Guideline on the investigation and management of acute transfusion reactions

The safety and efficacy of regional citrate anticoagulation for multiple consecutive therapeutic plasma exchanges with fresh frozen plasma as a replacement solution

BACKGROUND

Therapeutic plasma exchange (TPE) is an important blood purification technology and most patients require multiple consecutive TPEs. Regional citrate anticoagulation (RCA) could be used for membrane therapeutic plasma exchange (mTPE). However, there is no research on the metabolic complications of the RCA for patients receiving multiple consecutive mTPEs with fresh frozen plasma (FFP) as a replacement solution.

METHODS

We retrospectively included patients who used RCA for multiple consecutive mTPEs with FFP as a replacement solution in Xijing Hospital from 2020 to 2022. We collected blood gas analysis and electrolyte results before and after mTPE treatment and analysed the anticoagulation effectiveness and metabolic complications of the RCA.

RESULTS

A total of 33 patients who underwent 131 mTPE sessions were included, and 129 (98.5%) sessions were successfully completed. Severe hypocalcemia (19.1%) and metabolic alkalosis (58.5%) were frequently observed. In single mTPE sessions, there was a significant decrease in ionized calcium levels and significant increases in serum sodium, potassium, pH, bicarbonate, and base excess (BE) levels compared to pretreatment values. When comparing the values after the last treatment to the baseline values in all 33 patients, the serum sodium, pH, bicarbonate, and BE levels increased significantly, while the ionized calcium decreased significantly. The levels of pH, bicarbonate, and BE increased with the number of mTPE sessions, and the cumulative incidence of metabolic alkalosis reached 95.2% after the fifth treatment according to the Kaplan-Meier survival analysis.

CONCLUSION

RCA is an effective anticoagulation method for patients undergoing mTPE with FFP as a replacement solution. However, the metabolic complications associated with RCA, especially hypocalcemia and metabolic alkalosis, frequently develop in patients who undergo multiple consecutive mTPEs with FFP.

Association of Anaesthetists guidelines: the use of blood components and their alternatives

BACKGROUND

The administration of blood components and their alternatives can be lifesaving. Anaemia, bleeding and transfusion are all associated with poor peri-operative outcomes. Considerable changes in the approaches to optimal use of blood components and their alternatives, driven by the findings of large randomised controlled trials and improved haemovigilance, have become apparent over the past decade. The aim of these updated guidelines is to provide an evidence-based set of recommendations so that anaesthetists and peri-operative physicians might provide high-quality care.

METHODS

An expert multidisciplinary, multi-society working party conducted targeted literature reviews, followed by a three-round Delphi process to produce these guidelines.

RESULTS

We agreed on 12 key recommendations. Overall, these highlight the importance of organisational factors for safe transfusion and timely provision of blood components; the need for protocols that are targeted to different clinical contexts of major bleeding; and strategies to avoid the need for transfusion, minimise bleeding and manage anticoagulant therapy.

CONCLUSIONS

All anaesthetists involved in the care of patients at risk of major bleeding and peri-operative transfusion should be aware of the treatment options and approaches that are available to them. These contemporary guidelines aim to provide recommendations across a range of clinical situations.

Transfusion Rates in Free Flap Breast Reconstruction Patients: A Single-Centre Experience

Background Previous studies have demonstrated low transfusion rates in breast reconstruction with deep inferior epigastric perforator (DIEP) flaps. We often employ the transverse upper gracilis (TUG) flap; however, perioperative transfusion rates have not previously been studied in this group. Due to the different dissection and exposure required, transfusion rates may vary. We aim to ensure that perioperative resource use is appropriate and efficient, particularly group and save (G&S) sampling preoperatively. The objective of this study is to quantify transfusion rates in all patients undergoing free flap-based breast reconstruction and to determine the necessity of preoperative G&S sampling. Methods We retrospectively reviewed the electronic patient records, the electronic transfusion system, operation notes, and prescription records of all patients undergoing breast reconstruction using free-flap tissue transfer over one year. We identified transfusion of red blood cells and the current practice of perioperative G&S sampling in this patient group. These data were analysed using descriptive statistics. Results Of the 124 patients undergoing breast reconstruction with a free flap, a DIEP-based flap was deployed in 105, and a TUG flap in 14; in the remaining five, a selection of other flaps were utilised. Three patients required transfusion of blood products during their admission (2.4%), all after DIEP flap-based reconstructions. All received two units of packed red blood cells, with one transfusion on each of days one to three postoperatively. The indication for all three was slow but ongoing bleeding with low haemoglobin (less than 80 g/L) on routine full blood count. All recovered well following this. We found a low rate of transfusion in patients undergoing free flap breast reconstruction, with only three of 124 requiring transfusion (2.4%), all DIEP flaps. In addition to the published literature regarding DIEP flaps, we also include several TUG flaps in this cohort and several other flap types. None of the three transfusions were emergent in nature; all were completed with fully cross-matched blood according to local protocols. Conclusion We recommend that preoperative G&S sampling is not routinely necessary for patients undergoing free flap breast reconstruction. Preoperative G&S should be considered for those with a risk of atypical anti-red cell antibodies (for example, if previously transfused or pregnant), as cross-matched blood may take several days to be made available. We expect this judicious use of G&S sampling to significantly reduce costs and laboratory resource use without a significant effect on the use of emergency red cell units.

Shrimp allergy leading to severe transfusion reaction: A case report

Background

Transfusion reactions occur at an estimated incidence of 2 per 1.000 transfused products. Anaphylactic transfusion reactions are rarer, and seen in 1 per 10.000 transfusions, and are mostly related to platelet transfusions. Here, we describe a rare cause of a transfusion reaction.

Case presentation

A 19-year-old man underwent an allogeneic haematopoietic stem cell transplantation for sickle cell disease and developed an anaphylactic shock following a platelet transfusion, after excluding all common causes. The patient reported a shrimp allergy, and one of the blood/platelet donors had consumed shrimp the day before donation. Elevated levels of specific immunoglobulin E (IgE) directed against shrimp and tropomyosin allergens were found in the patient. Subsequent transfusions were performed with apheresis platelets from selected donors who were instructed to avoid shrimp consumption, and these transfusions were uneventfully.

Conclusion

When a severe transfusion reaction occurs in a patient with a known food allergy, an IgE-mediated (food-related) transfusion reaction should be considered after excluding other causes.

Reevaluation of the medical necessity of washed red blood cell transfusion in chronically transfused adults

BACKGROUND

Washing red blood cell (RBC) units mitigates severe allergic transfusion reactions. However, washing reduces the time to expiration and the effective dose. Automated washing is time- and labor-intensive. A shortage of cell processor tubing sets prompted review of medical necessity for washed RBC for patients previously thought to require washing.

STUDY DESIGN AND METHODS

A single-center, retrospective study investigated discontinuing wash RBC protocols in chronically transfused adults. In select patients with prior requirements for washing, due to a history of allergic transfusion reactions, trials of unwashed transfusions were performed. Patient demographic, clinical, laboratory, and transfusion data were compiled. The per-unit washing cost was the sum of the tubing set, saline, and technical labor costs.

RESULTS

Fifteen patients (median age 34 years interquartile range [IQR] 23-53 years, 46.7% female) were evaluated. These patients had been transfused with a median of 531 washed RBC units (IQR 244-1066) per patient over 12 years (IQR 5-18 years), most commonly for recurrent, non-severe allergic reactions. There were no transfusion reactions with unwashed RBCs aside from one patient with one episode of pruritus and another with recurrent pruritus, which was typical even with washed RBC. We decreased the mean number of washed RBC units per month by 72.9% (104 ± 10 vs. 28.2 ± 25.2; p < .0001) and saved US $100.25 per RBC unit.

CONCLUSION

Washing of RBCs may be safely reconsidered in chronically transfused patients without a history of anaphylaxis. Washing should be implemented judiciously due to potential lack of necessity and logistical/operational challenges.