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monnie48

RHIG for pt receiving O pos RBC's

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I would like to know what most facilities do regarding the transfusion of O positive RBC's to O negative female patient's <50yrs in emergent situations.  Do you routinely give RHIG in this situation?  We have recently changed our policy and I would like to know how others handle this

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You can't really give enough Rhogam to counteract the effects of a whole unit of packed red blood cells. I believe one vial covers a 30 ml whole blood bleed.

When our O neg inventory is critical, we give O pos to males and to females >50 years. In the past 3 years, we have not had to give Rh pos red cells to an Rh negative women <50 years.

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Hmmmmm kirkaw.  It depends on how much D Positive blood is given, whether you have access to IM anti-D in sufficient amounts, whether the patient is well enough to undergo an exchange transfusion, and how quickly you can replenish your D Negative blood stocks to be able to carry out the exchange transfusion, should one be possible.

 

Never say never!

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But Malcolm, there is a very subtle but important difference between what is "possible" and what is "realistic".  Personally, I would say that going through an exchange transfusion simply to prevent the formation of anti-D is not reasonable but then I'm married to a nurse who has an anti-D along with an anti-K and an anti-S so my view may be a little jaded. Oh ya, the D was provided by the birth of our son.  Our daughter was effected by it to the point of needing a double exchange transfusion which, I should mention, is not quite as dramatic in an infant as it is in an adult.  The daughter is now 31 and has three children of her own.  I relate this to remind folks that having an anti-D is not the automatic kiss of death.  Ok, enough of my semiannual philosophical drivel.  :crazy:

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In our policy it states to consult with medical director.  For a small amount, like what is in an Rh positive platelet product, administration of RHIG is simple solution and usually safe.   For larger volumes of Rh positive cells, like a whole unit of blood or more, administration of a large amount of RHIG can produce a transfusion reaction-like situation.  Like John said,   formation of anti D is not an automatic kiss of death.  

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..it might be if you are a male in a massive transfusion situation some time down the line though...

 

Scott

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Not really.  History shows that the vast majority of those involved in massive transfusion scenarios usually don't live long enough for their antibodies to be a factor.  Those that do, for some reason I don't really comprehend but maybe Malcolm can help out, seldom express much of an antibody mediated hemolytic transfusion reaction.  I think it's do to some form of immune suppression that occurs.  Throughout transfusion history far more patients have perished do to an ABO incompatibility than all the other antibody systems combined and that is usually due to a few units not a massive transfusion.  If I remember correctly anti - D does not utilize compliment and is therefore an extra vascular hemolysis which, as a general rule, can be managed for the most part.  Most facilities I have been associated with will not provide O Neg blood in an emergency situation for males and females over 50 and no RhIG is provided to those who happen to be D negative.  From that alone I'm fairly confident that, while preventing anti-D in young ladies it a worthwhile endeavor extraordinary efforts to do so is not really  called for.  As always, everything we do is a game of odds and how you respond to those odds is based on your knowledge and comfort level. 

 

I hope that's not quite as rambling and I think it is.  :confuse:

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I agree entirely with what you say John (and you are correct in that, apart from the unique "Ripley" anti-D, anti-D does not activate complement through to the membrane attack complex), and I also do not think that your post is "rambling"!

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I agree with John and Malcom.

Future transfusions?  Non-ABO antibodies are mostly 'extravascular' hemolysis and, as I've said before, 'Exanguination is a lot harder to treat than a delayed hemolytic transfusion reaction' so all those IgG antibodies tend to get 'ignored' during a massive transfusion situation.  We actually try to hold the 'totally compatible' RBCs until the bleeding is in control/stopped.  Plus, yes, there's the dilutional and immunomodulation effects of massive blood transfusion.

 

Check the 'Instructions for Use' on your Rh-Ig product.  Rh-Ig prophylaxis is usually recommended for Rh-neg patients who have received less than 20% Rh-Pos of their blood volume.  Furthermore, since giving Rh-Ig to such patients will cause a mild 'delayed hemolytic' reaction (that's how it works), the IFU recommends exchange transfusion if the Rh-Pos transfusion was greater than 20%.  But, as I said, I agree with John S. about all that.

 

PS We have records in our files of patients who developed Anti-D to Apheresis Platelet transfusions ... so, it does happen.  We do consider Rh-Ig per policy, but most of the time the patient is over 50yrs old so this becomes a mute/moot point.

Edited by JPCroke

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back in the early 70s we gave an RH+ rbc to an Rh= young female.  I believe we gave 27 doses of RhIg to this pt.  She developed anti-D.  I can see giving RhIg when administering Rh+ plts; seems futile to do it for rbcs.

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Did they have IV RhIG in the 70's?

 

We have a pregnant gal  who is reported to have been given 11 doses of RhIG when she had twins a couple of years ago.  Now her anti-D titer just hit 128 and she has developed a weak anti-C.  I don't know if it was a transfusion or if both babies half way bled out or what.  I also don't know what kind of RhIG she got.

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In that case David, it may well be that the anti-D immunoglobulin was not absorbed from the muscle into the circulation in time, and, in some rare cases, it has been shown that an IM dose of anti-D immunoglobulin never gets absorbed into the circulation.

 

The other thing is that, if the lady was somewhat portly (to put it delicately), she may have needed a larger dose, as the calculation for the amount of anti-D immunoglobulin given is, shall we say, based on the "standard British woman size"!!!!!!!!!!!!

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JPcroake, when you said that RhIg would give a mild hemolytic transfusion reaction would that be caused by the RhIg being attached to the Rh positive donor cells then subsequently being destroyed???

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We would give Rh Pos and then switch to Rh Neg once the bleeding is under control. The theory being that most of the Rh pos cell will end up on the floor and you may not get to the point of even needing the Rh neg.

 

If you give Rh Pos blood in a an emergency and then give a massive dose of immunoglobulin, aren't you effectively making your own transfusion reaction? The sensitised cells are going to be removed and the spleen is going to go into major overdrive. You're then going to end up with iatrogenic anaemia secondary to the immunoglobulin.

 

Malcolm - for the first time ever I am going to disagree with you. Exchange transfusion to prevent formation of anti-D - never heard anything so crazy in my life!

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It is the prerogative of anyone on this site to disagree with anything I may say, but I was once involved in just such a case.  It involved an 8-year-old D Negative female, who underwent exchange transfusion and cover with anti-D immunoglobulin, following a massive transfusion of D Positive blood.  She was followed for many months afterwards, but allo-anti-D was never detected in her circulation.

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