Giving O Positive Units to an Rh Negative patient

[TVC15]

Hi,

I have been a blood banker for over 6 years and have been very fortunate to have worked in a trauma setting at the start of my career and then as a Blood Center reference lab blood banker for the remainder of my career. I moved to CA 2.5 years ago and have found the blood banking practices to be slightly alarming in many ways. I recently was informed that one of the trauma centers here has a policy to give O Pos blood to all male and female trauma patients regardless of their Rh status. Does anyone else besides me find this to be a very poor blood transfusion practice?

I can’t imagine why anyone would want to give an Rh negative individual the opportunity to make anti-D!

What if the trauma patient is Rh neg with an anti-D and they happen to end up in a trauma center bleeding that has a policy to give O Pos blood in an emergency release situation?

At the trauma center I worked in the only time we would switch an O Neg patient to O Pos blood is if our supply was being depleted which required the pathologist’s written consent to give Rh pos blood to the Rh neg patient.

[Malcolm Needs ☆]

IN the UK, the Guidelines say to give O D Positive to males and females above the age of 60 in such a situation, but this Guideline is soon to change to females above the age of 50. I am comfortable with this.

[TVC15]

IN the UK, the Guidelines say to give O D Positive to males and females above the age of 60 in such a situation, but this Guideline is soon to change to females above the age of 50. I am comfortable with this.

Hi Malcolm,

Thanks for the response but my question is why risk it?

I always worked in BB's where it was the golden rule that you never give the patient the opportunity to make a clinically significant antibody especially an anti-D. I think it is poor practice to do such a thing especially when you have O Negs available. After all that is why Trauma Centers keep a larger stock of them then a typical hospital. I can understand the trauma center switching to Rh Pos blood if their supply is hitting a critical shortage level and the Blood Center has none to re-supply them with. O Negs are the blood type of choice for a trauma setting. We kept 6 O Negs in small refrigerator in the ER trauma "crash" room for them to use in an emergency release situation. As well as 6 O Negs in the ER OR to use in an emergency release situation. We were also in the process of traing the helicopter piliot to carry 2 O Negs with them when they fly to a crash site.

I am interested in hearing from anyone else who works in a trauma setting that has this policy...it is the first time I have ever heard of this practice.

Thanks!

Edited April 22, 2012 by TVC15

[Cliff]

What if the trauma patient is Rh neg with an anti-D and they happen to end up in a trauma center bleeding that has a policy to give O Pos blood in an emergency release situation?

Not speaking as a clinician, but this isn't usually a problem. If they are truly bleeding out, than anti-anything often won't be a problem - although I wouldn't want to test this theory with an ABO antibody.

I think it is poor practice to do such a thing especially when you have O Negs available.

This is an important reason. We have an inventory of over 700 units, and at times it is difficult to meet the needs to Rh neg trauma patients. Plus they don't always cooperate and come one at a time or when your supplies are at a good level. There are days where you might get more than one trauma at a time, or several back to back.

I've been at our facility a very long time and when we implemented trauma coolers about 20 years I asked the supervisor what we should do after we issue the first set of coolers, implying we might need another set. She looked at me like I had two heads. My first weekend on with the new trauma coolers we had back-to-back traumas. We now keep multiple sets of coolers ready.

[TVC15]

Not speaking as a clinician, but this isn't usually a problem. If they are truly bleeding out, than anti-anything often won't be a problem - although I wouldn't want to test this theory with an ABO antibody.

No kidding Cliff and neither would I!

I appreciate your response and I totally get that if they are bleeding out then it does not matter but what if they get to the trauma center needing only a few units of blood in an emergency release situation....this would not be good for the patient. Secondly if they made a strong anti-D in a trauma setting who gave O Pos and then the patient many years later needed hip replacement surgery then look at the longer work up involved in trying to rule out the other Rh anti-bodies not to mention having to phenotype the patient for all of the Rh antigens. Not only this but good practice would also include giving Rh phenotypically matched blood! This results in higher costs for the patient as well as tech time if the patient went to a regular hospital where work ups are performed. If they went to a hospital where they don't perform work ups...then off to the reference lab his sample must go. All of this extra work up and cost to the patient could all be avoided with just giving them O Negs.

This is an important reason. We have an inventory of over 700 units, and at times it is difficult to meet the needs to Rh neg trauma patients. Plus they don't always cooperate and come one at a time or when your supplies are at a good level. There are days where you might get more than one trauma at a time, or several back to back. I've been at our facility a very long time and when we implemented trauma coolers about 20 years I asked the supervisor what we should do after we issue the first set of coolers, implying we might need another set. She looked at me like I had two heads. My first weekend on with the new trauma coolers we had back-to-back traumas. We now keep multiple sets of coolers ready.

Multiple coolers are the right way to go! We not only had the little refrigerators in the crash room with 6 O Negs we also had 30 coolers to load up with ice packs and more units when we were hit with several traumas back to back. We put timers (setting them with 2 separate times on them...one would go off 10 minutes before the ice pack expires) as well as individual ID numbers. Upon issue we would set the timers and log in our cooler log sheet the location of where the cooler was going and the time it should be returned or re-iced. When the 10 minute timer went off the nurse assistant or who ever was with the cooler would return to the blood bank with the cooler and we would change out the ice packs and reset the time. If the cooler was not returned we went looking for it...which was rare. We trained the nurses and nursing assistants of the importance of bringing it back when the 10 minute timer sounded.

Edited April 22, 2012 by TVC15

[Likewine99]

Our Blood Bank policy is to give O pos to male trauma patients and females beyond 60 years of age (Level II trauma center). We made this process change in conjunction with input from our Bld Bk Med director and our director of trauma services. The trauma literature that the MD's refer to cite this as an acceptable practice.

The trauma director told me that from their side of the equation, when a patient experiences major trauma there are a multitude of things that occur physiologically and that their immune system becomes suppressed in the process since their body is basically trying to stay alive. Making an anti-D is the least of the problems to consider in a trauma situation. If you think about it, the blood is passing through their system so fast that there probably isn't time for the Rh pos cells to hang around long enough to cause any antigen exposure.

Inventory utilization factors into this decision also. You really want to save the Rh neg units for those patients who truly need them and not "waste them" on a trauma patient. I like Malcom am comfortable with this process too.

80% of the trauma patients at our hospital are males under the age of 30 and even if they do develop an anti-D during this transfusion episode, hopefully if they are ever in need of a transfusion in the future it won't be in the emergent situation. If they do they now they become one of those patients who really need the Rh neg units, like your stated example.

Just remember, no Blood Banker or MD wants to give Rh pos blood to an Rh neg patient but you do what you have to do to help the patient.

BTW, I live in the metropolitan St. Louis, MO area and there are 3 major trauma centers here and all 3 of them follow the O pos to male trauma policy.

[Mabel Adams]

I am surprised to hear that there is a US trauma center that doesn't follow this policy. Remember that 85% of those emergency transfusion patients will turn out to be Rh pos. Then there is the fact that a fairly significant number of transfused patients aren't alive a year later. Also, if all the trauma centers used only O neg for emergency release they would probably have worse shortages and might not have it for the young female emergency patient or the bleeding Rh neg patient with anti-D. Lastly, the proof is in the pudding: this has been a common policy for the past ~10 years and it doesn't seem to be causing any particular patient harm for the reasons listed above.

We don't Rh phenotype patients that have made anti-D; nearly all of them will be cde/cde and finding the occasional r'r or r"r won't change what blood we give them. I can't think of any reason we would try to give them blood that is positive for E just because they are r"r. If they were r'r' it would take awhile to get any r'r' units of blood in anyway so we would wait to see if they made the antibody before using up such a precious resource. Rh phenotyping is more of a reference lab tradition than one used in hospitals I think.

Maybe when they can grow O neg stem cells into blood units, we can go back to using only O neg for uncrossmatched blood.

[TVC15]

I am surprised to hear that there is a US trauma center that doesn't follow this policy.

Actually I am surprised that any US trauma center would give Rh Neg patients O Pos blood. It is apparently a regional thing. I worked at a very large Level 1 Trauma center in The Texas Medical Center. No where that I have worked in Texas would follow a policy such as that.

Remember that 85% of those emergency transfusion patients will turn out to be Rh pos. Then there is the fact that a fairly significant number of transfused patients aren't alive a year later. Also, if all the trauma centers used only O neg for emergency release they would probably have worse shortages and might not have it for the young female emergency patient or the bleeding Rh neg patient with anti-D.

Actually poor hospital blood unit inventory control would be more to blame for shortages in the US. Working in blood centers for most of my career the O Negs are the most abused and wrongly ordered. They are held until they become short dated units. Many of those hospitals send those units back to the Blood Supplier who then supplies them to the Trauma centers. At the large trauma center where I worked we almost never encounter a shortage of units...we would buy from out of state Blood Centers or the Red Cross if our local blood center could not provide enough. We NEVER had an issue obtaining O Neg units. So I think it is hog wash to see using O Negs on trauma patients as a waste...that is what they should be used for.

Lastly, the proof is in the pudding: this has been a common policy for the past ~10 years and it doesn't seem to be causing any particular patient harm for the reasons listed above.

My concern was not only the harm to the patient but the unnecessary cause for developing a very clinically significant ABO antibody, plus the added costs to the patient for the workup and the Rh phenotyping. I don't see how you can claim the proof is in the pudding...you don't know the outcome of everyone who has developed anti-D due to being transfused Rh Pos blood. It is just a bad and unnecessary practice. I surely would not want to have an Rh antibody/antibodies due to being given Rh Pos blood.

We don't Rh phenotype patients that have made anti-D; nearly all of them will be cde/cde and finding the occasional r'r or r"r won't change what blood we give them. I can't think of any reason we would try to give them blood that is positive for E just because they are r"r. If they were r'r' it would take awhile to get any r'r' units of blood in anyway so we would wait to see if they made the antibody before using up such a precious resource. Rh phenotyping is more of a reference lab tradition than one used in hospitals I think.

Having to give any combination of rr units to an Rh Neg person who made anti-D through a blood transfusion is all the more reason why they should not be given the opportunity to make anti-D or any of the other Rh antibodies. BTW many large surgery hospitals performing serious surgeries have very skilled blood bankers who perform all of what reference centers perform when it comes to antibody ID except for the rare antibodies that require rare anti-sera or rare blood cells.

If a person makes anti-D then they are capable of making any other Rh anti-body that they are negative for. It is good blood bank practice to give them Rh phenotypically matched blood. I have personally have come across an Rh neg person with a true anti-D and two additional Rh anti-bodies. I have encountered this more than once.

Edited April 23, 2012 by TVC15

[Malcolm Needs ☆]

Maybe when they can grow O neg stem cells into blood units, we can go back to using only O neg for uncrossmatched blood.

.

Don't hold your breath quite yet, but, on the other hand, we may be closer to that situation than you think.

I heard a wonderful lecture recently given by Professor Dave Anstee (Director of the International Blood Group Reference Laboratory and the Bristol Institute of Transfusion Science and the University of Bristol), and his group are getting very close to being able to do just this.

They have been able to "grow" up to 5mL aliquots of group O, D Negative packed red cells from stem cells. All of the testing on these cells appear to be normal (oxygenation, deoxygenation, deformability, etc).

The word "brilliant" is much overused, but Dave is frighteningly brilliant, and a thoroughly great bloke to boot, with a laid back atitude that is almost horizontal!

:excited::excited:

[David Saikin]

I agree with Malcolm - and this is our policy. Also, when push comes to shove, it is better to make anti-D than to exsanquinate. As to the comment further down the line about ABO incompatible - WELL,, the patient will survive for a few days but when their ABO isoagglutinins come back, all that ABO incompatible blood hemolyzes in a few hours usually leading to the demise of the patient.

IN the UK, the Guidelines say to give O D Positive to males and females above the age of 60 in such a situation, but this Guideline is soon to change to females above the age of 50. I am comfortable with this.

[Barbarakym]

the only time we would switch an O Neg patient to O Pos blood is if our supply was being depleted which required the pathologist’s written consent to give Rh pos blood to the Rh neg patient.

I work in Ca, and this is our policy as well. ONEG unless our supply is depleted below our minimum safety, need pathologist approval and doctors need to sign saying patient condition demands blood, (emergency release with this as one of the criteria).

Kym

[TVC15]

I work in Ca, and this is our policy as well. ONEG unless our supply is depleted below our minimum safety, need pathologist approval and doctors need to sign saying patient condition demands blood, (emergency release with this as one of the criteria).

Kym

Outstanding to hear this! I knew Texas could not the only place this practice is in place! Like I said why risk it especially when O Negs are not a problem to come by!

What region of CA do you work in?

[mollyredone]

TVC15, I work in Oregon and we are allowed a maximum of 6 ON units at our hospital. That number used to be our minimum. We live three hours from our supplier and 2 hours from another trauma hospital. We do not have the luxury of handing out ON to everyone who comes through the door bleeding!

[TVC15]

TVC15, I work in Oregon and we are allowed a maximum of 6 ON units at our hospital. That number used to be our minimum. We live three hours from our supplier and 2 hours from another trauma hospital. We do not have the luxury of handing out ON to everyone who comes through the door bleeding!

Are you a Level I trauma center? Level I trauma centers usually have access to a good supply of O Negs. I am specifically speaking about trauma centers. O Negs should be used on trauma patients in the emergency release situtaion for all of the reasons I have mentioned.

[mollyredone]

No, we are a lowly level III trauma center.

[Cliff]

TVC15,

We are a Level 1 trauma center, and while I understand your passion, I respectfully disagree with you.

We do have a policy to give O neg to a female of child bearing potential, but personally I can't see the harm in giving O pos to a male of unknown type. Odds are overwhelmingly in our favor that the person will turn out to be Rh pos. If they are truly bleeding out, it's very unlikely they will form an antibody.

We have a healthy supply of O neg, but there are times when we have to get our residents involved with rationing group O to all O patients.

We issued both O pos and O neg in our trauma coolers and leave it to the physician to decide what is best. We often get a specimen soon so we can give type compatible shortly after the coolers are issued - I know, this further supports your theory. :tongue:

Over the years there have been many times where our O neg supply has been depleted or nearly depleted.

I do respect your opinion, but I think in over 20 years in a Level 1 trauma center with 40+ OR's I've seen quite a lot, and we need to to be good managers of the precious O negs and use them when they are warranted.

What about a 50 year old male who just went through 20 O negs in the OR, and ends up using over 75 more units. Would you advocate that we deplete our entire region? I know our medical staff would have switched to O pos long before we got that far.

Keep in mind managing the inventory is also a patient safety issue.

Kindly disagreeing,

Cliff

[TVC15]

TVC15,

What about a 50 year old male who just went through 20 O negs in the OR, and ends up using over 75 more units. Would you advocate that we deplete our entire region? I know our medical staff would have switched to O pos long before we got that far.

Keep in mind managing the inventory is also a patient safety issue.

Kindly disagreeing,

Cliff

Cliff thank you for respectfully disagreeing but I also disagree with giving O Negs to an O Pos patient. In the above scenario I would personally run down to the patient if the trauma staff could not send up a specimen. I would personally collect the blood gushing out of them to get a blood type so that we would not have to deplete our O Neg supply. Our trauma staff were very well trained to get a specimen to us NOW! I have only once had to go down and collect the blood running out of the patient.

[Cliff]

In the scenario I mentioned I meant to say the type of the patient was O neg. We would intentionally give O pos.

[TVC15]

In the scenario I mentioned I meant to say the type of the patient was O neg. We would intentionally give O pos.

Sure that makes total sense to me....but the real question is how do you know the exact moment they have stopped bleeding out? Less than 1mL of Rh Pos blood in an Rh Neg person can cause sensitization. But sure in that scenario it would make sense.

[Mabel Adams]

Here are a couple of abstracts from pertinent articles in case you are interested.

[ATTACH]627[/ATTACH]

[Likewine99]

TVC15, back when I worked in a Level I trauma center we had a B neg male that we had to switch to B pos b/c we ran out of B negs. We also had another instance of an A neg female of child bearing age that we had to switch to A pos. At the time I was as concerned about this practice as you are now.

The supervisor, a well seasoned SBB reminded me that "80% of all Rh negative patients are non-responders, regardless of how much of the D antigen you expose them to". She also reminded me that we needed to get product out the door or the patient wasn't going to make it.

I understand that you are not comfortable with the practice but the physician has the ultimate responsitilbity for the patient and if trauma literature supports this practice and your institution has approved it then there you have it.

Like Cliff I am respectfully disagreeing with you on the basis that in the 30+ years that I've practiced in the Blood Bank I've never seen O negs "not a problem to come by" regardless of the size of hospital where I was working.

Thanks for bringing this up and asking for input from the forum, I find this thread very enlightening. One of the reasons why I love this site!

[Eagle Eye]

OK level I trauma center in East coast. O Neg to only child bearing age females. All male patient and female over 50 needing massive transfusion---We switched them to Rh Pos as soon as the massive protocol is called. Our trauma referigerator has sign to use O Neg only for child bearing age females. We are fortunate that we get specimen soon enough so we can type specific blood and plasma. We need pathologist approval to switch Rh Neg to Rh Pos.

I would not want to waste any O neg on male patient or female over 50. We been through a case where we almost depleted our invetory of Rh Neg for child bearing age female. I do not recall a need to switch RH for the child bearing age female. We try to manage our inventory by making sure we keep our Rh Neg supply for child bearing age female.

[Malcolm Needs ☆]

Likewine99, whilst I agree with sentiments about a number of D negative individuals that never seemed to make anti-D however many times their immune system is insulted with a D positive stimulus, I think that your numbers are a bit out.

These individuals, according to figures published by Mollison, are more like 10 to 15%. There are also about the same number of D negative individuals who are easily stimulated to make anti-D (just show them a photograph of a D positive red cell, and they make anti-D), and then the rest have a "normal" immune response.

Nevertheless, as I said in an earlier post, I still agree with your post otherwise.

[AMcCord]

There was a study done in Dade County in regards to uncrossmatched blood for trauma cases. It covered hundreds (if not thousands) of individual cases over a period of years, including some folks back for a second or third trauma admit - think gunshot wounds, stabbings and MVAs. One of the angles it addressed was patients who had antibodies (including anti-D from previous trauma admit Rh pos transfusions). The conclusion was...if they are bleeding, transfuse them and worry about the crossmatch/antibodies later. As I remember it, the study addressed both the use of uncrossmatched red cells and using Rh pos red cells. Anybody remember where and when that one was published?

[Mabel Adams]

That study sounds a bit like one that was in the abstracts I attached above.