O Positive transfusion to unknowns in Massive

[Kym]

The small hospital I work per diem at recently switched all massive recipients to getting O positive.  Even Rh men and women older than 50 whose Rh is unknown.  I’m confused. Are we giving Anti D antibodies to 15% of our men now if doctors call a code massive ? I am retired with decades of experience and came back to work 2 days a week. 

Edited May 12 by Kym

[Malcolm Needs ☆]

No, you are giving group O, D Positive red cells to these patients; not anti-D.  Of these patients, 15% of the White patients have the potential to then become immunised and may produce anti-D themselves, but better that than dying.  However, not all such recipients will produce an anti-D, as it is well-known that when blood is given in a situation where the patient may be exsanguinating, the patient is less likely that normal to make such antibodies.  Even if they do go on to make anti-D, as they are male, the chances of the anti-D affecting a future pregnancy are zero, whatever the WOKES may say these days.

We have been doing this in the UK for at least a decade, and we have not experienced many problems with either male or female (over 50) patients.

[Neil Blumberg]

The rate of alloimmunization in massive transfusion trauma patients who receive D positive red cells appears to be quite a bit lower than seen in healthy adults exposed to D positive red cells many years ago in the original trials.  Perhaps as low as 1-2%, not 40% as seen in healthy recipients of test doses.

[jshepherd]

Exactly what Malcolm and Dr. Blumberg said - we've been doing this (in the states) for more than 10 years at my facility, rarely do we see an Rh neg trauma patient, and even rarer do they make an antibody to D if they survive, which for us is a significant percentage of trauma patients we see (98% survival rate). The key is giving the mismatch during a massive bleed, not just a onesie twosie transfusion. This is also why we give type A plasma to unknown type trauma patients, instead of AB. 

[Bet'naSBB]

We give Rh pos WB to any patient over 50kg that they call MTP on and keep it as the primary resource in our adult ED refrigerator.  

That being said, I have attached two articles concerning this very subject should you like to read about some studies done.

Anti-D in Trauma Patients.pdf Rh negative risk with Rh pos RBC.pdf

[Kym]

5 hours ago, jshepherd said:

Exactly what Malcolm and Dr. Blumberg said - we've been doing this (in the states) for more than 10 years at my facility, rarely do we see an Rh neg trauma patient, and even rarer do they make an antibody to D if they survive, which for us is a significant percentage of trauma patients we see (98% survival rate). The key is giving the mismatch during a massive bleed, not just a onesie twosie transfusion. This is also why we give type A plasma to unknown type trauma patients, instead of AB. 

Yes this is my issue.  Most of our “codes” are truly the old 2 unit unxm. Ie:  they are NOT bleeding out. Get 2 units of o Pos bleeders. 
 

also many of these people are repeat offenders. Ie. Here for more fights or racing car crashes. Young guys. Not all not most. But many. And 80% of our codes called. Give ONLY 2 units of PC. 
 

What kind of transfusion reaction does a person get if they receive 2 units opos blood when they have Anti D ?  Is it no big deal?  What are symptoms?  How bad a reaction is it? 

[Neil Blumberg]

It varies from no reaction to lethal hemolysis.  Anti-D is not entirely predictable in causing severe hemolysis.  But mostly bad stuff happens :).  This is true to some extent for anti-A and anti-B, although these are more dangerous as they fix complement in vivo better than anti-D in general.  Joe Bove (my original mentor) reported a case of a patient receiving multiple units that were ABO major incompatible with no reaction.  Not typical, but illustrative of the variability.

[jshepherd]

Yes, when there isn't a true massive, it is more likely the patient may make an antibody. That said, we have the same procedure here as you Kym: we give O pos to males and women over childbearing age for ANY emergent release red cells. If they only get 1 or 2 units, then so be it. This is part of the battle of using inventory appropriately and calling a code/massive appropriately....and never the twain shall meet.....  

[Kym]

4 hours ago, jshepherd said:

Yes, when there isn't a true massive, it is more likely the patient may make an antibody. That said, we have the same procedure here as you Kym: we give O pos to males and women over childbearing age for ANY emergent release red cells. If they only get 1 or 2 units, then so be it. This is part of the battle of using inventory appropriately and calling a code/massive appropriately....and never the twain shall meet.....  

That is my problem. There will be no educating by blood bank on educating drs with current mgr. AND this policy NOT related to inventory shortage. Could have 20 oneg units (15 is our normal desired inventory of oneg) and still won’t use oneg in massive. Though our policy states pick up 2 pc first.  Then if they want more other products on demand. like I said drs use this as the old “give me 2 units oneg unxm” policy. BTW totally different from my last job just last year where each pack is picked up together as a unit.   

What argument could I present to try to get them to change the policy that those first 2 units should be oneg like any unxm  with opos to follow if more unxm needed ?

I’m old school where first we do no harm  so this makes me feel we are harming and not caring. Very hard for this old lady. After 37 years of thinking antibody formation on purpose is not a good thing.   

 

[jshepherd]

Not sure I can help your argument, as we give O pos immediately to all males and females over 50, for any amount of emergency products. If you're wanting to argue for O negs as the first products when the blood type is unknown, it may not be received well, as this is very much becoming no longer the norm across the country, as far as I know. 

[Kym]

18 hours ago, jshepherd said:

Not sure I can help your argument, as we give O pos immediately to all males and females over 50, for any amount of emergency products. If you're wanting to argue for O negs as the first products when the blood type is unknown, it may not be received well, as this is very much becoming no longer the norm across the country, as far as I know. 

Well i guess quality just not there anymore. Like all things. Not caring we are endangering future life. Going with the odds. You are right. Only things matter any more are cost and convenience. No wonder they don’t really train any more theory etc. it’s all technician work now. 🤷‍♀️

[Bet'naSBB]

23 hours ago, Kym said:

Well i guess quality just not there anymore. Like all things. Not caring we are endangering future life.

On the contrary - The quality IS there and we are saving lives better than before.   Statistics show that: 

1) - most "Trauma" MTP patients are male...  So, making anti-D is the least of their worries - like our team always says......they have to LIVE to have a problem.

And, 2) - it is not nearly as likely for RH neg females who are bleeding excessively and get Rh pos units to make anti-D as you may think........and the quality of care for the few females who do get pregnant after an Rhpos transfusion AND make anti-D is so much better now. Again - they have to LIVE through the traumatic episode to make anti-D and then get pregnant and have a baby.  IF all that is possible after their trauma experience I think they'll be thrilled and having anti-D will be a non-issue.

You might want to read the articles I posted above in this thread.  They're really helpful.

[Mabel Adams]

We give O pos for all uncrossmatched blood orders for males and females over 50.  We've done it for a couple of decades.  We avoid it if the recipient is known to have anti-D already.  We have seen very few make anti-D.

[Kym]

45 minutes ago, Mabel Adams said:

We give O pos for all uncrossmatched blood orders for males and females over 50.  We've done it for a couple of decades.  We avoid it if the recipient is known to have anti-D already.  We have seen very few make anti-D.

That’s reassuring. I hope you are correct. Goes against all the care and concern we used to have about giving blood before. “Unknown” by definition means just that. Nothing about their transfusion history or reactions is known so why oneg to begin with.
 

I think the concern for a bad transfusion reaction or something that could affect their life (future emergency giving antigen positive to a pt with a significant antibody and cause harm) is just not there anymore it appears to me. Wonder why we tried so hard before.  Maybe better care after transfusion reactions make it less dangerous 🤷‍♀️. I know I have no say.  

 

But risk giving opos when you have well stocked oneg? I just don’t get what we are saving it for. I always understood emergency as in no oneg available.  But to plan on not caring is kind of mind boggling.  So yes. I hope we have ok experience too.

 

Though giving even one anti D when you didn’t need to seems like harm to patient. Would have been thought that ways years ago.  Thanks for your words of comfort. 

[Malcolm Needs ☆]

"Though giving even one anti D when you didn’t need to seems like harm to patient. Would have been thought that ways years ago.  Thanks for your words of comfort."

You are STILL not giving ANTI-D Kym; you are giving D Positive red cells.

The other thing is that, within the White populations, but more so in the Asian populations, there is a very good chance that giving group O, rr blood will stimulate the production of an anti-c (IF any Rh antibody is stimulated), and that can be just as "dangerous".

[Marilyn Plett]

O negs are still used in excess of their numbers in the general population. I've worked on both the donor side and the transfusion side. The pressure on O neg donors is huge. They are asked to donate as often as possible. We owe it to these donors to be good stewards of their donation.

[John C. Staley]

I've said it before, inertia is the strongest force in the universe.  From my 35+ years as a blood banker and supervisor of both donor services and transfusion services, I have come to the conclusion that, as a general rule, blood bankers are extremely slow to change when not resisting it completely.  This appears to be especially true if they are not actively involved in the change or keeping up on the literature.  I saw a great may changes during my tenure and not all of them were comfortable at first.  Giving O Pos blood to massive bleeds was just one of them.  The data supports it, no matter what our long held concerns and fears try to tell us.  Many of those long held fears and concerns were primarily theoretical, especially in how prevalent and disastrous the outcomes would be.  I have a number of stories to prove my point but I think I'll stop now and step off my soapbox.

[Mabel Adams]

I'll add that this policy is in keeping with the guidelines of the AABB and Red Cross.  If, in the US, we used O neg instead of O pos, we certainly would not have enough O neg left for known Rh neg patients or those with anti-D.  We are on allotment for O neg and can't get more than our quota without the supplier's medical director approving a medical release.  No change in sight.  We can't trade the certain harm to those patients for the potential harm for the trauma patients who are 85% likely to be Rh pos, usually male, unlikely to make anti-D, and usually not likely to require emergency transfusion more than once in their lives.  I'll admit that I am having some of the same qualms with the new policies to use O pos whole blood for traumas of any age and gender.  Their arguments about the modern treatment of HDFN are probably right, but they are harder to accept for me.  We had to start keeping O pos on our helicopters last year because we couldn't manage the O neg rotations anymore.  Same risk as the whole blood argument.  The only young female transported got the unit of liquid plasma and not O pos red cells.

[Kym]

13 hours ago, John C. Staley said:

I've said it before, inertia is the strongest force in the universe.  From my 35+ years as a blood banker and supervisor of both donor services and transfusion services, I have come to the conclusion that, as a general rule, blood bankers are extremely slow to change when not resisting it completely.  This appears to be especially true if they are not actively involved in the change or keeping up on the literature.  I saw a great may changes during my tenure and not all of them were comfortable at first.  Giving O Pos blood to massive bleeds was just one of them.  The data supports it, no matter what our long held concerns and fears try to tell us.  Many of those long held fears and concerns were primarily theoretical, especially in how prevalent and disastrous the outcomes would be.  I have a number of stories to prove my point but I think I'll stop now and step off my soapbox.

I’m old enough to remember when both asbb and arc have been wrong and later changed their policy. Giving opos to all Du Pos is one.  Plts don’t give anti d is another. And more. 

I do not agree that this is best way to manage. I’m not much for going along just because everyone does. There is No certain harm of others here. That is a sales topic. ALL is unknown. and every body is equally important  or equally unimportant. “First do no harm” doesn’t say ‘except’ when it’s inconvenient. 

First massive policy is very dependent on drs using it properly  and yet most do not. All blood taken but ffp returned?  Only 2 units taken no other products used? No plts/ cro taken   The point was to make whole blood   The army proved best way to handle true massives  sure gushing out:  opos goes on floor  immune system not kick in  I get it   BUT that is not how it’s usually being used in hospitals across the US. 

I think better policy would be give 2 units oneg in emergency with unknown and get a type complete within 30 min   I have proven in my less than educated hospital (as far as following massive or emergency policies)  that you can easily get a tube of blood in CLS hands in 10 min  do quick front type and bam 15 min  can give positive blood to positives. So complete aborh and screen in 45 min   So full group/type within 30 min when spinning that tube down  education  phlebs respond to bedside  etc 

80% of our massive  are not massive at all.  Drs just want a quick response  

 

 

 

Edited May 19 by Kym

[John C. Staley]

There is going along to go along and then there is accepting ample amounts of data from extremely reliable sources.  It's not about "sales" it's about trying to serve the population in general, based on the best knowledge we have currently and being willing to accept that.  If what you are doing works for you in your little corner of the world, that's great but making light of advancements because it doesn't fit your paradigm and accusing some of the best professionals out there of being uncaring is..........

I'll stop now.  I've been in this group for more years than I care to count and don't want Cliff to ban me. 

[Mabel Adams]

On 5/17/2024 at 12:42 PM, Kym said:

That’s reassuring. I hope you are correct. Goes against all the care and concern we used to have about giving blood before. “Unknown” by definition means just that. Nothing about their transfusion history or reactions is known so why oneg to begin with.
 

I think the concern for a bad transfusion reaction or something that could affect their life (future emergency giving antigen positive to a pt with a significant antibody and cause harm) is just not there anymore it appears to me. Wonder why we tried so hard before.  Maybe better care after transfusion reactions make it less dangerous 🤷‍♀️. I know I have no say.  

 

But risk giving opos when you have well stocked oneg? I just don’t get what we are saving it for. I always understood emergency as in no oneg available.  But to plan on not caring is kind of mind boggling.  So yes. I hope we have ok experience too.

 

Though giving even one anti D when you didn’t need to seems like harm to patient. Would have been thought that ways years ago.  Thanks for your words of comfort. 

Did you know that in the UK they would be appalled that we might give K+ blood to a female with childbearing potential in the US because we don't routinely K type either the units or the patient?  D isn't the only immunogen out there (although it is certainly very immunogenic, and the number of positive donors outnumber the number of K pos donors).  Still, there are other risks than making anti-D that some are equally concerned about.

[Malcolm Needs ☆]

47 minutes ago, Mabel Adams said:

Did you know that in the UK they would be appalled that we might give K+ blood to a female with childbearing potential in the US because we don't routinely K type either the units or the patient?  D isn't the only immunogen out there (although it is certainly very immunogenic, and the number of positive donors outnumber the number of K pos donors).  Still, there are other risks than making anti-D that some are equally concerned about.

We would indeed!!!!!!!!!!!!!!!!!!!!!!!!!!

[Kym]

On 5/13/2024 at 6:14 AM, Neil Blumberg said:

The rate of alloimmunization in massive transfusion trauma patients who receive D positive red cells appears to be quite a bit lower than seen in healthy adults exposed to D positive red cells many years ago in the original trials.  Perhaps as low as 1-2%, not 40% as seen in healthy recipients of test doses.

To answer path labs question in my email today: did any of these answer my Question. Answer was no. But this came closer cuz gave me a couple statistics. 40% of “healthy” pts make anti D after exposure. And 2% of massive.  

Well my question was basically for people just getting 2 units opos who turn out to be oneg, How many make anti D. And if they make anti D how much does it affect them?  And NO I’m not talking about pregnancy.  That’s the ONLY part of the anti D I’ve ever seen a study on. And that’s only thing medicine seem to care about  

So basically on this older study of 40% getting Anti D after regular exposure (not bleeding out. Not getting tons of blood:  JUST getting 2 units. Home the next day or 2 type patients).  I still don’t know is this a risk to them.  Or have we been too worried about antibodies all these years ?  What type of transfusion reaction would it be if later they got more positive blood? 

[Malcolm Needs ☆]

11 hours ago, Kym said:

Well my question was basically for people just getting 2 units opos who turn out to be oneg, How many make anti D. And if they make anti D how much does it affect them?  And NO I’m not talking about pregnancy.  That’s the ONLY part of the anti D I’ve ever seen a study on. And that’s only thing medicine seem to care about  

I am sorry, but this part of your post is simply untrue.

I have checked in my copy of Mollison PL.  Blood Transfusion in Clinical Medicine.  6th Edition, 1979.  Blackwell Scientific Publications.  In this is an entire Section in Chapter 8 devoted to "Rh Immunization by Transfusion", where he describes a large amount of experimentation, both involving deliberate injection of D Positive red cells into D Negative individuals, and also of D Positive units being transfused into D Negative individuals, bot accidentally and deliberately in the case of bleeding patients, including cases where only one unit was transfused.
 

Without looking through all of the editions that I own, I am almost certain that this work was quoted in the later editions, including the 12th edition written by Harvey Klein and the late, great Dave Anstee.

[Neil Blumberg]

Transfusion has much more serious adverse effects than making an anti-D.  Increases in infection, sepsis, thrombosis, inflammation and mortality for example. 

There are no data to my knowledge of long term effects of anti-D formation in patients not having future pregnancies.  Most such patients come to the attention of the transfusion service because they have anti-D or simply because they are Rh (D) negative. They are then transfused with D negative blood if need be, in something like 99.99% of cases.  The rare patient who gets Rh positive blood (trauma patients) do sometimes have increases in bilirubin, LDH, etc. and delayed or rarely acute transfusion reactions. These are bad for patients, so you are right, for these rare patients, the outcomes can be dire.  But there few alternatives to transfusing Rh (D) positive blood to most patients in emergencies.  And very few will have future transfusion reactions.