SOP help for switching to OP PRBCs in trauma

[mollyredone]

I would love to have a little help writing a procedure for switching from ON to OP in a trauma when you haven't received a BB specimen yet. I'm thinking two ON uncrossmatched, then switch to OP for males and females over 55(?) until a specimen is received. I know some people automatically give OP to all males, but we may stay a little conservative here. Does anyone have an SOP to share? Post it here or send me a message!

Thanks, Mari

[mollyredone]

Anyone??

[ElinF]

We just have a statement in our "Red Blood Cell Choices for Transfusion" Policy that states that O positive can be given to RH negative people (minus women of child bearing years) with the physician or pathologist approval. You just have to have your pathologist sign off on it and get the doctor's ok with it- which may be harder depending on how they feel about that. Sometimes our reference lab won't even send us O negative blood if it is for a male.

We have a hard enough time transfusing Rh negative blood to Rh positive patients. Doctors don't like that either. It takes some explaining sometimes! crazy doctors...

[mollyredone]

Thanks Elin, Our pathologist would like a standard policy so he doesn't have to be notified every time. I think our ER docs are on board with it, since we seem to be in a permanent shortage mode with ON. I'm not sure if we want to state "2 ON upon arrival, then switch to OP for males until we get a specimen" or what. Does that make sense? Our max inventory is supposedly now 6 for ON and we are 3 hours from ARC, or 1-1/2 hours from another town if it's delivered by highway patrol. And you can go through those six units pretty fast!!

Mari

[Mabel Adams]

Remember that 85% of those patients will be Rh positive. This is a strong part of why many of us start with O pos unless the patient has child-bearing potential. If you can't do that, what you propose is not unreasonable, especially if you are likely to ship a patient out after the 2 O negs.

[Eagle Eye]

If the patient is not child bearing age female, why waste even two O Neg on male patient. I believe you should conserve your O Neg for the patient who needs O Negative blood.

[Liz]

Thanks Elin, Our pathologist would like a standard policy so he doesn't have to be notified every time. I think our ER docs are on board with it, since we seem to be in a permanent shortage mode with ON. I'm not sure if we want to state "2 ON upon arrival, then switch to OP for males until we get a specimen" or what. Does that make sense? Our max inventory is supposedly now 6 for ON and we are 3 hours from ARC, or 1-1/2 hours from another town if it's delivered by highway patrol. And you can go through those six units pretty fast!!

Mari

I feel very strongly that the Medical Director/Pathologist must approve and assume accountability/responsibility and document that s/he is infromed to remove the responsibility from you and other BB staff. You may call her/him/or delegate and get the ok by phone and document that.

[David Saikin]

Our policy is that only females of childbearing age will be given Rh= red cells during massive transfusion protocol.

[mollyredone]

Liz, that's why we want to write this procedure, so it is accepted as our standard. The pathologist will inform the medical staff that this is what we have to do to conserve our O Negatives for our numerous real ON patients.

[David]

I would love to have a little help writing a procedure for switching from ON to OP in a trauma when you haven't received a BB specimen yet. I'm thinking two ON uncrossmatched, then switch to OP for males and females over 55(?) until a specimen is received. I know some people automatically give OP to all males, but we may stay a little conservative here. Does anyone have an SOP to share? Post it here or send me a message!

Thanks, Mari

Here's what ours says,

...... Use Rh negative only for females age 50 or younger, all others will receive Rh positive (unless they have a documented anti-D).

We presented it to our Performance Improvement Committee which functions as a Transfusion Committee. Since they've approved it we can make the switch as needed. We inform the attending Dr when we do but we do not ask for permission. If our Medical Director in not on-site at the time, or its on 2nd or 3rd shift, we tell him the next day. All our trauma and ER docs have no issues with the practice.

[Mabel Adams]

Is the question about using O pos on patient's with an unknown type or giving Rh pos blood to a known Rh neg patient that is using a lot of blood? I would set a policy for the former and for that latter at least have a policy of notifying the ordering physician that Rh pos will be given.

In the case of the unknown type, if you use 2 O negs first and then switch to O Pos and your patient turns out to be Rh pos, you have wasted 2 O negs. If you do the same but your patient turns out to be Rh neg you have already exposed the patient to the D antigen so the 2 O negs didn't help the situation very much. You would be better off to save them to fill him up with at the end after he bled out all the Rh pos blood you started with. The only time starting with O neg for a male makes sense is if you are sure he is not going to need more than 2 units and he is Rh neg.

[SMILLER]

Our policy has us switching if it looks like our inventory of O Neg units is going to be exhausted (generally, if it looks like 10 units or more will be needed). We usually have plenty of O negs on hand so we do not have to do this very often. When we do switch we are to inform the physician and BB manager. We also have a protocol for giving rhogam to appropriate cases.

We just dont like the idea of immediately switching Rh on those males and older females just because pregnancy is not an issue. Patients who end up being Rh neg and having anti-D as a complication for Blood Banks for the rest of their lives doesnt sit well with us.

We are fortunate to have a nearby Blood Supply Center that usually can respond within 45 minutes with more O negs if we need them.

Edited January 18, 2012 by SMILLER

[mollyredone]

Smiller, I agree you don't want to create antibodies, but the rate of anti-D formation in trauma patients, or any patient under stress, is much less than previously thought. What about the other antibodies the patient may have that you are stimulating when you give a unit of blood to an unknown patient? If the patient is desperate for blood, they need to have blood. Our maximum inventory of ON is currently hovering about 6 and we are three hours from our supplier! If that patient with anti-D comes in under any other situation, we would give Rh neg.

[mollyredone]

Thanks for the input, Mabel. I think I will try for automatically giving OP to male traumas and massive transfusion. In a typical massive transfusion, we would be out of ON in 1 hour! Something's gotta give!

Mari

[SMILLER]

Smiller, I agree you don't want to create antibodies, but the rate of anti-D formation in trauma patients, or any patient under stress, is much less than previously thought. What about the other antibodies the patient may have that you are stimulating when you give a unit of blood to an unknown patient? If the patient is desperate for blood, they need to have blood. Our maximum inventory of ON is currently hovering about 6 and we are three hours from our supplier! If that patient with anti-D comes in under any other situation, we would give Rh neg.

Mari

I would say that exposing a patient to D is more likely to cause an immune response than other antigens, but I appreciate your point. It is just not practical to screen for all antigens a apteitn might respond to. But all blood units are already screened for D when we get them.

However, if you have a short supply of O negs, that is another factor you must take into account. In your situation, we would probably have the same policy as you are considering. ('course, I would make sure that your pathologist has signed off on everything, and it goes throught he usual committees before you make any policy changes.)

It seems like you should be able to keep more O negs on hand, however, than just 6 or so. We keep 20 on hand, and if the outdates get short, we give them to other A or O patients and restock.

[Mabel Adams]

I think that the Red Cross formula for calculating blood inventory does not adequately deal with remote hospitals. Small hospitals that deliver babies or have massive transfusion patients at least start there need to be able to save the life of at least one group O hemorrhaging patient until they can get more blood or ship the patient out. The further you are from your supplier time-wise, the more group O donor blood you need to keep--with maybe an inclement travel bonus if your blood comes over snowy mountain passes or to or from frequently fogged-in airports. (The O negs will probably just have to risk Rh exposure if they bleed too hard.) A bad bleeder can use 10 units the first hour. If there is decent damage control (and those intra-uterine balloons for post-partum bleeds) plus maybe some FFP or cryo, the second hour shouldn't use so much but 20 units over 2-3 hrs isn't too impossible. I don't expect ARC to support a hospital with a level of inventory they will only need once every 50 years, but once a year, sure; once every 2 years? yeah. Once every 5 years, probably. Once every 10 years, maybe, maybe not. At least if it is my family member in the car wreck out in the boonies I think they should have the possibility of survival.

[tbostock]

Studies have shown that only 10% of Rh Neg patients will make anti D during a massive transfusion situation when exposed to Rh Pos blood. So go ahead and give Rh Pos to males and post menopausal women if you need to.

[Eagle Eye]

Is the question about using O pos on patient's with an unknown type or giving Rh pos blood to a known Rh neg patient that is using a lot of blood? I would set a policy for the former and for that latter at least have a policy of notifying the ordering physician that Rh pos will be given.

In the case of the unknown type, if you use 2 O negs first and then switch to O Pos and your patient turns out to be Rh pos, you have wasted 2 O negs. If you do the same but your patient turns out to be Rh neg you have already exposed the patient to the D antigen so the 2 O negs didn't help the situation very much. You would be better off to save them to fill him up with at the end after he bled out all the Rh pos blood you started with. The only time starting with O neg for a male makes sense is if you are sure he is not going to need more than 2 units and he is Rh neg.

I totally agree with Mabel and other posters. WHy waste even two O Negs? should not worry about patient making anti-D....you can give Rh Neg once that patient makes anti-D not all of them produce anti-D. Those two O negs are valuable for us---level one trauma center....some time we get trauma patient using 30-40 units in <3 hrs.....

All Trauma cases, it is very important to get that specimen ASAP. we are fortunate that our trauma surgeons are with us on this and most cases they bring specimen before initiating trauma protocol and we are able to give type specific in 10 to 15 mins.

[Mabel Adams]

The only other worry I have sometimes had was the women over 50 that had anti-D already from pregnancies in the distant past. I usually get past it by reminding myself of how many more of our traumas are young men than older women. Also, since RhIG has been available here since I think 1968, there should be getting to be fewer and fewer older ladies with anti-D as the years go by. Lastly, the antibody will be bled out quickly and we can fill them up with Rh neg units after we do their type and antibody ID(and finish our panic attack)--and maybe then we will still have some Rh neg units to fill them back up with. Remember, Rh antibodies are not good at fixing complement so are unlikely to cause intravascular hemolysis and thus, a life-threatening transfusion reaction.

[L106]

You brought up some good points, Mabel.