How low does it go??!!

[Deny Morlino]

This is the sort of question I hope to determine better answers to in the coming year. AABB has a webinar series starting January 12th covering the topic of patient blood management. I hope to gain some solid information to effect (affect?) adjustments in the transfusion practices in my facility. I tend to agree with Auntie-D on this. If the patient is not symptomatic to trigger a transfusion, then avoid transfusing.

[LCoronado]

Our patient was 47 years old. She was kept on telemetry throughout but no adverse cardiac effects were noted.

[Nancy L.]

A good friend of mine who lives in a distant state is a chronically anemic MS patient. She is quadriplegic so is not physically active. She became extremely weak and confused and was taken to the hospital where she was found to have a HGB of 1.6 gm/dl. They panicked and quickly gave her 6 units of packed cells. Surprise, surprise........she had a heart attack. She recovered and is doing well. What were they thinking slamming in so much blood so quickly. Her poor system hadn't had that much blood in circulation for months. Talk about overload!

[Malcolm Needs ☆]

That is exactly what I was talking about in an earlier post.

[Deny Morlino]

What were they thinking slamming in so much blood so quickly. Her poor system hadn't had that much blood in circulation for months. Talk about overload!

Obviously they weren't thinking! That was the same concern I had with the recent case here. Thankfully all appears to be well with the patient. This is a topic on my list to discuss with my pathologist.

[webersl]

High 2's and low 3's is not terribly uncommon among our Sickle Cell patients.

[Edit: It's embarrassing when you post after the first page, not realizing that the conversation has moved on. I do that all the time. Sorry.]

Edited January 5, 2012 by webersl

[Mabel Adams]

I too am hoping to start the process toward patient blood management. One aspect of it is to transfuse the patient not their lab values. Had that been done, these patients could have mostly avoided transfusion as you all say.

[L106]

Since I never win any contests I have to jump in here - this may be my day. A few months ago we had a patient in the ED with a migraine headache. This 45 kg (99 lb.) female had a hgb of 0.3, RBC 0.23.

Surely you will win the prize with this one!! OMG!!!

[carolyn swickard]

"High 2's and low 3's is not terribly uncommon among our Sickle Cell patients" - quote

I find that amazing. I know that with the antigen mismatches between donor and user populations, you don't want to transfuse them any more than you have to, but wouldn't a HGB level that low trigger a crisis because of the lack of O2 in the blood? We don't get many sickle cell pts here, so I don't deal with them too much. Any information would be appreciated.

[Malcolm Needs ☆]

Well, I can tell you from a paper written by, I think, Liley (of Liley's lines fame) that, when he was in Africa, he saw transfusions into abdominal cavities of children with sickle cell disease, because their veins were so shot from continuous transfusions, that they only gave blood when the Hb was around that level. It gave him the idea of giving IUT via the abdominal cavity of the foetus. I'll try to dig out and cite the full reference (but it may take a bit of time).

Or it may have been a review article by Prof Sir Cyril Clarke (I'll try to find it anyway).

Edited January 16, 2012 by Malcolm Needs

[Auntie-D]

Agreed with others about circulatory overload but another way to look at it is that a person with a Hb of 4, transfused numerically, could get 6 units of blood. That is 6 donor exposures. Imagine if that person developed and antibody to an antigen in every pack and ended up, with say, 6 different antibodies. What happens if that patient then needs blood due to an actual clinical need?

There was an african descent chap who had had a few top up transfusions (reason never investigated) who developed 3 antibodies. He was admitted into hospital with moderate GI bleeding and a rapidly falling haemaglobin and 6 units were requested. I cross matched 6 and all came up strongly positive. I set up a panel and empirically cross matched the whole of our blood fridge resulting in only one suitable unit! Samples were sent to our reference centre who had no suitable units, they forwarded the samples on out of the area and two more were found suitable.

The surgeons were reluctant to transfuse incompatible blood and gave just the one unit that morning. The two other units arrived late afternoon and the patient was taken to theatre. At the lowest point his Hb was 4.2 and after the surgery and 3 units it was 5.4. He was put on iron and erythropoietin and had no further transfusions. He left hospital 3 weeks later with a haemaglobin of 8. He now does autologous frozen donations

This happened when I was Still very new to the job and I have, fortunately, not seen a similar case since!

[Malcolm Needs ☆]

What were the antibody specificities Auntie-D.

Note to everyone: I haven't forgotten my promise about looking out that paper to cite. I just haven't had time yet (meeting after meeting after meeting after......................).

[Auntie-D]

What were the antibody specificities Auntie-D /QUOTE]

It was 13 years ago and I can't remember I was a noob at the time and was a bit stunned by it all - empirically team cross matching 80 units. All I can remember is that it was an antibody with low frequency in the black population but extremely high incidence in the white population.

[Malcolm Needs ☆]

Nasty!

[Dr. Pepper]

What were the antibody specificities Auntie-D /QUOTE]

It was 13 years ago and I can't remember I was a noob at the time and was a bit stunned by it all - empirically team cross matching 80 units. All I can remember is that it was an antibody with low frequency in the black population but extremely high incidence in the white population.

That was my question, too. Short of universities perhaps, hospitals are the most colorblind places I know, chock full of various and interesting ethnicities. Interesting - until you get one as a patient with the nasty antibodies. On a parallel vein (no pun intended), I have my students phenotype themselves when they rotate through BB. Every West African student has been Fy(a-b-) and we just had two Asian students (Vietnamese and Nepalese) who are Le(a+b+). We had one who was group O, e and s neg. Our reagent manufacturer wanted her as a panel cell donor but I don't know if she ever followed through. Point being, it's kind of dry to lecture on the blood groups but a lot more fun when the kids can see these things in themselves.

[Malcolm Needs ☆]

I agree Phil. That's how I found out I was Ch-.

Unfortunately, the H&S police and other suits have virtually outlawed the practice in the UK now.

[Malcolm Needs ☆]

I still cannot findthe exact paper I was going to cite, but this one by Sir Cyril Clarke is really, really worth a read.

Clarke Sir Cyril. Rhesus haemolytic disease of the newborn and its prevention (Historical Annootation). British Journal of Haematology 1982; 52: 525-535.

I'll keep hunting for the one I meant to cite.

Edited January 22, 2012 by Malcolm Needs
Fingers working faster than brain.

[DPruden]

Surely you will win the prize with this one!! OMG!!!

.3?? Yikes! I thought the 1.0 postpartum hemorrhage patient we had was the lowest I would ever hear about!

[Dr. Pepper]

I agree Phil. That's how I found out I was Ch-.

Unfortunately, the H&S police and other suits have virtually outlawed the practice in the UK now.

Malcolm, who are the H&S police (I'm trying to guess: holiness & sanctity, honesty & sensititvity, honor & service, hide & seek...)

[Malcolm Needs ☆]

Health and Safety police Phil!