Transfusion Medicine: A Clinical Guide

LANDES BIOSCIENCE

Table of contents 1. How to Order Blood

5. The Complex Patient

2. The Anemic Patient

6. The Obstetric Patient

3. The Coagulopathic Patient

7. The Pediatric Patient

4. The Thrombocytopenic Patient and Qualitative Disorders of Platelet Function

8. The Neonatal Patient

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Transfusion Medicine: A Clinical Guide

9. Other Special Patients 10. Transfusion Reactions

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Transfusion Medicine: A Clinical Guide

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Schexneider

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Katherine Schexneider

v a d e m e c u m

Transfusion Medicine

A Clinical Guide

Katherine Schexneider, MD

Naval Medical Center Portsmouth Portsmouth, Virginia, USA

LANDES BIOSCIENCE

Austin, Texas USA

VADEMECUM Transfusion Medicine: A Clinical Guide LANDES BIOSCIENCE Austin, Texas USA Copyright ©2008 Landes Bioscience All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Printed in the USA. Please address all inquiries to the Publisher: Landes Bioscience, 1002 West Avenue, Austin, Texas 78701, USA Phone: 512/ 637 6050; FAX: 512/ 637 6079 In-text art by Kathryn Sauceda Cover art modification by Nicole Todd ISBN: 978-1-57059-703-9

Library of Congress Cataloging-in-Publication Data Schexneider, Katherine I. Transfusion medicine : a clinical guide / Katherine Schexneider. p. ; cm. -- (Vademecum) Includes bibliographical references and index. ISBN 978-1-57059-703-9 1. Blood--Transfusion--Handbooks, manuals, etc. I. Title. II. Series. [DNLM: 1. Blood Transfusion--Handbooks. WB 39 S328t 2008] RM171.S33 2008 615'.39--dc22 2008015993

While the authors, editors, sponsor and publisher believe that drug selection and dosage and the specifications and usage of equipment and devices, as set forth in this book, are in accord with current recommendations and practice at the time of publication, they make no warranty, expressed or implied, with respect to material described in this book. In view of the ongoing research, equipment development, changes in governmental regulations and the rapid accumulation of information relating to the biomedical sciences, the reader is urged to carefully review and evaluate the information provided herein.

Dedication To S. Gerald Sandler, MD Teacher, mentor, scholar Thank you for everything.

About the Author...

Dr. Katherine Schexneider on a medical mission trip in rural South Africa, 2007.

KATHERINE SCHEXNEIDER, MD, is the Medical Director, Blood Bank at a tertiary care medical center. She is board-certified in Anatomic and Clinical Pathology and holds subspecialty boards in Transfusion Medicine. She received her medical degree from Uniformed Services University after studying history at UC Berkeley. Her interests are in management of massive transfusions and use of fresh frozen plasma in patients with mild coagulopathy. She particularly enjoys teaching transfusion medicine, whether at the bedside or in the lecture hall, to physicians and nurses at all levels of experience. She has previously authored a review manual covering all of clinical pathology and two articles on transfusion medicine topics. Outside of the hospital, Dr. Schexneider is a competitive runner (of no special ability) and avid baseball fan. She and her husband split time between their Portsmouth, Virginia and suburban Maryland homes.

Contents Preface ........................................................................ ix 1. How to Order Blood .................................................... 1 2. The Anemic Patient ...................................................... 7

2.1 Anemia without Ongoing Blood Loss........................................................ 8 2.2 Anemia with Ongoing Blood Loss ............................................................11 2.3 The Patient with Antibodies .......................................................................15 2.4 The Sickle Cell Anemia Patient and Autoimmune Hemolytic Anemia ........................................................................................17 2.5 The Surgical Patient ......................................................................................21

3. The Coagulopathic Patient ......................................... 25

3.1 Factor Deficiencies ........................................................................................26 3.2 The Warfarin Patient ....................................................................................29 3.3 The Liver Failure Patient and Chronic DIC ...........................................31 3.4 The Surgical Patient ......................................................................................35 3.5 The Patient Requiring Minor Procedures ................................................38

4. The Thrombocytopenic Patient and Qualitative Disorders of Platelet Function .................................... 41 4.1 Simple Thrombocytopenia..........................................................................42 4.2 Immune Thrombocytopenic Purpura .......................................................47 4.3 Thrombotic Thrombocyotpenic Purpura ................................................50 4.4 The Uremic Patient .......................................................................................54 4.5 The Patient on Anti-Platelet Agents .........................................................56

5. The Complex Patient .................................................. 59 5.1 Massive Transfusion......................................................................................60 5.2 DIC ..................................................................................................................66 5.3 The Septic and Critically Ill Patients .........................................................70

6. The Obstetric Patient—Special Situations .................. 75

6.1 Postpartum Hemorrhage ............................................................................76 6.2 Severe Postpartum Hemorrhage and Evolving Disseminated Intravascular Coagulation ...........................................................................77 6.3 Hemolysis, Elevated Liver Enzymes and Low Platelets .......................80 6.4 Maternal Immune Thrombocytopenic Purpura .....................................84

7. The Pediatric Patient—Special Situations ................... 89

7.1 The Pediatric Oncology Patient .................................................................90 7.2 The Critically Ill Child .................................................................................94 7.3 Thalassemia and Chronic Transfusions ....................................................98 7.4 The Pediatric Surgical Patient .................................................................. 102

8. The Neonatal Patient—Special Situations ................. 107

8.1 Hemolytic Disease of the Newborn ....................................................... 108 8.2 NAIT ............................................................................................................ 112 8.3 Dedicated Units ......................................................................................... 115 8.4 Neonatal Coagulopathy............................................................................ 117

9. Other Special Patients .............................................. 121

9.1 Autologous Donors ................................................................................... 122 9.2 Directed Donors ........................................................................................ 126 9.3 Jehovah’s Witnesses and Other Religious Considerations ................ 129

10. Transfusion Reactions .............................................. 135 Index ........................................................................ 145

Preface This book provides both scientific background and practical advice for the physician preparing to transfuse his/her patient. The background covers the basic pathophysiology and current research of transfusion medicine in a concise manner and refers the reader to well-written review articles for in-depth treatment. The advice is what I endorse from the authors referenced, major, well-respected trials published in peer-reviewed journals, and consensus statements and also my own recommendations, based on my experience as a board-certified transfusion medicine physician at a major medical center. The guidance I provide here is what I offer to physicians on a daily basis. It is specific. Yes, there are triggers throughout the book. That being said, responsibility for the decisions rests with you, and your own good clinical judgment is as much a part of the transfusion treatment plan as is this text. Although there are “classic patients,” each real patient is a variation on the theme, with unique features that require you to fine tune the standard approaches I offer. Transfusion medicine is more, far more, than medicine by the numbers. I probably use the word “integrate” more than any other word in this text besides “transfusion.” I’ll help you integrate as best I can. I have attempted to write for physicians at all levels and across the specialties, from the medical student (student doctor) to the attending. I would hope that a house officer could read the pertinent section of this book in the middle of the night, grasp the essential features of his patient’s disorder, then order blood appropriately, and even speak coherently about what he learned at morning rounds. What you learn here you may not have encountered before in your study of medicine. Didactic education in transfusion medicine is scant in most medical schools, and hospital-based instruction is too often catch-as-catch-can, with senior residents simply repeating what they remember to juniors, snippets of late-night conversations that they didn’t really understand the first time. I try to improve on that with clear, brief explanations (at 3:00 A.M., you can only handle so much blood banking, I know this) and rational, evidence-based consultation, so you can execute a treatment plan with some substance. Here is how the book is laid out. With the exceptions of the first and last chapters, each chapter discusses a patient type, i.e. the anemic patient, or the neonatal patient. Within each chapter are the more common disease states; there are few zebras in this book. The format tries to balance bullet-form text boxes with prose which explains major concepts in complete sentences. Thus, Key Principles, Role of Laboratory Tests and Treatment Plan are in box or

table format; these are the take-home messages of each section. The Chapter Overview, Basic Concepts and The Whole Patient are in paragraph form. Here, I try to explain transfusion medicine, pathophysiology, etc. in some detail so you understand what I am recommending and why. The Eight-Second Summary is transfusion medicine for one type of patient boiled down to one or two sentences. Quick Questions include the more common queries I have been asked by house staff and attending physicians alike. Good luck with your patients. Katherine Schexneider, MD Portsmouth, Virginia, USA

Acknowledgements My physician colleagues deserve the greatest credit for this book. Through their questions, requests for assistance and clinical insights, they helped shape my approach to transfusion medicine and made me recognize the need for a handbook. It has been a privilege to serve them these past several years, and broadly, I thank all of them for their input, but I must acknowledge several by name. The transfusion needs of patients in the intensive care units introduced me to some exceptional physicians, and I am particularly grateful to Pablo Pizzaro, MD, Abhik Biswas, MD and Bob Englert, MD as the heads of these units at my hospital. They added to my clinical knowledge far more than I increased their grasp of blood banking. Three others deserve special mention. Cindy Piccirilli, MD, has provided steady encouragement for me in my work. Jen Thompson, MD, continually reminds me that house officers desperately need instruction, didactic or curbside, in the basics of blood transfusion. Finally, Doug Miller, MD, was the inspiration for Quick Questions, and some of the examples in this book came directly from our conversations in the hallways. Two transfusion medicine physicians, S. Gerald Sandler, MD and Susan Roseff, MD, have both been superior mentors to me, always available, and always offering sound advice. Hundreds of consultations, formal and casual, laid the content for the book. The atmosphere of collegiality, the tone of enthusiastic cooperation set by the people above on their own wards on a daily basis, gave me the impetus to write. This was no solitary effort. I am also indebted to the publishing team. I thank Ron Landes, MD, for accepting it for publication and believing it will help physicians become better transfusionists. Cynthia Conomos and Celeste Carlton have guided the project from day one with professionalism and energy.

Disclaimer The views expressed in this book are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

CHAPTER 1

How to Order Blood Key Principles • The Type and Screen only provides information about your patient. It does not reserve blood for him. • The Type and Cross reserves packed red blood cells (RBC) for your patient, usually for 72 hours. • The Blood Bank does not crossmatch fresh frozen plasma (FFP), platelets or cryoprecipitate. • Irradiation only prevents Transfusion-Associated Graft Versus Host Disease. It has nothing to do with cytomegalovirus (CMV). • Leukoreduction reduces (does not eliminate) the risk of CMV transmission and Human Leukocyte Antigen (HLA) alloimmunization. • 10ml/kg of RBCs, FFP or platelets is a typical transfusion for neonates and infants.

Chapter Overview

This chapter outlines the correct terminology for ordering blood and explains briefly what your Blood Bank does with patient samples and blood products (RBCs, FFP, etc.) when you write orders. Perhaps the only time anyone taught you how to order blood was at 2:00AM on a medical student rotation, and by 2:15 a Type and Screen was indistinguishable from a Type and Cross, and you were too tired to think about blood banking any longer. In fact, I don’t even remember having a late night tutorial on ordering blood when I was a medical student or transitional intern. I learned this as a pathology resident and transfusion medicine fellow. It’s actually pretty straightforward, and it’s written down here, so you can flip through the pages of this chapter instead of racking your brain. I’ve provided some examples of correct orders at the end of this chapter as a go-by.

Basic Concepts The Type and Screen (T+S)

The T+S provides your patient’s ABO and Rh type from testing on the red blood cells, mixing them with reagent anti-A and anti-B antibodies. The Blood Bank also takes your patient’s plasma and mixes it with two or three reagent red cells to Transfusion Medicine: A Clinical Guide, by Katherine Schexneider. ©2008 Landes Bioscience.

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Transfusion Medicine: A Clinical Guide

determine if the plasma contains any clinically significant antibodies to antigens commonly found on red blood cells. These antibodies are not the anti-A in a group B person (we determine this in the typing), but rather anti-E in an E-negative person, for example. There are about a dozen of these antibodies which the Blood Bank tests for. While we make anti-A or anti-B naturally according to our own blood type, we make these other antibodies usually through exposure (transfusion or pregnancy), or sometimes naturally. The two or three reagent red cells have a mix-and-match of the dozen antigens on their surface. If your patient’s plasma reacts with any of the red cells, the Blood Bank performs the same test on 10-13 different red cells to isolate the offending antigen(s). If the initial antibody screen is negative, you can be reasonably confident that finding compatible RBCs will be quick and straightforward. If the screen is positive, the Blood Bank must check the antigens on red cells from a particular unit of blood prior to crossmatching it. If negative for the offending antigen, the technician will crossmatch the unit (more on this soon); if positive, he/she sticks that unit right back on the shelf and tries another. Remember that the T+S by itself only tests your patient’s blood; it does not match your patient’s blood (plasma) with units in the Blood Bank. That’s what the Type and Cross is for. Order a T+S if there is a small possibility (