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dothandar

Surgery patient with antibody to high frequency antigen

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Here is a hypothetical situation that most IRL may have faced. I am just wondering how any of you may handle this. 

Patient with an antibody to high incidence antigen (say, anti-Jk3) is going to surgery. Surgeon would like to have 2 units available in case this patient needs blood. MMA (monocyte monolayer assay) testing or ADCC (antibody dependent cellular cytotoxicity) assay indicate reactive (clinically significant). What would you do? 

1) look for donor for this patient

2) Deglyz one frozen/rare unit right before the surgery 

3) other (indicate) 

 

Edited by dothandar

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It honestly depends upon the specificity.  I was lucky enough to have worked at NHSBT-Tooting Centre, where we had a project running looking for rare donors (originally run by Peggy Leake, and since by Alan Gray) for well-over 25 years.  As a result, we have access to all sorts of rare donors.

In most cases, therefore, we would either look for a (known) donor or order a couple of units from the National Frozen Blood Bank.

If the worst comes to the worst, we would look for cryopreserved units in other countries.

Lastly, if time allowed, we would think in terms of autologous units and testing family members.

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1 hour ago, Malcolm Needs said:

It honestly depends upon the specificity.  I was lucky enough to have worked at NHSBT-Tooting Centre, where we had a project running looking for rare donors (originally run by Peggy Leake, and since by Alan Gray) for well-over 25 years.  As a result, we have access to all sorts of rare donors.

In most cases, therefore, we would either look for a (known) donor or order a couple of units from the National Frozen Blood Bank.

If the worst comes to the worst, we would look for cryopreserved units in other countries.

Lastly, if time allowed, we would think in terms of autologous units and testing family members.

It seems to most reasonable to either recruit donors or encourage autologous donation. Had the patient Hct is too low to donate autologous unit or there is no donor turned up by the surgery date (which hypothetically cannot be delayed), would you go ahead and thaw the cryopreserved unit from your frozen bank before a surgery (taking a chance that the unit may be wasted if not given within 24 hours) or would the patient go into surgery without thawed (or liquid) unit available on shelf. 

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It depends (again) upon the antibody.

If the antibody is NOT known to cause clinically significant transfusion reactions, our doctors MAY decide that giving known uncross-match compatible blood, with a cover of IVIgG (+/- something like methylprednisolone), and keep the cryopreserved units in reserve.

If the antibody IS known to be clinically significant, AND the patient's pre-operative Hb is both stable and adequate (depending upon the condition of the heart, and the underlying pathology - and the co-operation of the Anaesthetist), how much the patient is expected to bleed, and how far the hospital is from the blood centre, we may thaw and reconstitute the units, but keep them at the Centre local to the patient's hospital.  This would allow us to get the units to the hospital quickly (blues and twos, if need be), but, if the units are NOT required, we keep them and send them out to all of our Centres as a rare reagent cell.

If the antibody is known to be clinically significant, and the patient is likely to bleed/has a low pre-op Hb (i.e. nothing is going right for them), we would provide the units thawed and reconstituted, at the hospital, and if they are not used, and are wasted - so what?  At least we tried!

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1 hour ago, Malcolm Needs said:

It depends (again) upon the antibody.

If the antibody is NOT known to cause clinically significant transfusion reactions, our doctors MAY decide that giving known uncross-match compatible blood, with a cover of IVIgG (+/- something like methylprednisolone), and keep the cryopreserved units in reserve.

If the antibody IS known to be clinically significant, AND the patient's pre-operative Hb is both stable and adequate (depending upon the condition of the heart, and the underlying pathology - and the co-operation of the Anaesthetist), how much the patient is expected to bleed, and how far the hospital is from the blood centre, we may thaw and reconstitute the units, but keep them at the Centre local to the patient's hospital.  This would allow us to get the units to the hospital quickly (blues and twos, if need be), but, if the units are NOT required, we keep them and send them out to all of our Centres as a rare reagent cell.

If the antibody is known to be clinically significant, and the patient is likely to bleed/has a low pre-op Hb (i.e. nothing is going right for them), we would provide the units thawed and reconstituted, at the hospital, and if they are not used, and are wasted - so what?  At least we tried!

Thank you for the detailed explanation and laying out all the possible case scenarios. Amazing as always! 

 

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