If a small site that doesn't stock irradiated blood has to give emergency transfusion or a bigger place can't provide several rounds of an MTP that are irradiated, what are the risks? I know that patients who had a Stem Cell transplant in recent years must get irradiated products or face a very dangerous form of GVHD.  I know that patients on purine analog drugs should get irradiated blood, but I don't know how dangerous it is if they don't.  Otherwise, most patients seem to get irradiated because they are candidates for future transplants.  Clearly, we can't let patients bleed to death but, if we get an MTP order on someone our system says needs irradiated blood, what do we tell the pathologist or ED doc about the risk?  Our patient was a non-Hodgkins lymphoma who has not had a transplant, and I see no evidence of cladribine or fludarabine drugs in his list, so I think he is okay.  I know that the doctors are the ones taking responsibility, but I want to understand the relative risks of various patient conditions with regard to GVHD.

I do not see how a genuine massive protocol can be supported with irradiated products. This is based on experience supporting patients during many massive transfusion protocol in a level 1 hospital, and also working in/with two facilities with three different types of irradiator. The irradiating process is just not that fast. I imagine the practical solution would be to give irradiated blood once the patient's bleeding is getting under control. I wonder if the patients stressed systems would prevent GVHD response? 

10 hours ago, Ensis01 said:

I wonder if the patients stressed systems would prevent GVHD response? 

I leave that for the physicians to respond to, but I suspect that since there will be lingering lymphocytes, no, they would not be protected.

I, too, was part of a large level 1 trauma center.  Our inventory was typically 700 - 1,000 RBCs.  We were 100% irradiated.  Once they were received, they went right into the irradiator room (we had a double door fridge in there.  We usually had someone in irradiating most of the first and second shift, we had two old cesium irradiators.  It was very hard to keep up.  We looked into getting two x-ray irradiators, but it was cost-prohibitive, even with the government program where they would take the cesium ones away and pay for half the cost of the new ones.

@Cliff  Wow.  That's a LOT of irradiated units.  Here in Canada, irradiated blood has a shorter expiry due to the red cell membrane damage.  Is that the same for you?

Our policy - if an MHP is called on a patient who requires irradiated blood - is to inform the physician and provide the oldest RBC (preferably over 14 days old) because the number of viable lymphocytes should be decreased.  Of course that doesn't help for PLT.

1 minute ago, AuntiS said:

Here in Canada, irradiated blood has a shorter expiry due to the red cell membrane damage.  Is that the same for you?

Yes, we needed to reduce the expiration to 28 days from the date of collection.

We issued about 100 units of RBCs a day, we didn't outdate a lot.

We had a huge cancer population, we just felt it was safer to irradiate everything.  We also adopted 100% leukoreduction much earlier than most facilities.

Almost all our platelets are pathogen reduced so they aren't much more of a worry than usual in an MTP.

Does anyone know how likely TA-GVHD is in patients on drugs like fludarabine and cladribine? The inserts just say that the patients should get irradiated units, but I would guess that the risk is lower than someone 4 months post stem cell transplant.  I've heard that TA-GVHD is 95% fatal, but I think that is in a recent transplant cohort. Bleeding to death is also fatal. The nuance is in the ED doc's perception of how likely it is that the patient is bleeding to death. Most of our irradiation patients are only candidates for transplant so I think their risk is small if they don't get irradiated blood in an emergency.  They can probably postpone the transplant.  In our most recent case at one of our small hospitals, I could see that the patient had no recent transplant and was not on those purine analog drugs so felt his risk was low and he did fine after getting 1 irradiated RBC and one non then going to IR to fix his second spontaneous splenic rupture in the setting of lymphoma and DOAC. 

Our irradiated red cells have an updated expiry of 14 days max and are not irradiated if older than 2 weeks.

Non-Hodgkins lymphoma does not require irradiated products.