Ag neg units still give pt temp spike

[lalamb]

Problem w/ a patient having temp spikes after A pos, E-, c- units is started.

Hx = A pos w/ an anti-E.

Rh phenotype = C+ E- c- e+. No other phenotyping done.

Patient knew to ask for Benedryl before recieving blood.

Units transfused since 4-14 = 15 LRBC, 20 plts

Pt given benedryl and tylenol, pre transfusion.

ABSC = neg, DAT at this time = neg

What could be causing the temp spikes? (current cultures are neg)

One suggestion was to give washed cells - would this help?

Planning on giving more blood in 2 days...if he spikes another temp, what can we do?

[Yanxia]

There are three cause to spike temp by transfusion, one is hemolysis , one is bacteria, and leucocyte.

Maybe something in the plasma such as some factor released from leucocyte can cause fever, so I think wash the unite before transfusion is a choice.

[Bill]

How high is the temp spike and for how long? In almost 40yrs of laboratory/blood bank experience I have seen more than once where fooling the patient has prevented fever and/or rash. The way we have done it is to use a leukoreduction filter (even though the blood is leukoreduced) and tell the patient that it is a very special filter that works better than the regular filter. This has worked more than it hasn't. Never underestimate the power of the mind.

[lalamb]

How high is the temp spike and for how long? In almost 40yrs of laboratory/blood bank experience I have seen more than once where fooling the patient has prevented fever and/or rash. The way we have done it is to use a leukoreduction filter (even though the blood is leukoreduced) and tell the patient that it is a very special filter that works better than the regular filter. This has worked more than it hasn't. Never underestimate the power of the mind.

1st rxn: temp went from 99 to 103.5, after 106 ml of blood

2nd rxn: temp went from 99.2 to 102.4, after 18 ml of blood

Pt was given Benedryl pre-transfusion on both occassions, tyleno on the second.

Pathologist asked about washing the RBC's but the blood bank ref lab seemed to think it wouln't make a differnce : the amount of WBC's in a leukoreduced PRBC unit is about the same as in a platelte pheresis pack (which the patient rec'd with no temp spike). Also, that the preservatives are very similar - so washing that out might not be useful.

Redrawn specimen today: DAT and Auto are weakly/barely positive , microscopically, so I sent the specimen out. I keep thinking the patient is starting to develope another AB...

[Malcolm Needs ☆]

1st rxn: temp went from 99 to 103.5, after 106 ml of blood

2nd rxn: temp went from 99.2 to 102.4, after 18 ml of blood

Pt was given Benedryl pre-transfusion on both occassions, tyleno on the second.

Pathologist asked about washing the RBC's but the blood bank ref lab seemed to think it wouln't make a differnce : the amount of WBC's in a leukoreduced PRBC unit is about the same as in a platelte pheresis pack (which the patient rec'd with no temp spike). Also, that the preservatives are very similar - so washing that out might not be useful.

Redrawn specimen today: DAT and Auto are weakly/barely positive , microscopically, so I sent the specimen out. I keep thinking the patient is starting to develope another AB...

Could be he is developing another antibody, but I think that this would be coincidental to the symptoms.

I agree that it could be something like an HLA or leukocyte antibody, and that it just so happens that the antigen was expressed in the the red cell units, but not in the platelet units.

This thought is strengthened by the fact that the patient himself knew to ask for Benedryl - he has obviously experienced this kind of thing before. I think washing is a good idea, despite what your Reference Laboratory may say - even to show whether or not it would ameliorate the problem.

:confused::confused:

[Liz]

We wash the units 3x in such cases. It could well be extra cellular cytokines.

Liz

[rravkin@aol.com]

Would Irradiation of the PRBC's be of any assistance?

[David Saikin]

As bizarre as this sounds, we had a patient who ALWAYs had a reaction when transfused under fluorescent lights. Transfused in the dark - no problem.

[Malcolm Needs ☆]

Would Irradiation of the PRBC's be of any assistance?

It is doubtful, as this is unlikely to alter the antigen in the plasma that is probably causing the spike in the temperature.

:confused::o:o

[lalamb]

Would Irradiation of the PRBC's be of any assistance?

Platelets were originally requested to be irradiated, so all of his stuff is now irradiated

[Malcolm Needs ☆]

Platelets were originally requested to be irradiated, so all of his stuff is now irradiated

That is as maybe, but was that to try to stop the spike in temperature, or for another reason (prevention of TA-GvHD?) altogether?

I don't know; I am only curious.

:confused::confused:

[John C. Staley]

No body has asked!! What is the patient's diagnosis? Is it possible that the temp spike had nothing to do with the transfusion? Possibly just a timing coincidence.

I had an ICU patient spike a temp one time during a transfuison. It was a warm summer day, the blinds were open and the sun was bathing the bed in it's wam glow. Another time a patient was septic and having regular temp spikes, again the transfusion timing just happened to coincide with the next temp spike.

I know we have to rule out the possibility of a transfusion reaction but some times the answer is not a Unicorn.

:blahblah:

[lalamb]

Patient has been seen/treated at another hoospital and was transfered to us last thurs. Got ahold of the patinets workup from the BB ref lab (that both hospitals use), and in included negative eluates , some weakly pos and some neg DAT's,and a neg platelet antibody.

Current dx = fever, leukemia, anemia, thrombocytopenia. hgb (2 days ago) = 7.2

Thank you all for yor FAST input. This indeed may be coincidental to his current fever (cultures are still neg), but is still unsettling. This doesn't happen often so after having 2 i n a row, want to try to have it not happen again.

[Losmeister]

Hello...

actually I am a sometime lurker who works at the Ref Lab that Lalamb sends specimens to...

( 20 yrs BB experience ( as well as Hemo, Chem et cet) , 3rd yr at Ref Lab at a local Blood Bank- see http://www.bbr.org/ )

Patient has developed an anti-K ( see above # of units since April 2010, no wonder...)

Malcolm stated above and I concur, washing is a good idea if only to see whether or not it helps at all...

[Liz]

Interesting development.

Liz

Edited July 14, 2010 by Liz

[Malcolm Needs ☆]

Hello...

actually I am a sometime lurker who works at the Ref Lab that Lalamb sends specimens to...

( 20 yrs BB experience ( as well as Hemo, Chem et cet) , 3rd yr at Ref Lab at a local Blood Bank- see http://www.bbr.org/ )

Patient has developed an anti-K ( see above # of units since April 2010, no wonder...)

Malcolm stated above and I concur, washing is a good idea if only to see whether or not it helps at all...

Even though the patient now has anti-E+K though (we would have recommended K- blood from the start, by the way, for anyone who is K- and who is likely to become transfusion dependent), it is unlikely, I would have thought anyway, that the numbr of red cells in a unit of platelets would have been sufficient to cause his symptoms, whilst the number of red cells in a unit of LDRCs would, obviously be enormous in comparison, and would probably have caused much more severe symptoms than a spike in temperature??????????

And, presumably, he had these spikes before the de novo anti-K, as he was already asking for medication during his transfusions?????

:confused::confused:

Edited July 14, 2010 by Malcolm Needs
Had an after-thought!

[Losmeister]

The temp spikes reported by Lalamb is the first I'd heard of this.

More detailed info and patient hx is something I've missed being once removed

into the reference laboratory as opposed to the xfusion services in the hospitals

I was employed at previously.

We've crossmatched ~40 platelets for this patient w/ 100% compatability,

so he's doesn't SEEM to have platelet antibodies.

As for going K- preemptively, I'll bring it up to our technical director,

its a logical extension to the way we treat the 5 major Rh antigens presently.

[Malcolm Needs ☆]

The temp spikes reported by Lalamb is the first I'd heard of this.

More detailed info and patient hx is something I've missed being once removed

into the reference laboratory as opposed to the xfusion services in the hospitals

I was employed at previously.

We've crossmatched ~40 platelets for this patient w/ 100% compatability,

so he's doesn't SEEM to have platelet antibodies.

As for going K- preemptively, I'll bring it up to our technical director,

its a logical extension to the way we treat the 5 major Rh antigens presently.

Sorry, I think the temperature spikes due to platelet transfusions was an invention of mine! I think I mis-read the post (at my age, the eyes begin to fade fast, and my eyesight was never that great anway)!!!!!!

Yes, the K antigen is about the third or fourth most immunogenic of the "common" antigens, and so our national guidelines state that we should give K- in all cases of transfusion dependency (assuming, of course, the recipient is K- to begin with) and the same applies to all females below the age of 60 (again, assuming that they are K- to begin with).

That is what the guidelines say; it is quite remarkable how many examples of anti-K we see in such patients or in primi gravida women - must all be naturally occuring?????????!!!!!!!!!!!!!!!!!!!!!!!!

:sarcasm::sarcasm:

[clmergen]

We have a sickle cell disease patient that routinely has transfusion reactions from blood, even with premedicating with tylenol and benedryl. He now will only agree to a transfusion if his hemoglobin is less than 4 g/dL (I think those are the right units).

[Malcolm Needs ☆]

We have a sickle cell disease patient that routinely has transfusion reactions from blood, even with premedicating with tylenol and benedryl. He now will only agree to a transfusion if his hemoglobin is less than 4 g/dL (I think those are the right units).

Has he got red cell antibodies, HLA antibodies, or could it be recurrent hyperhaemolysis?

:confused::confused:

[clmergen]

He doesn't hemolyse the cells, but he gets a fever, chills, etc. He has antibodies to Jkb, Fya, E, C, S, M, Jsa, and Kpa.

[Malcolm Needs ☆]

He doesn't hemolyse the cells, but he gets a fever, chills, etc. He has antibodies to Jkb, Fya, E, C, S, M, Jsa, and Kpa.

Good Lord! He sounds like he's going for the set!!!!!!!!!!

I am prepared to bet quite a lot of money then that, even when given antigen negative cross-match compatible blood, he has probably made enough HLA antibodies to make most units give him a non-haemolytic, febrile transfusion reaction, and he sounds like he really is a live candidate for washed red cells, because there are always some leukocytes left, even in leukodepleted blood - not to mention the free-floating cytokines.

Wow! Finding blood for him must be the highlight of your day!!!!!!!!!

:eek::eek:

[clmergen]

Finding blood for him is easy - I call my blood supplier and make them find the blood. Patient was started on transfusions at a facility that did not have a sickle cell disease protocol and came to us with the antibodies and the reactions. He has similiar reactions in another state. I wouldn't be surprised about HLA antibodies. Washed cellls have not been discussed for him, but I know that IVIG has been.

[Malcolm Needs ☆]

Finding blood for him is easy - I call my blood supplier and make them find the blood. Patient was started on transfusions at a facility that did not have a sickle cell disease protocol and came to us with the antibodies and the reactions. He has similiar reactions in another state. I wouldn't be surprised about HLA antibodies. Washed cellls have not been discussed for him, but I know that IVIG has been.

Yup, IVIG is excellent stuff, but it is not a panacea.

Have a think about washed cellular components, but be prepared for your Clinical lead to tell you that Malcolm's suggestion is idiotic!!!!!!!!!!!!!!!!!!!!!!!

:redface::redface:

[Marilyn Plett]

Finding blood for him is easy - I call my blood supplier and make them find the blood. Patient was started on transfusions at a facility that did not have a sickle cell disease protocol and came to us with the antibodies and the reactions. He has similiar reactions in another state. I wouldn't be surprised about HLA antibodies. Washed cellls have not been discussed for him, but I know that IVIG has been.

I doubt that your blood supplier finds it easy to find blood for this patient. Most suppliers work long and hard to try to find these kinds of units, both testing and recruiting.