Giving RH pos RBCs units to RH neg patients

[MERRYPATH]

I am getting confused in my D antigen thinking.

I work at a BB that is fully capable of using a regions whole supply of RH negative RBCs. When we get into a shortage it is easy to look back and say this should never have happened and that should never have happened. While in the situation I think I need to push harder and stomp my foot more to switch to RH pos RBCs. On the other hand I am not the physician and I am concerned that my years of experience be used as a force for good and not evil. I am always thinking of changing to RH pos when we are getting to 8 units or more of RH negative RBCs...I am guessing most of you are thinking why so late...we have a good supply of all types generally. We are also seeing surgeries where they are 2 and 3 times or more into many patients, it can be a population of people who have multiple transfusions in their past...sometimes even RH neg patients who recd RH pos units their last OR. We actually see very little of the emergency uncrossmatched patient, but we see a lot of the issues of chronic transfusion, so I am wondering if switching RH neg patients to RH pos will be more problematic in our patient population. In the usual hospital situation a need for transfusion is transitory and those patiens my never be transfused again, in our situation they are likely to need to be transfused and soon. So we give RH pos to an RH neg person in a bad CABG, their 2nd or 3rd, or maybe an LVAD...the patient ends up on ECMO for weeks to a month and many more transfusions to come and then pehaps their heart transplant. If they DID make anti D it would finish them...right? I know that is the fear of the docs we go to for approval. How do you all look at this issue? Thanks

Edited July 27, 2015 by MERRYPATH

[galvania]

Well, it is never easy to make a hard and fast rule for all cases.  However, thinking back to first principles can help.  Anti-D is to avoid at all costs in women of child-bearing age who can still have children (For example, I mean in a 25 year old woman who is having her uterus removed for cancer is of child bearing age, but can't have children).  You have finite stocks of D neg blood, and your young women should be the priority.  Your second priority should be your patients who are transfusion dependent for life - like sicklers or thalasssaemics. For other chronic transfusions, well, it depends what 'chronic' means, and how much blood you have available and how often the patient needs blood.  I would argue that probably for a 90-year old who is not likely to live more than 6 months who needs 2 units of blood every month, you could probably switch to D+ if you needed to without much of a problem.  I wouldn't do it on a 40 year old who was receiving blood regularly now but with hopes of remission.   Then you have to think that in cases of massive bleeding, the blood doesn't usually stay in the patient long enough for the immune system to 'see' it, so in cases of heavy bleeding it's better to give your D+ first and then switch to D- once the patient is stable.  But that's only my opinion.....

[David Saikin]

Where I work if I have 6u of O= I'm a happy guy - unless I have an O= bleeder.  Our policy for unxm is O+ unless the pt is a female of childbearing age.  I am not averse to switching (have only done it rarely in 20+ yrs here) but that is a decision my Medical Director makes in consult with the pt's MD.  I tell my staff that they cannot give it all away - we need to have at least 2u for the female of child bearing age who may show up.  I also don't want to give just 1u of + rbcs . . . The docs have to make this call at my place.

[Auntie-D]

It makes every sense to start with Rh pos for a massive haemorrhage patient - can I get my place of work to adopt this policy? Grrrr no! And we only hold 8 O negs so once you use 2 massive haemorrhage packs you are switching to O Pos anyway so why 'waste' the O negs - why not just start with O Pos?

 

But then there's the ones where they initiate the MHP and only use 2 units...

[NancyC]

We have made it policy that if the bleeder is an adult male or a female beyond child bearing years, they automatically get O Pos. We only have 6 - 8 O Negs at any given time and we are 2 1/2 hours away from our blood supplier so we are protective of our O Neg supply.

[Eoin]

I think these decisions must be made on a case by case basis - in consultation with the attending consultant / anesthetist / trauma specialist or the MHP coordinator. This gives you some tools to assess how severe the expected loss is likely to be - plus apply all the reasons Galvania gave.

If MHP is called - I would expect the scientists to assess the above first before just giving O Negs (except to females who are potential child bearers).