Massive transfusion with an antibody

[janet]

I'm a little worried.....we had an esophogeal varacies patient bleeding out this afternoon....he has an anti-c so of course it was tough to keep up.

After the initial 10 units given before a sample was obtained (these units c negative) we thought all our hard work is just being bled out, we would wait until bleeding was controlled and give antigen negative for the units that would remain in him.

Last request for 4 (still uncrossed - but we finally have a sample) we called once again to ask how the bleeding was - still profuse - so no phenotyped blood issued.

I left after an hour overtime leaving staff with 8 compatible units, FFP, cryo and platelet pools just issued - instructions to communicate before any more blood issued and switch to those compatible units when bleeding controlled. I just called to see how things were going - tech told me things were good, he had stabilized and no more units were requested (hgb 129!).

So, he is all incompatible units at this point - sure we've diluted his antibody with plasma, platelets and cryo - I am worried he will go into crisis due to transfusion reaction now.

Any thoughts out there??

[jcdayaz]

I'm a little worried.....we had an esophogeal varacies patient bleeding out this afternoon....he has an anti-c so of course it was tough to keep up.

After the initial 10 units given before a sample was obtained (these units c negative) we thought all our hard work is just being bled out, we would wait until bleeding was controlled and give antigen negative for the units that would remain in him.

Last request for 4 (still uncrossed - but we finally have a sample) we called once again to ask how the bleeding was - still profuse - so no phenotyped blood issued.

I left after an hour overtime leaving staff with 8 compatible units, FFP, cryo and platelet pools just issued - instructions to communicate before any more blood issued and switch to those compatible units when bleeding controlled. I just called to see how things were going - tech told me things were good, he had stabilized and no more units were requested (hgb 129!).

So, he is all incompatible units at this point - sure we've diluted his antibody with plasma, platelets and cryo - I am worried he will go into crisis due to transfusion reaction now.

Any thoughts out there??

I would not be terribly concerned about transfusing non-c neg units during your patient's crisis period. Typically in a situation such as you described, the blood is going out as fast as it is going in. The patients typically don't have the "foreign" blood in their system long enough to have any sort of reaction. It is prudent at this point, however, to begin giving c antigen negative units. It sounds like the "crisis" period is over.

You might want to "suggest" to the patient's attending DR to order a DAT and maybe monitor that result for a day or two. Other than that, I would do nothing!

[Malcolm Needs ☆]

I would be a little worried about a delayed haemolytic transfusion reaction.

Like jcdayaz, I would monitor regularly for a positive DAT, and keep a weather eye open for signs of renal failure, dropping Hb, rising bilirubin, rising serum LDH, etc, and I wonder if your Consultant should consider IVIG (bit expensive if it is thought that the sitution is contained).

Also like jcdayaz, I would keep a goodly amount of c- red cells available, just in case of a further crisis bleed, possible DIC and the remote possibility of the need for an exchange transfusion.

[kate murphy]

I would agree with the suggestion to monitor DAT's for a while. How long? Don't know. Your medical director should also work with the pt's doc so he/she will know what to look for in the case of a delayed hemolytic.

Though I would be surprised if one occurs. We have had cases like this (anti-Fya!, anti-C, anti-S) where a delayed hemolytic never occured. The theory is that all the pt's antibody has bled out along with all the red cells. After a trauma like this, there seems to be a period of "immune shock" where no antibody production occurs. No antibody, no reaction. I would not advocate IVIG - it would probably cause a pos DAT and you'd have no yardstick to check for delayed reaction.

[Malcolm Needs ☆]

I would not advocate IVIG - it would probably cause a pos DAT and you'd have no yardstick to check for delayed reaction.

Very good point Kate (although it may be needed to alleviate clinical signs of a reaction, should one occur).

I also agree with you about the immune shock.

:):)

[jcdayaz]

I would be a little worried about a delayed haemolytic transfusion reaction.

Like jcdayaz, I would monitor regularly for a positive DAT, and keep a weather eye open for signs of renal failure, dropping Hb, rising bilirubin, rising serum LDH, etc, and I wonder if your Consultant should consider IVIG (bit expensive if it is thought that the sitution is contained).

Also like jcdayaz, I would keep a goodly amount of c- red cells available, just in case of a further crisis bleed, possible DIC and the remote possibility of the need for an exchange transfusion.

Malcolm,

Does "Consultant" mean DR or Pathologist in the UK?

I must confess to enjoying seeing the different terminology used in our countries!

[AMcCord]

I'm a little worried.....we had an esophogeal varacies patient bleeding out this afternoon....he has an anti-c so of course it was tough to keep up.

We had a patient like this, though she also had an anti-Di(a) to go with her anti-c. She came in bleeding out 5-6 times over the course of a year. We were also forced to give uncrossmatched blood and some c positive blood. Fortunately, the patient did not have an acute or delayed reaction in any of these visits. We kept a close eye on her Hgb and renal function until dismissalt each time. We always dreaded a return visit from her.

[John C. Staley]

Over the years I have noticed a couple of things. One is that antibodies that don't activate compliment seldom result in serious hemolytic transfusion reactions no matter how much incompatible blood you transfuse under emergency situations. Usually is seems the more you give them the better the outcome. Sure you want to watch these folks closely but also don't be surprised when there are not indications of transfusion reactions, delayed or otherwise.

A wise old ER doc one time told me that bad blood was better than no blood and that my friends, is a fact. A wise old Blood Banker told me that if you get the ABO right everyting else will pretty well work out. Between these two I have witnessed some remarkable things and have come to realize that transfusing "incompatible blood" is not the automatic kiss of death.

Now, having said that, you still need to do the best you can with the resources available to you, recognize the limitations of the situation and your ability to function within those limitations. Medicine is not a perfect world and if you want it to be you are in for a great deal of dissapointment.

Wow, I wonder what I had for breakfast that brought this out???

:faint:

[David Saikin]

Your patient will probably develop a pos DAT after a few days . . . and survive because that is something that can be dealt with. Exsanguination is never acceptable. Years ago we had an open heart with anti-E,-K-,-Fya. They knew they could go with 3 units. When I came back to work the next night, she was going back to the OR for the 3rd time - already receiving about 50 units and we weren't typing for anything . . . patient survived fine. Like John said, if you get the ABO right chances are everything will work out.

[tbostock]

I agree; with massive transfusion the theory is to throw the blood at them untested for the Ag while they are bleeding out. In the meantime, get a bunch of Ag negative ready so when the crisis is over, you can start giving them Ag negative blood. We've had a few experiences with it, with no bad outcome. One interesting one...an elderly man with a ruptured femoral artery. We quickly brought 2 units of O Neg to the ED which they rapidly transfused, then we found an anti-c and anti-E. Yikes...we started furiously screening units, gave him a couple more, but they got it quickly under control. The "funny" part is that the trauma doc came down the next day very upset...said that he ordered O Neg because he thought that had "nothing on it". Hmmmm...wouldn't that be nice. We explained to him that even O Neg units have antigens, but in the case, the patient survived, so the right decision was made to give uncrossed units.

[Malcolm Needs ☆]

Malcolm,

Does "Consultant" mean DR or Pathologist in the UK?

I must confess to enjoying seeing the different terminology used in our countries!

The Consultant in the UK is the "Top Doc" in any branch of Medicine, so "Yes", it would mean DR or Pathologist.

It's not just the different terminology that I find interesting, but also the different spellings. These can even be confusing within our own country. It is now common practice to use "leucocyte" as the posh word for a white cell in the UK, but some pedants (guess who is one of those!!!!!!!!) stick to "leukocyte", because the word stems from the Greek, rather than the Latin.

I must confess that I do have some difficulties understanding some of the initials commonly used in the US. I think I've got to grips with "OR" and "ER" now though!

On another theme running through this thread, Dr Brian McClelland, writing a chapter in "A Manual for Blood Conservation" (and not, as I put in my book review by error, "A Manual for Blood Conversation") edited by Dafydd Thomas, John Thompson and Betty Ridler, 1st edn, tfm Publishing Limited, 2005 (and a thoroughly good read, I might add) said,

"Transfusion has risks, but bleeding to death is fatal."

:D:D:D:D:D

[jcdayaz]

Over the years I have noticed a couple of things. One is that antibodies that don't activate compliment seldom result in serious hemolytic transfusion reactions no matter how much incompatible blood you transfuse under emergency situations. Usually is seems the more you give them the better the outcome. Sure you want to watch these folks closely but also don't be surprised when there are not indications of transfusion reactions, delayed or otherwise.

A wise old ER doc one time told me that bad blood was better than no blood and that my friends, is a fact. A wise old Blood Banker told me that if you get the ABO right everyting else will pretty well work out. Between these two I have witnessed some remarkable things and have come to realize that transfusing "incompatible blood" is not the automatic kiss of death.

Now, having said that, you still need to do the best you can with the resources available to you, recognize the limitations of the situation and your ability to function within those limitations. Medicine is not a perfect world and if you want it to be you are in for a great deal of dissapointment.

Wow, I wonder what I had for breakfast that brought this out???

:faint:

HaHa! Perhaps some over-powered Wheaties for breakfast??!

I agree entirely with what you have posted. Yes, we should always try to give antigen appropriate blood if we are able. However, we should not let a patient die because we have run out of c neg units (or whatever the specificity)!!

Your "wise old ER DR" was indeed VERY wise. We have to be able to use our training and experience to make these sometimes difficult decisions. When a patient is in a crisis situation...your wise BB'r is right...get the blood type right and you are good to go.

Esophageal varacies=BADNESS. I have UNFORTUNATELY seen a few of these patients in the acute phase....it is UGLY!!!!!

Wow John, did you and I have breakfast together this morning and I forgot all about it?

[jcdayaz]

On another theme running through this thread, Dr Brian McClelland, writing a chapter in "A Manual for Blood Conservation" (and not, as I put in my book review by error, "A Manual for Blood Conversation") edited by Dafydd Thomas, John Thompson and Betty Ridler, 1st edn, tfm Publishing Limited, 2005 (and a thoroughly good read, I might add) said,

"Transfusion has risks, but bleeding to death is fatal."

:D:D:D:D:D

[janet]

Thanks for all the words of wisdom.

So far so good for our patient .... his hgb was staying stable 90-100 g/L today (no more units given). A total bili last night at midnight was 101 umol/L and 68 this morning. DAT at midnight 1+ IgG (gel) and 2+ this morning. Our medical director requested they watch these the next few days.

Post 'crisis' testing showed he had 17 compatible units and 7 incompatible (all in the last 2 hours before bleeding was controlled).

I read up in ISSITT and feel a little better - these extravascular reactions don't cause DIC or renal failure very often. Spleen and liver work hard to remove all those sensitized cells.

When I spoke with his nurse today things didn't look too positive for him (didn't sound like the transfusion issue was the only issue).

Thanks again all - so nice to be able to reach out for help!

[Malcolm Needs ☆]

Wow John, did you and I have breakfast together this morning and I forgot all about it?

Now, having a mind like a sewer, I'm worried bout this post.

Does your opthalmologist husband know about this tryst??????????????!!!!!!!!!!!!!!!!!!!!!!!!!!!

:eyepoppin:eyepoppin:eyepoppin:eyepoppin:eyepoppin

[jcdayaz]

Now, having a mind like a sewer, I'm worried bout this post.

Does your opthalmologist husband know about this tryst??????????????!!!!!!!!!!!!!!!!!!!!!!!!!!!

:eyepoppin:eyepoppin:eyepoppin:eyepoppin:eyepoppin

Oh My...Malcolm..

I was trying to reinforce John's "what did I have for breakfast" statement. I felt I went a smidge overboard in my response to his post.

Joke, TOTAL JOKE!! No Tryst. NEVER!!

I know you were joking, but I wanted to clear it up for everyone else!

[John C. Staley]

Now, having a mind like a sewer, I'm worried bout this post.

Does your opthalmologist husband know about this tryst??????????????!!!!!!!!!!!!!!!!!!!!!!!!!!!

:eyepoppin:eyepoppin:eyepoppin:eyepoppin:eyepoppin

Now Malcolm, you really do need to get you mind out of the gutter.

Had we had breakfast together I'm fairly certain jcdayaz would not have forgotten so soon.

Besides, I don't play golf.

:floating::floating:

[Malcolm Needs ☆]

LOVE IT!!!!!!!!!

:haha::haha:

[jcdayaz]

Now Malcolm, you really do need to get you mind out of the gutter.

Had we had breakfast together I'm fairly certain jcdayaz would not have forgotten so soon.

Besides, I don't play golf.

:floating::floating:

Okay, I have to stoop to ask....what is your "golf" statement in reference to? My husband? He is most assuredly not "one of those" DR's that we all hate!!!

By the way....I have no doubt I would not have forgotten so soon had such an event happened....

[Malcolm Needs ☆]

Okay, I have to stoop to ask....what is your "golf" statement in reference to? My husband? He is most assuredly not "one of those" DR's that we all hate!!!

By the way....I have no doubt I would not have forgotten so soon had such an event happened....

Tiger Woods possibly??????????!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:D

[jcdayaz]

Tiger Woods possibly??????????!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:D

Oh!! How did I miss that?? GOOD ONE JOHN!!

Oops. "How did I miss that?" is not one of those questions you want to hear from a Blood Banker!!! Or, I also dread hearing "ooops" and/or "Oh no!":eek:

[John C. Staley]

Very good Malcolm. Rumor has it he's changing his name from Tiger to Cheeta.

[L106]

Very good Malcolm. Rumor has it he's changing his name from Tiger to Cheeta.

Sad, huh?

Regarding your previous comment by the "wise ole ER doc", I was taught early in my career "It is better to treat a patient for a transfusion reaction a couple days down the road than to have a patient dead from exsanguination today."

[Mabel Adams]

That's the long version of surgery's concept of "Dead now? Dead later?--let's make it later."

We had to give blood to a trauma patient with anti-e (coincidentally run over by a golf cart driven by her friend). She developed a pos DAT but showed no other signs. We were able to finish off with antigen neg units and only had to give her a few untested units.

I hate that we don't always get good info on how fast patients are bleeding and then they stop just as we have started the Rh pos units for the neg patient or, as you describe, untested units in the face of an antibody. Those are frustrating cases. We literally gave one unit Rh pos blood to an Rh neg patient because he was bleeding so profusely and he used no more blood and 2 months later was back with anti-D. Worse things happen, but I like to do better than that.

[Malcolm Needs ☆]

That's the long version of surgery's concept of "Dead now? Dead later?--let's make it later."

We had to give blood to a trauma patient with anti-e (coincidentally run over by a golf cart driven by her friend). She developed a pos DAT but showed no other signs. We were able to finish off with antigen neg units and only had to give her a few untested units.

I hate that we don't always get good info on how fast patients are bleeding and then they stop just as we have started the Rh pos units for the neg patient or, as you describe, untested units in the face of an antibody. Those are frustrating cases. We literally gave one unit Rh pos blood to an Rh neg patient because he was bleeding so profusely and he used no more blood and 2 months later was back with anti-D. Worse things happen, but I like to do better than that.

I agree.

Good communication is of paramount importance in these cases.