Jennifer Andrews

Transfusions for anemia in adult and pediatric patients with malignancies

n Abstractn n Anemia is present in over two-thirds of patients with malignant hematological disorders. The etiology of anemia predominates from ineffective erythropoiesis from marrow infiltration, cytokine related suppression, erythropoietin suppression, and vitamin deficiency; ineffective erythropoiesis is further exacerbated by accelerated clearance due to antibody mediated hemolysis and thrombotic microangiopathy. As the anemia is chronic in nature, symptoms are generally well tolerated and often non-specific. Transfusion of red blood cells (RBCs) is a balance between providing benefit for patients while avoiding risks of transfusion. Conservative/restrictive RBC transfusion practices have shown equivalent patient outcomes compared to liberal transfusion practices, and meta-analysis has shown improved in-hospital mortality, reduced cardiac events, re-bleeding, and bacterial infections. The implications for a lower threshold for transfusion in patients with malignancies are therefore increasingly being scrutinized. Alternative management strategies for anemia with IV iron and erythropoietin stimulating agents (ESAs) should be considered in the appropriate settings.n n

Blood ordering from the operating room: turnaround time as a quality indicator

BACKGROUND: Quality indicators in transfusion medicine are necessary for patient safety and customer satisfaction. The turnaround time (TAT) of issuing red blood cells (RBCs) has emerged as a quality indicator but is not an established benchmark. We examined the TAT for issuing RBCs from the blood bank to the operating rooms (ORs) at Vanderbilt University Medical Center (VUMC) and Stanford University Medical Center (SUMC).

Challenges with Navigating the Precarious Hemostatic Balance during Extracorporeal Life Support: Implications for Coagulation and Transfusion Management

For the past four decades, extracorporeal life support (ECLS) has been used to treat critically ill adult and pediatric patients with cardiac and/or respiratory failure, and there are increasingly numbers of centers worldwide performing ECLS for numerous indications. Despite the progress with advancing the technology, hemorrhagic and thrombotic complications are frequently reported and associated with worse outcomes, but the exact cause is often elusive or multifactorial. As a result of the interaction between blood and an artificial circuit, anticoagulation is necessary and there is resultant activation of coagulation, fibrinolysis, as well as, an increased inflammatory response. While unfractionated heparin (UFH) remains the mainstay anticoagulant used during ECLS, there is a paucity of published data to develop a universal anticoagulation guideline and centers are forced to create individualized protocols to guide anticoagulation management while lacking expertise. From an international survey, centers often use a combination of tests, which in turn result in discordant results and confused management. Studies are urgently needed to investigate optimization of current anticoagulation strategies with UFH, as well as, use of alternative anticoagulants and non-thrombogenic biomaterials. Blood transfusion during extracorporeal support typically occurs for several reasons, which includes circuit priming, restoration of oxygen carrying capacity, maintenance of a hemostatic balance, and treatment of hemorrhagic complications. As a result, the majority of patients will have been exposed to at least one blood product during extracorporeal support and transfusion utilization is high. ECLS Centers have adopted transfusion thresholds based upon practice rather than evidence as there have been no prospective studies investigating the efficacy of red cell (RBC) transfusion in patients receiving extracorporeal support. In addition, RBC transfusion has been associated with increased mortality in ECLS in several retrospective studies. Additional studies are needed to establish evidence based thresholds for transfusion support and diagnostics to guide transfusion therapy to assess efficacy of transfusion in this population, as well as, exploration of alternatives to transfusion.

Evaluation of febrile, nonneutropenic pediatric oncology patients with central venous catheters who are not given empiric antibiotics.

OBJECTIVEnTo evaluate the practice of empiric antibiotics for febrile, nonneutropenic pediatric oncology patients with a central venous catheter (CVC) in place.nnnSTUDY DESIGNnEpisodes of fever without neutropenia (absolute neutrophil count [ANC] ≥500 cells/mm(3)) were reviewed retrospectively in pediatric oncology patients with a CVC undergoing chemotherapy. Characteristics and symptoms were compared between patients with bacteremia and patients without bacteremia.nnnRESULTSnA total of 392 episodes of nonneutropenic fever in 138 subjects (52 females; 38%) were reviewed. In this cohort, the median age at an episode was 7 years, and the majority of patients had a diagnosis of acute leukemia (54%). Median ANC was 3100 cells/mm(3) (IQR, 1570-5980 cells/mm(3)). Median temperature was 38.7°C (IQR, 38.3-39.2°C). Twenty-four infectious episodes (6%) occurred in 18 subjects, and 5 CVCs required removal; all patients requiring removal admitted and received antibiotics owing to chills. There were no significant difference in age, sex, or ANC between patients with bacteremia and those without bacteremia; however, mean temperature was higher in the patients with bacteremia (39.4°C vs 38.7°C; P = .003). No deaths due to sepsis occurred, and no CVCs were removed because antibiotics were not administered empirically.nnnCONCLUSIONnOur practice of observing pediatric oncology patients undergoing chemotherapy with CVCs who are not neutropenic does not appear to lead to increased serious adverse outcomes and avoids antibiotic exposure for >90% of patients without a bacterial infection.

Updated analysis: central venous access device infection rates in an expanded cohort of paediatric patients with severe haemophilia receiving prophylactic recombinant tissue plasminogen activator

Central venous access devices (CVADs) are used in the care of paediatric haemophilic patients with difficult peripheral access, but their use is limited by complications such as infection. We previously published our experience with monthly recombinant tissue plasminogen activator (r‐tPA) administration to CVADs of haemophilic patients as an intervention for infection prophylaxis, which suggested a 10‐fold decrease in infection rate compared to published rates without r‐tPA.

Leukocyte and plasma activation profiles in chronically transfused patients with a history of allergic reactions

Allergic transfusion reactions are drawbacks to the benefits of transfusion. Classically, allergic transfusion reactions depend on histamine release from mast cells or basophils, but other leukocyte subsets may also be important. Thus, we propose to better define the exact leukocyte subsets involved in allergic transfusion reactions.

Clinical Pattern in Hypotensive Transfusion Reactions.

BACKGROUND:Hypotensive transfusion reactions (HyTRs) may be underreported and have been associated with patients taking angiotensin-converting enzyme inhibitors (ACEIs) receiving poststorage leukoreduced blood products through negatively charged filters. Although bedside leukoreduction is no longer commonplace, HyTRs still occur and are insufficiently characterized in the prestorage leukoreduction era. We describe recently reported cases at our institution. METHODS:We reviewed transfusion reaction records at Stanford Healthcare from January 2014 to April 2015. HyTRs were defined by National Health Safety Network Hemovigilance Module classification. RESULTS:Eleven HyTRs occurred in 10 patients. All were adults (mean age 71.7 years; range 45–92 years), 7 were male, and all underwent major surgery 0 to 2 days before the reaction. Nine patients underwent cardiac or vascular surgery, and all 10 were taking ACEIs with the last dose taken within 48 hours of the transfusion reaction in 9 patients. Nine patients were on extracorporeal circuits within 24 hours before the reaction (median duration 180 minutes; range 87–474 minutes). In 5 reactions, the implicated unit was restarted with resultant recurrent hypotension. Implicated units included 9 packed red blood cells, 1 apheresis platelet, and 1 plasma frozen within 24 hours. CONCLUSIONS:Contrary to what has been previously reported in the era of prestorage leukoreduction, HyTRs at our institution showed consistent patterns in patients at risk. Patients scheduled to undergo major surgery with cardiopulmonary bypass may benefit from earlier preoperative cessation of ACEIs or temporarily switching to an alternative drug class.

Effect of Pre-Transplant Red-cell Transfusion Events on Transplant Related Mortality and Overall Survival in Children with Leukemia Undergoing Hematopoietic Stem Cell Transplant

Background: Recent studies have shown that an elevated ferritin level prior to hematopoietic stem cell transplant (HSCT), serving as a surrogate marker of body iron load, is independently associated with transplant related mortality (TRM) and inferior overall survival (OS) in adult oncology patients. nStudy Design and Methods: We performed a retrospective cohort study of 112 children with leukemia treated at our institution over a 10 year period, and compared TRM and OS after HSCT in those children with and without high red-blood cell (RBC) transfusions. Both groups were similar in regards to age, diagnoses, donor type (matched related, matched unrelated, mismatched related, mismatched unrelated), stem cell source (peripheral blood, umbilical cord, bone marrow), baseline liver, cardiac and renal function, and median follow-up time. However, more children in the low RBC transfusion event cohort had high Karnofsky/Lansky performance scores (83.5% vs 54.5%, p=0.001) and fewer had recurrent leukemia or other forms of advanced disease compared with the children more heavily transfused (41.8% vs 87.9%, p<0.0001). nResults: No association was observed between high RBC transfusion exposure and TRM. High RBC transfusion events were associated with lower OS at 5 years in univariate analysis (38% versus 61%, p=0.04); in multivariate analysis, this association was not significant (hazard ratio=1.3, 95% confidence interval 0.7-2.5). nConclusion: Further studies in children are needed to investigate iron overload and HSCT outcomes.

Transfusion practices and complications in thalassemia: Transfusion practices and complications in thalassemia

The severe forms of thalassemia are the most common inherited anemias managed with regular blood transfusion therapy. Transfusion policies and complications are critical to quality of life and survival, but there is a lack of standardized care.

An Unusual Case of Abdominal Pain and Hyponatremia in a 16-Year-Old Girl With Disordered Eating

This diagnostic dilemma explores the differential diagnosis of abdominal pain in a teenager with anxiety, disordered eating, and hyponatremia. A previously healthy 16-year-old girl presented to the emergency department with 1 week of severe, diffuse abdominal pain and constipation, as well as several episodes of nonbloody, nonbilious emesis. Her symptoms began several days after she decreased her caloric intake in an attempt to lose weight. She had been drinking 48 to 60 oz of water per day for several days before admission in an attempt to ameliorate her constipation. She also admits to drinking alcohol the night before her pain began. She had visited several other emergency departments before her presentation to our hospital, and she had been sent home on a bowel regimen without amelioration of her symptoms. On arrival to our emergency department, she described severe diffuse abdominal pain. Her abdomen was tender to palpation throughout but soft with no rebound tenderness or peritoneal signs. The remainder of her physical examination yielded normal results. She was found to have hyponatremia with a sodium level of 122 and no neurologic sequelae. Abdominal radiograph showed moderate constipation but her abdominal pain continued even after bowel cleanout. The home, education, activities, drugs, sex, suicide, and safety assessment revealed several stressors, including a recent suicide in the family and a history of disordered eating and anxiety. Here, we present her case, diagnostic evaluation, ultimate diagnosis, and complications.