1
|
Stevenson J, DeGroote NP, Keller F, Brock KE, Bergsagel DJ, Miller TP, Cornwell P, Fasano R, Chonat S, Castellino SM. Characteristics and outcomes of pediatric oncology patients at risk for guardians declining transfusion of blood components. Cancer Rep (Hoboken) 2022; 6:e1665. [PMID: 35792092 PMCID: PMC9875642 DOI: 10.1002/cnr2.1665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/01/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transfusion of blood products is a necessary part of successful delivery of myelosuppressive regimens in pediatric cancer. There is a paucity of literature characterizing outcomes or management of pediatric patients with cancer when transfusion is declined. AIMS The objective of this paper is to describe the clinical characteristics, care, and outcomes of patients with cancer at risk for declining transfusion. METHODS AND RESULTS A retrospective cohort of patients aged 0-21 years with cancer managed at Children's Healthcare of Atlanta between 2006 and 2020 and with ICD-9 codes indicating risk of "transfusion refusal" or Jehovah's witness (JW) religion was identified. Demographics, disease, and management were abstracted. Descriptive statistics were performed to examine associations with transfusion receipt. Among 35 eligible patients identified as at risk for declining transfusion, 89% had primary guardians who identified as JW, and 45.7% identified as Black, non-Hispanic. Only 40% of guardians actively declined transfusion. Transfusion recipients had significantly lower hemoglobin (g/dl) and platelet counts (1000/μl) at initial presentation (9.6 vs. 11.9, p < .002 and 116.0 vs. 406.5, p = .001, respectively) and at nadir (5.9 vs. 8.7, p < .001 and ≤ 10 vs. 154, p < .001, respectively) than non-recipients. Legal intervention was required in 36.4% of those who ultimately received a transfusion. CONCLUSION Among pediatric cancer patients whose medical record initially indicated a preference for no transfusion, 60% of guardians accepted blood products when prescribed for oncology care. Guidelines for systematic management and transfusion sparing approaches are needed to honor guardian's preferences when possible yet while maintaining equitable cancer outcomes in this population.
Collapse
Affiliation(s)
- Jason Stevenson
- Department of Pediatrics, Division of Graduate Medical EducationEmory UniversityAtlantaGeorgiaUSA
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Frank Keller
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Hematology/OncologyEmory UniversityAtlantaGeorgiaUSA
| | - Katharine E. Brock
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Hematology/OncologyEmory UniversityAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Palliative CareEmory UniversityAtlantaGeorgiaUSA
| | - D. John Bergsagel
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Hematology/OncologyEmory UniversityAtlantaGeorgiaUSA
| | - Tamara P. Miller
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Hematology/OncologyEmory UniversityAtlantaGeorgiaUSA
| | - Patricia Cornwell
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA
| | - Ross Fasano
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Hematology/OncologyEmory UniversityAtlantaGeorgiaUSA
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Hematology/OncologyEmory UniversityAtlantaGeorgiaUSA
| | - Sharon M. Castellino
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaAtlantaGeorgiaUSA,Department of Pediatrics, Division of Pediatric Hematology/OncologyEmory UniversityAtlantaGeorgiaUSA
| |
Collapse
|
2
|
Johns C, Bakhtary S, Wu R, Nedelcu E. A Single-Center Description of Pediatric Transfusion Reactions and Preventable Patient Harm. Hosp Pediatr 2021; 11:e334-e338. [PMID: 34635509 DOI: 10.1542/hpeds.2020-005173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES In previous studies, researchers highlight that children have higher rates of transfusion reactions than adults. However, little is known about the pediatric populations that experience reactions, and there are no reports that consider appropriateness of pediatric transfusions in relation to preventable harm. With this study, we aim to describe pediatric transfusion reactions occurring at an academic institution and to quantify transfusion reactions that resulted from inappropriate transfusion indications, thereby identifying an area of potentially preventable patient harm (PPH). METHODS This is a case series of acute transfusion reactions in pediatric patients at a single institution from January 2018 to December 2019. We reviewed patient data, clinical documentation, and transfusion reaction reports to determine the appropriateness of transfusions and calculate PPH. RESULTS A total 155 acute transfusion reactions occurred in 106 pediatric patients, amounting to a total reaction rate of 544 of 100 000 transfusions. In 65% of reactions, the indication for transfusion was appropriate by institutional standards; 23% had questionable indication; and 12% were not indicated. The rate of potential PPH from inappropriate transfusions was 67 of 100 000 transfusions. CONCLUSIONS Transfusion reactions that occur during inappropriately ordered blood transfusions represent PPH. Efforts should be made to develop transfusion guidelines, standardize practice, and educate physicians to prevent transfusion-related harm.
Collapse
Affiliation(s)
| | | | - Ruobin Wu
- Pathology, University of California San Francisco Medical Center, San Francisco, California
| | | |
Collapse
|
3
|
Reeves HM, Goodhue Meyer E, Harm SK, Lieberman L, Pyles R, Rajbhandary S, Whitaker BI, Delaney M. Neonatal and pediatric blood bank practice in the United States: Results from the AABB pediatric transfusion medicine subsection survey. Transfusion 2021; 61:2265-2276. [PMID: 34110629 DOI: 10.1111/trf.16520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/05/2021] [Accepted: 04/21/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND There are limited standards guiding the selection and processing of blood components specific for neonatal and pediatric transfusions. Therefore, blood banks (BBs) and transfusion services must create their own policies and procedures. STUDY DESIGN AND METHODS The American Association of Blood Banks (AABB) Pediatric Transfusion Medicine Subsection Committee developed a 74-question survey to capture neonatal and pediatric BB practices in the United States. RESULTS Thirty-five centers completed the survey: a response rate 15.8%. Responses indicated that most carry a mixed inventory of red blood cells (RBCs); 94.2% allow more than one type of RBC product for small-volume (SV) and large-volume (LV) transfusions to neonatal and pediatric patients. Many had storage age thresholds for RBCs transfused to neonates (SV = 60%, LV = 67.7%) but not older pediatric patients. The use of Group O for nonurgent RBC transfusion in neonates was common (74.2%). Responses related to special processing of RBCs and platelets indicated that 100% RBC and platelets are leukocyte-reduced (LR) for neonates and 97% for non-neonates. Irradiation of RBCs and platelets was commonly performed for neonatal transfusion (88.6%). Providing cytomegalovirus (CMV) seronegative products, volume reduction, and washing were variable. All centers transfused single-donor apheresis platelets; 20% allowed pathogen reduction (PR). The majority of centers have strategies limiting the amount of incompatible plasma transfused; however, few titrate ABO isoagglutinins in plasma-containing products (20% for platelets and 9.1% for plasma). CONCLUSIONS Variability exists in BB practice for neonatal and pediatric transfusion. Future studies are needed to understand and define best BB practices in these patient populations.
Collapse
Affiliation(s)
- Hollie M Reeves
- Department of Pathology, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Erin Goodhue Meyer
- American Red Cross Biomedical Services, Columbus, Ohio, USA.,Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Sarah K Harm
- University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Ryan Pyles
- SSM Health Cardinal Glennon Children's Hospital, Fenton, Missouri, USA
| | | | - Barbee I Whitaker
- Center for Biologics Evaluation and Research, Office of Biostatistics and Epidemiology, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Meghan Delaney
- Pathology and Laboratory Medicine Division, Children's National Medical Center, Washington, DC, USA.,Pathology and Pediatrics Departments, The George Washington University, Washington, DC, USA
| |
Collapse
|
4
|
Yanagisawa R. Preventing adverse reactions in pediatric transfusions using washed platelet concentrate. Pediatr Int 2021; 63:391-403. [PMID: 33290634 DOI: 10.1111/ped.14572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 12/02/2020] [Indexed: 01/04/2023]
Abstract
Blood transfusion is an important form of supportive care in children; however, transfusion-associated adverse reactions (TARs) are a problem. As with adults, allergic transfusion reactions (ATRs) and febrile non-hemolytic transfusion reactions (FNHTRs) are major TARs, and the frequency of ATRs caused by platelet concentrate (PC) tends to be particularly high. The plasma component of the blood product is thought to be a major factor in the onset of TARs such as ATR and FNHTR. By contrast, in children, age, underlying disease, and number of blood transfusions may be relevant patient-related factors. Although acetaminophen or diphenhydramine may be used prophylactically to prevent TARs, there is no clear evidence of their effectiveness. Volume-reduced PC is used to prevent TARs; however, it may be difficult to maintain the quality of platelets. Plasma-replaced PC stored with platelet additive solution raises the concern that TARs cannot be completely prevented by residual plasma. Washed PC removes most of the plasma, so it can effectively prevent ATR and FNHTR. The recent development of platelet additive solution [M-sol, bicarbonate Ringer's solution supplemented with acid-citrate-dextrose formula A (BRS-A)] in Japan has enabled the maintenance of the quality of platelets for long periods. The clinical use of washed PC in Japan has therefore progressed. Washed PC with M-sol or BRS-A for pediatric patients can effectively prevent TARs without diminishing the transfusion effect. The supply of washed PC has begun from the Japanese Red Cross Society, and it has become possible to use washed PC at all medical institutions in Japan.
Collapse
Affiliation(s)
- Ryu Yanagisawa
- Division of Blood Transfusion, Shinshu University Hospital, Matsumoto, Japan.,Center for Advanced Cell Therapy, Shinshu University Hospital, Matsumoto, Japan
| |
Collapse
|
5
|
Zerra PE, Josephson CD. Transfusion in Neonatal Patients: Review of Evidence-Based Guidelines. Clin Lab Med 2020; 41:15-34. [PMID: 33494882 DOI: 10.1016/j.cll.2020.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Transfusion of red blood cells, platelets, and fresh frozen plasma in neonatal patients has not been well characterized in the literature, with guidelines varying greatly between institutions. However, anemia and thrombocytopenia are highly prevalent, especially in preterm neonates. When transfusing a neonatal patient, clinicians must take into consideration physiologic differences, gestational and postnatal age, congenital disorders, and maternal factors while weighing the risks and benefits of transfusion. This review of existing literature summarizes current evidence-based neonatal transfusion guidelines and highlights areas of current ongoing research and those in need of future studies.
Collapse
Affiliation(s)
- Patricia E Zerra
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Egleston Hospital, 1405 Clifton Rd, Atlanta, GA 30322, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA 30322, USA; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Egleston Hospital, 1405 Clifton Rd, Atlanta, GA 30322, USA.
| |
Collapse
|
6
|
Goel R, Josephson CD, Patel EU, Petersen MR, Packman Z, Gehrie E, Bloch EM, Lokhandwala P, Ness PM, Katz L, Nellis M, Karam O, Tobian AAR. Individual- and hospital-level correlates of red blood cell, platelet, and plasma transfusions among hospitalized children and neonates: a nationally representative study in the United States. Transfusion 2020; 60:1700-1712. [PMID: 32589286 DOI: 10.1111/trf.15855] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Factors associated with red blood cell (RBC), plasma, and platelet transfusions in hospitalized neonates and children across the United States have not been well characterized. METHODS Data from the Kids' Inpatient Database (KID) 2016 were analyzed. KID is a random sample of 10% of all uncomplicated in-hospital births and 80% of remaining pediatric discharges from approximately 4200 US hospitals. Sampling weights were applied to generate nationally representative estimates. Primary outcome was one or more RBC transfusion procedures; plasma and platelet transfusions were assessed as secondary outcomes. Analysis was stratified by age: neonates (NEO; ≤28 d), and nonneonates (PED; >28 d and <18 y). Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs). RESULTS Among 5,604,984 total hospitalizations, overall prevalence of transfusions was 1.07% (95% CI, 0.94%-1.22%) for RBCs, 0.17% (95% CIs, 0.15%-0.21%) for plasma and 0.35% (95% CI, 0.30%-0.40%) for platelet transfusions. RBC transfusions occurred among 0.43% NEO admissions and 2.63% PED admissions. For NEO admissions, RBC transfusion was positively associated with nonwhite race, longer length of hospitalization, highest risk of mortality (aOR, 86.58; 95% CI, 64.77-115.73) and urban teaching hospital location. In addition to the above factors, among PED admissions, RBC transfusion was positively associated with older age, female sex (aOR, 1.10; 95% CI, 1.07-1.13), and elective admission status (aOR, 1.62; 95% CI, 1.46-1.80). Factors associated with plasma and platelet transfusions were largely similar to those associated with RBC transfusion, except older age groups had lower odds of plasma transfusion among PED admissions. CONCLUSIONS While there is substantial variability in the proportion of neonates and nonneonatal children transfused nationally, there are several similar, yet unique, nonlaboratory predictors of transfusion identified in these age groups.
Collapse
Affiliation(s)
- Ruchika Goel
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Mississippi Valley Regional Blood Center, and Simmons Cancer Institute at SIU SOM, Springfield, Illinois, USA
| | - Cassandra D Josephson
- Department of Pathology, Center for Transfusion and Cellular Therapies, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Aflac Cancer Center and Blood Disorders Service, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Eshan U Patel
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Molly R Petersen
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Zoe Packman
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eric Gehrie
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Evan M Bloch
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Parvez Lokhandwala
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Paul M Ness
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Louis Katz
- Mississippi Valley Regional Blood Center, Davenport, Iowa, USA
| | - Marianne Nellis
- Department of Pediatrics, New York Presbyterian Hospital - Weill Cornell Medicine, New York, New York, USA
| | - Oliver Karam
- Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| |
Collapse
|