Exchange Transfusion for Sickle Cell Patients

[Mary**]

Last night, we had a hospitalist request that we do an exchange transfusion on an adult sickle cell patient. Fortunately they transferred the patient to a larger hospital. We do not have any aphersis equipment.

I have very little knowledge about this procedure. Can any of you explain how it is done?

Thanks.

[Malcolm Needs ☆]

Last night, we had a hospitalist request that we do an exchange transfusion on an adult sickle cell patient. Fortunately they transferred the patient to a larger hospital. We do not have any aphersis equipment.

I have very little knowledge about this procedure. Can any of you explain how it is done?

Thanks.

Hi Mary,

As I understand it (from chats with my hospital colleagues) it is just a scaled-up version of what happens with a neonatal exchange transfusion, but with certain differences. Of course, it does not involve a doctor sitting there with a couple of syringes and a three way valve, but a unit is taken off the patient, to be replaced by the donor blood, and then another unit is taken off the patient, to be replaced by more donor blood, and so on. The exchange is not total, but goes on until the HbS level has been brought down to the predetermined desired level.

[kate murphy]

We do both manual and automated red cell exchanges for sicklers in crisis, or pre-op.

You need to know the patient's total blood volume, the % hgb S, and the desired ending % hgb S. That will tell you how many units to exchange. For a normal sized adult, we usually exchange 6-7 units. All rbc units need to be HgbS tested - sickle trait donors can give, but you wouldn't want to give them to a sickler in crisis.

Automated exchanges take about 45 minutes through a central line or peripheral lines. Easy in/out at the same time.

Manual exchanges can take several hours - we advocate 2 lines - one for in, one for out. The output line does need a stopcock - a syringe and an empty blood bag attached. Syringe out 50-60 ml, close the stopcock, run in 50-60 mls of "good" blood. Do it again. And again........

We generally delegate this chore to junior heme residents. Good experience for them.

[John C. Staley]

Kate, I'm curious, how well does this work out for the patient? Does it really help or are we doing something because we need to do something?

This is well out of anything I had ever been involved in. We did get involved in plasma exchanges for a number of different problems but never RBC exchanges for sickle cell patients.

[Malcolm Needs ☆]

Kate, I'm curious, how well does this work out for the patient? Does it really help or are we doing something because we need to do something?

This is well out of anything I had ever been involved in. We did get involved in plasma exchanges for a number of different problems but never RBC exchanges for sickle cell patients.

I know that you were actually directing your question to Kate, John, but please forgive me for interfering!

We often have to provide blood for this procedure to the larger London Teaching Hospitals in our area, and it is usually for the prevention of a CVA in a young sickle cell patient, or for the treatment of sickle chest syndrome, treatment of priapism and also to bring down the proportion of HbS prior to the patient undergoing general anaesthetic (an oxygen poor situation) and, very, very occasionally, so that they can take a flight (another oxygen poor situation) so, yes, it really does help.

Again, sorry to both Kate and you for butting in.

:)

[adiescast]

Kate, I'm curious, how well does this work out for the patient? Does it really help or are we doing something because we need to do something?

This is well out of anything I had ever been involved in. We did get involved in plasma exchanges for a number of different problems but never RBC exchanges for sickle cell patients.

I have to say, the one time I observed this procedure it had an amazing effect on the patient. When we went in, the patient was in extreme pain, tensed up and writhing, unable to be still or straighten out. By the time we got a couple of units exchanged, the patient actually straightened out and fell asleep. I have never seen such a dramatic change for such a (relatively) simple procedure. If this is representative of sickle exchanges, I am all for the process!

[Eagle Eye]

we routinely do RBC exchange on SC disease patient with symptoms of crisis with chest syndrome. WE give RH & K phenotypically match RBC to all our sickle Cell disease patient with negative antibody screen(no historical antibody). Patient who has history of antibody, we have protocol to go case by case. (we extend match to duffy, kid, S, s).

Sometime we also do RBC exchange on patient who are on liver transplant list to lower HgB S below 30%.

[Share]

When you do an exchange for SCD - do you have to reconstitute the unit to a certain Hct like a neonatal exchange transfusion or do you infuse FFP separately or is FFP necessary since is not a total exchange??

[Eagle Eye]

No. We do not use FFP. Only packed RBCs are used. Basically you are replacing RBCs. (I am referring to automated RBC exchange).

We do not do RBC exchange for neonates but when we did, we reconstituted RBC with AB plasma.

[kate murphy]

I agree with all - and very well put.

Most of our sicklers we exhange are in crisis. We match K and HgbS neg. We do not reconstitute with FFP (as we would for a neonate exchange). Many of our sicklers are "frequent flyers" - we see them often for routine transfusions. We phenotype at first presentation, so we know what common antigens they are neg for. We give Ag neg if they start showing an antibody.

For kids, we usually try to give "young" blood - less than 2 weeks old (the blood, not the kid).

We do have a group of kids that we transfuse routinely, in the hopes of preventing a stroke. Giving young blood means we transfuse less often - every 6 weeks as opposed to every 4 weeks. These kids become iron overloaded when transfused often, then need chelation therapy for the excess iron. Treat one problem, cause another. Exchanges work better, as the "old" blood doesn't break down and cause iron buildup. Sickle cell disease is one of the more heartbreaking diseases out there.

[Malcolm Needs ☆]

I Sickle cell disease is one of the more heartbreaking diseases out there.

Absolutely.

[jcdayaz]

I once worked in a Trauma I facility Charity hospital in Louisiana. Charity hospital in Louisiana=large numbers of sickle patients.... We had in place a "Sickle Protocol". That entailed antigen typing the patient for C,E,K the first time we had them. We would then transfuse antigen-matched blood for those antigens. It greatly reduced the patients' response to foreign antigens...of course, it didn't stop it...but it helped significantly.

I saw some VERY complicated antibody cases there! I specifically remember one patient who would get down to a 4 gm HgB before we would even try to transfuse....she was only compatible with her sister who couldn't always do DD units....

[Malcolm Needs ☆]

I know what you mean.

I think I am correct in saying that we have a thalassaemic patient somehwere in the UK who has 24 identified atypical alloantibodies (so far).

[jcdayaz]

I know what you mean.

I think I am correct in saying that we have a thalassaemic patient somehwere in the UK who has 24 identified atypical alloantibodies (so far).

Wow!! 24?? Talk about a nightmare!!

[Malcolm Needs ☆]

Well, fortunately most of them are directed against low-incidence antigens, though not all by any means, but the patient is still a right pain for whom to find potentially compatible blood.

There is some good news though; the patient is not in my patch of hospitals!!!!!!!!!!!!!!!!!!!!

Strangely enough though, the patient we had the biggest problems finding blood for just recently only had 2 antibodies; an anti-Fy3+Jka.

We had no Fy(a-b-), Jk(a-b+) donors on the books in the UK!

Edited December 8, 2009 by Malcolm Needs

[Gumby]

Absolutely.

One of the reasons for RBC exchange transfusion in sickle cell patients is to prevent repeat strokes. It has been shown that once the level of Hgb S is over 35% that there is a significant increase in probability of strokes. By decreasing the level of Hgb S to 12% or less this will prevent the chance for the patient to have a stroke and loss of brain function. We have recently started this protocol at our facility. It takes between 10-15 units of blood to decrease the amount of Hgb S from levels in the 30's to lower teens. The procedure at our facility is done with apheresis machine and takes about 4-5 hours. We are currently seeing patients in the age range of 20-35.

[L106]

I think I am correct in saying that we have a thalassaemic patient somehwere in the UK who has 24 identified atypical alloantibodies (so far).

Oh my gosh!!!! I definitely think that he/she is one individual that should be denied a passport or visa!!!! (Obviously, for the benefit of those of us "on the other side of the pond", as you say!)

[John C. Staley]

One of the reasons for RBC exchange transfusion in sickle cell patients is to prevent repeat strokes. It has been shown that once the level of Hgb S is over 35% that there is a significant increase in probability of strokes. By decreasing the level of Hgb S to 12% or less this will prevent the chance for the patient to have a stroke and loss of brain function. We have recently started this protocol at our facility. It takes between 10-15 units of blood to decrease the amount of Hgb S from levels in the 30's to lower teens. The procedure at our facility is done with apheresis machine and takes about 4-5 hours. We are currently seeing patients in the age range of 20-35.

Next question, how long does this last or how often do you have to perform the procedure. I recognize that each patient is different but on average what would the length of time be between exchanges? A 10-15 unit exchange on a patient with multiple antibodies every month would be difficult to impossible.

:surrender:surrender:surrender

[adiescast]

How long it lasts seems to depend on the patient's condition. For a patient in pretty good condition, it can last a couple months. For a patient who has been at it for awhile, it sometimes gets down to once a week. And yes, it becomes extremely difficult to get 10-15 units. We have a teenage patient with anti-E, anti-K, anti-Fya, and anti Fyb that is getting biweekly exchanges. The blood center has had to identify donors that are compatible with him and schedule them in rotation to keep up. Thank God for dedicated donors who care about the patient!

[Malcolm Needs ☆]

Thank God for dedicated donors who care about the patient!

Amen to that.

:)

[Gumby]

As far as I know this will continue for the rest of the patients life. RBC exchange transfusion are only done after the patient's level of Hgb S reaches a level above 30%. For most patients that is once a quarter but we currently have a patient that this is done once a month. Between the monthly exchages, each week the patient has 1 or 2 unit of blood removed and replaced. By performing these procedures we are providing a better quality of life for them and meeting the needs of our customers.

[Marilyn Plett]

I can't pass up a chance to make Malcolm jealous. For the past 2 years, we've been testing all African-American donors with BioArray and found approximately 90 Fy(a-b-) Jk(a-) donors. Expensive? Yes. But we had at least 3 patients requiring red cell exchanges with that phenotype! Our biggest source of black donors has been high schools in predominately minority communities.

[irshadaad]

we also supply for exchange transfusion for sicklers ,units which are sickle neg and the Rh pheno and K compromising rbcs after they will remove a unit or so from the pt no ffp...in special situations only the physician will request for a desired Hct

[Malcolm Needs ☆]

I can't pass up a chance to make Malcolm jealous. For the past 2 years, we've been testing all African-American donors with BioArray and found approximately 90 Fy(a-b-) Jk(a-) donors. Expensive? Yes. But we had at least 3 patients requiring red cell exchanges with that phenotype! Our biggest source of black donors has been high schools in predominately minority communities.

Mission accomplished Marilyn!

I am extremely jealous!!!!!!!!!!!!!!

:(:(

[clmergen]

We have a sickle cell patient with an Anti-U that gets exchanged every 6 - 8 weeks. For her we ignore our Sickle Cell Protocol which is to give antigen matched for the Rh's and K. We have about 10 patients that do get RBC exchange transfusions on a regular basis. In fact we keep a log to track them.