A pos blood.  As far as RhIG goes, as mentioned above, forget about it.  All it will do at this point is cause more problems.   That's what I would do.

[jshepherd]

Sorry Malcolm! Agreed, our policy is that all females are of childbearing age until they are 50 years old, so we would give RhIg when indicated for an 11 year old. But thank you for clarifying that excellent point! 

[applejw]

For us it would depend upon the patient's age and child-bearing potential.  If that is unknown or unclear, routine transfusion after MTP would be A NEG.  Additional massive bleeding A POS.