Presentation on theme: "Introduction to Transfusion Medicine"— Presentation transcript:
1 Introduction to Transfusion Medicine Yara Park, MD and Araba Afenyi-Annan, MD, MPHDepartment of Pathology and Laboratory Medicine
2 Scenario 145 year old man with no significant PMH presents to the ED with 2 day history of coffee ground emesis and dark stoolsHe also reports dizziness on standing and DOEVitals: T 37.1, P 113, BP 102/59, R 24CBC: WBC 8.4, Hgb 7.3, Hct 22%, plts 243KDoes he need blood?
3 pRBC Transfusion AVOID Transfusion based on Lab Values alone Indications: PROVIDE O2 carrying capacitySymptomatic anemiaTachycardia >100 bpmMental status changesECG signs of cardiac ischemiaAnginaShortness of breath, light headedness or dizziness with mild exertionAVOID Transfusion based on Lab Values alone
5 UNC Indications for pRBC transfusion Hgb < 8 in asymptomatic patientHgb < 11 in symptomatic patientAcute/anticipated blood loss > 15% TBVChronic transfusion regimenNeonate with blood loss > 10% TBVNeonate with respiratory distress and Hct < 45%
6 pRBC Transfusion RBCs suspended in Volume= 250 to 300 mL Expiration anticoagulant (citrate based)Additive Solution - ASProvides nutrients to support RBC metabolismVolume= 250 to 300 mL65% RBCs, 35% plasma and AScontains WBC’s and some plateletsExpiration42 days = Shelf life stored at 1-6° C4 hrs of release from Blood Bank, must use within 30 minutes
7 pRBC Transfusion Transfuse slowly Indications: PROVIDE O2 carrying capacityTransfuse slowlywithin 4 hours release from Blood Bank1 unit pRBC will increase the average adult recipient’s (70 kg)Hemoglobin by 1 g/dLHematocrit by 3%5 ml/kg will increase the pediatric patient’sHemoglobin by 1 gm/dl, Hematocrit by 3%
8 pRBC Transfusion RBCs should be infused alone or with 0.9% NaCl through a 170µm clot-screen filterNEVER mixed withCalcium containing solutionsMay cause clumping or clotsDextroseHypotonic,may cause hemolysis or clumpingMedicationsHypertonic solutionsAVOID infusing with Lactated Ringers
9 Next Step – Scenario 1 What do we order next? Type Type and screen Type and cross
10 Blood Type WHAT IS IT? Determination of the ABO and Rh (D) types Performed at room temperatureFRONT TYPE –what’s on the cells?Mix 2 drops of patient cells with 2 drops of reagent antibodies to A, B and D antigens in different test tubesAgglutination indicates presence of antigenBACK TYPE – what’s in the serum?Mix 2 drops patient serum with both A and B reagent cellsAgglutination indicates presence of antibodyReciprocal relationship: front and back types must match
11 Blood Type FRONT TYPE –what’s on the cells? Mix 2 drops of patient cells with 2 drops of reagent antibodies to A, B and D antigens in different test tubes, Agglutination indicates presence of antigen
12 Blood Type BACK TYPE – what’s in the serum? Mix 2 drops patient serum with both A and B reagent cells. Agglutination indicates presence of antibody
13 ABO System A Anti B B Anti A O -- Anti A, anti B Anti A,B AB A and B Blood TypeFront TypeAntigen on cellsBack TypeAntibody in serumAAnti BBAnti AO--Anti A, anti BAnti A,BABA and B
14 Antibody ScreenDetermines if pt has antibodies to other major blood groupsRequiresCombining pt serum with 3 different RBCs with known blood group phenotypeIncubate at 37 C to detect IgG antibodiesAddition of Coombs serumAnti-human IgG : enables in vitro agglutination if IgG presentIf screen is +, antibody specificity is determined by a more extensive panel of testing RBCsIncludes an autocontrolDoes not include a a DAT (Direct Coombs)
15 ScreenPatient serum + 3 cells of known phenotype
18 Crossmatch Electronic Crossmatch Immediate Spin Crossmatch For patients without antibodiesIf patient has an active screen, can get blood w/i minutesImmediate Spin CrossmatchRapid, room temp mixing of patient serum with donor RBCs to confirm ABO compatibilityFull CrossmatchFor patients with antibodiesRequires incubation and Coombs serum to confirm the patient’s IgG will not react with donor RBCsTakes ~45 minutes to complete
19 Sample Requirements Know hospital approved policy ! Patient ID Accuracy is Critical#1 cause of fatalities is human errorPrimary ID: 2 unique identifiersFull name and MR numberMust match exactly with requisition and Information systemSpecial armband may be requiredSecondary InfoDate, time of collection, initials of phlebotomistUnacceptable: unlabeled or hemolyzed
20 Sample RequirementsSample reflects current immune system status of patient> 1 sample per hospitalization may be requiredSample may be used for up to 72 hoursException: Pre-care sample which may be used for up to 14 days as long as patient has not been transfused or pregnant in the previous 3 monthsP
21 Scenario 1 (continued) Type: O negative Screen: Positive Suddenly, patient has another episode of bloody emesisPatient is now difficult to arouse, pulse is 140 and he is hypotensiveThe blood bank says it will be at least one hour before XM blood availableWhat are your options?
23 Scenario 28 year old girl with Hgb SS disease who presents to clinic for routine follow-upReports no new problems and is doing well in schoolVitals: T 37.1, P 88, BP 110/78, R 18, O2 99%RACBC: WBC 8.4, Hgb 7.3, Hct 22%, plts 243KDoes she need blood?
24 Scenario 2pRBCs are only indicated to provide oxygen carrying capacityThe patient is stable and doing wellHas high tolerance for anemia
25 Scenario 2 (continued)Three weeks later, the same patient presents to the ED with pain in her right leg and back. Is also SOB.Vitals: T 37.6, P 113, BP 102/59, R 24, O2 92%RACBC: WBC 8.4, Hgb 5.3, Hct 16%, plts 443KDoes she need blood?
26 Scenario 2 – Results Type: A positive Screen: Positive and the patient has a history of multiple alloantibodies (anti-C, K, Jka, Fya, s)With this combination of antibodies, only 0.25% of available units will be compatibleThe Blood Bank has 2 units of compatible blood but both are frozen
27 Frozen UnitspRBCs can be frozen using glycerol and stored up to 10 yearsOften only resource for patients with multiple allo- antibodiesTo use, must thaw and washWashingTakes ~1.5 hours per unitCan only wash one unit at a timeDecrease recovery of red cellsAfter thawed and washed, unit expires in 24 hours and cannot be re-frozen
28 Scenario 3 65 year old woman with GIB Transfused during CABG 5 years ago and has 2 children
30 Warm autoantibodiesIn routine testing, usually all cells react with patient’s serumMay appear to have specificity but not necessary to determine specificity of the WAA for transfusion purposesRule out underlying unexpected alloantibodies
31 Next Steps Direct Coombs (DAT) Start with polyspecificIf +, then perform the DAT splitFind out transfusion and pregnancy historyAdditional testingLow Ionic Strength Solution (LISS)Eluations and AdsorptionsPatient phenotypeSelected cell screens
33 Transfusing WAA patients-Risks Difficult to exclude alloantibodiesTransfusion may stimulate alloantibody productionTransfusion may intensify the autoantibodyTransfusion may suppress erythropoiesisDestruction of transfused cells may increase hemoglobinuria and hemoglobinemia
34 Transfusing WAA patients For patients who are rapidly hemolyzing, transfusion is often required as a life-saving measureCan be challenging due to the complex laboratory work-up and the acute clinical needsTransfusion should not be held solely because of serologic incompatibilityTransfuse the smallest amount possible to maintain an adequate oxygen level, not to reach an arbitrary number
35 Transfusing WAA patients Usually well toleratedTransfused cells may not survive any longer than the patient’s own cells
36 Scenario 417 year old male with AML, s/p 2 rounds of chemotherapy presents for next treatmentDuring therapy, platelet count falls to 18,000 and patient experiences hematuriaWhat are the transfusion options?
37 PlateletsPooled platelet concentrates (PC’s) from several whole blood donations6 pack, 4 pack, 10 packMultiple donors = One therapeutic dosePlatelets, apheresisone donor, one donation, one or more therapeutic dosesSuspended in citrated plasmaStored at 20-24º C up to 5 days onlyVery susceptible to shortages!!!
38 Blood Collection/ Manufacturing Whole Blood DonationDonor whole blood centrifugedSeparated in after collection by centrifugation intopRBCPlatelet rich plasma (platelet concentrate)Plasma (FFP)
40 Blood Collection/ Manufacturing ApheresisAutomated centrifugal blood separatorDonor whole blood separated on line to collect one or more componentspRBCPlatelet, apheresis = 6 platelet concentratesPlasma (FFP)
41 Apheresis SeparatorsAutomated apheresis blood separators may be used for donation or therapeutic applications
42 PlateletsPLT surfaceABO antigens but not RhPlatelet specific AgsHLA- A and HLA-BContain trace amounts RBC’s making Rh type importantRh- female gets Rh- PLT
43 Indications for PLT Transfusion Thrombocytopenia: quantitative defectsProphylactic transfusion for PLT <10kFor invasive procedure, trauma , bleeding with PLT count <50kRapidly falling PLT count with bleedingPlatelet dysfunction: qualitative defectsUremiaAspirin ingestionPost- Cardiopulmonary Bypass
44 Platelets One therapeutic dose of PLTs platelet count 30-50k Apheresis or 6 pooled platelet concentrates platelet count 30-50k
45 Scenario 4 (continued)The patient undergoes his third round of chemo and requires multiple pRBC and platelet transfusionsHe now is in his fourth round of chemo and is again thrombocytopenicMonday 4 AM plts 9 K Transfused 1 apheresis pltTuesday 3 AM plts 11K Transfused 1 apheresis pltWeds AM plts 10K Transfused 1 apheresis plt
46 Is he responding to plts? ANSWER: Need to check 1 hour post countsDifferentiate increased consumption from refractorinessWednesday 4AM plts 10KTransfused 1 apheresis platelet at 6AMPost-count Wednesday 7:30AM plts 11KAppears to not be responding appropriately= Refractory
47 Platelet Refractoriness Monitor efficacy of transfusion by measuring PLT count within 1 hour of transfusionConserve precious resourcesMinimize transfusions and risksAssist in recognizing platelet alloimmunization vs. consumptionCommon causes of “refractoriness”BleedingFeversHepatosplenomegalyAlloimmunization
48 Platelet Alloimmunization Seen in patients who receive many transfusionsUsually caused by HLA Class 1 antibodiesOrder HLA antibody screen (PRA) to test for antibodies and also order HLA typeIf PRA is positive, blood bank will order HLA-matched plateletsOther option, platelet drip (also used for ITP patients with life/organ threatening bleeds)
49 Scenario 5 63 year old man presents to the ED with fevers and AMS Wife reports flu-like symptoms for previous 48 hours, now confused and difficult to arousePMH: Prostate CA, HTNVitals: T 39.2, P 108, BP 76/45, R 22PE: Altered man in moderate distress
50 Scenario 5 (continued) Labs: What is the best product for him? WBC 23K, Hct 42%, plts 107KPTT 37.7s, INR 1.3, fibrinogen 68D-Dimer 13,000Blood cultures: gram negative rodsWhat is the best product for him?
51 Fresh Frozen Plasma FFP Contents: 200-300 mL + Frozen within 8 hrs of collectionStored -18º C for up to 1 yearOnce thawed, can be kept at 1-6º C for 24 hrsContents:1 unit/mL of all clotting factors including labile Factors V and VIII~400 mg fibrinogenCitrate as anticoagulant
52 FFP Indications Treatment of multiple coagulation factor deficiencies Massive transfusionTraumaLiver diseaseDICUnidentified deficiencyWarfarin reversal prior to emergent invasive procedures (5-8 ml/kg)PT/PTT > 1.5x normalDOSE: ml/kg to attain 30% Factor level
53 CryoprecipitateCold insoluble white precipitate that forms when FFP is thawed at 1-6º CRemoved from FFP by centrifugation and refrozen at – 20º COnce thawed, kept at room temperatureCONTAINS:80 to 150 IU Factor VIII:C (antihemophilic factor)150 mg fibrinogenVon Willebrand FactorFibronectinFactor XIII
54 Cryoprecipitate Each unit =10-15 mL Pool 10 units = typical adult dose Indications:Deficiency of fibrinogen, Factor VIII or XIIIImprove platelet function in uremiaDose calculation based onPatient’s weight and hematocrit : plasma volumeDesired increase in Factor level
55 Scenario 5 (continued)For this patient, cryoprecipitate is the appropriate productCan provide large doses of fibrinogen in a small volume
57 Leukocyte reductionFiltration with specialized leukocyte removing filtersPre-storage vs. Post-storageIndications:Prevent CMV transmissionPrevent alloimmunization to leukocyte antigens in patients who will require chronic transfusionPrevent recurrent febrile non-hemolytic transfusion reactionsMay require special request depending on hospital policyAt UNCH, all pre-storage leukocyte reduced RBCs/PLTs
58 Washing Removal of plasma by washing RBC or platelets with saline Indicated :For prevention of severe allergic reactionsAnaphylaxisIgA deficiencyTime consuming, labor intensive, delays transfusion, decreases transfusion increment slightly, changes expiration date (24 hours)Does not substitute for leukocyte reduction
59 Irradiation Prevent graft versus host disease (GVHD) Blood products from blood relatives and HLA matched products must be irradiated due to similar HLA antigensIndicated in severe immunodeficiency settings (lymphopenia)BMTHematopoietic malignancies undergoing chemotherapyPremature infants and IUTSevere combined immunodeficiencyDisadvantagesChanges product expiration date (28 days from irradiation)Increased potassium
60 Scenario 66 year old boy with AML and neutropenic fevers is given a unit of pRBCs for Hgb of 7.6 g/dL and SOB30 minutes into the transfusion, the patient complains of chills and back painWhat is the next step?
63 Suspected ReactionHemolytic reaction symptoms are not specific and include:FeverChillsHypotensionOozing from IV siteBack painHemoglobinuiaIf any of these occur STOP transfusion, provide appropriate supportive care, notify blood bankSend repeat samples for blood bank evaluationDO NOT restart the unit
64 Blood Bank Work-Up Serum color check DAT (Direct Coombs) Culture Determines if antibody is coating red cellsCultureRetype patient
65 Adverse Effects of Transfusion Acute Transfusion Reactions < 24 hoursImmuneAllergicHemolyticFebrile, non-hemolyticAnaphylacticTransfusion related acute lung injury (TRALI)
66 Adverse Effects of Transfusion Delayed Transfusion Reactions > 24 hoursImmuneHemolyticGVHDPlatelet refractorinessPost transfusion PurpuraDevelopment of anti-platelet antibodies
67 Adverse Effects of Transfusion Transfusion Reactions Non-ImmuneAcuteCirculatory Overload (Volume excess)Septic shock from bacterial contamination of blood productDelayedIron OverloadInfectious Disease transmission
68 Transfusion Transmitted Disease Risks Infectious Agent or OutcomeEstimated Risk per Unit TransfusedEstimated % of Infected Units that transmit or cause clinical sequelaeVirusHIV-1 and -21:1,400,000-1:2,400,00090HTLV-1 and –II1:256,000-1:2,000,00030HAV1:1,000,000HBV1:58,000-1:147,00070HCV1:872,000-1:1,700,000WNV?B19 parvovirus1:3,300-1:40,000Low
69 Scenario 745 year old man with colon cancer, currently undergoing chemotherapyPresents to clinic with epistaxis and platelet count of 15,000Given one unit of platelets
70 Scenario 7 (continued)Five minutes into the transfusion, the patient develops SOBO2 saturation drops from 99% to 82% on room airWhat is in the differential
72 Scenario 822 year old woman with menorrhagia who presents to clinic with SOB and dizzinessReports prolonged heavy bleedingVitals: T 37.1, P 115, BP 85/60, R 20PE: Pale, fatigued appearing woman; flow murmur
73 Scenario 8 You decide she needs pRBCs How do you consent her for blood/blood products?
74 Basic Principles of Informed Consent Consent is a processRequires comprehension by patientVoluntary & free from coercionNot legally bindingMay be revoked at any timeProspective
75 Elements of Informed Consent Information to the patientExplanation of interventionBenefitsRisksAlternativesOpportunity for questions/clarificationAvailability of choices (including refusal)Autonomous patient decisionDocumentation of process
78 Physician Responsibility Formulate a course of action based on clinical expertise, judgment, and best available informationGive the patient enough information about the plan to make an independent decision about whether or not to accept recommendation.
79 Information to Patient Statement of patient’s medical conditionExplanation of interventionBenefitsRelief of symptoms, prevention of complicationsLikelihood of achieving goalRisksAlternativesPrognosis with or without intervention
80 Patient Discussion Points Need for transfusionBenefitsTreatment such as increase O2 carrying capacityPrevention such as preoperatively for potential coagulation factor or platelet lossStatement of the likelihood of successRisksClinician to determine
81 Standards for Risk Disclosure No national standardProfessional organizationsState lawsCase LawReasonable Patient StandardSimple Subjective StandardReasonable PhysicianReasonable Patient Standard; CA, NJ NY and WA physicians explain all medically reasonable courses of treatment and non-treatment option in a manner that a reasonable patient in the same or similar circumstances would require to make an informed choice. Does not apply to situations where unforeseeable condition arises. No duty to disclose every single detail of the proposed treatment or operation.Simple Subjective Standard: HA, LA, TX physicians to disclose “enough information for the paitent or guardian to make an informed decision, may have established disclosure panels for a given treatment/procedure.”Reasonable Physician: physician disclose information that other reasonable physicians in good standing within their community would give to their patients about the particular therapy or procedure; “professional custom and practice standard”; many have abandoned as too simplistic.
82 Risks of Transfusion: What to disclose? Infectious disease risks-see tableNoninfectious disease risksMost common include allergic, FNHTRRare but potentially fatalAcute HTR, Bacterial contamination, TRALIPatient specificCoexisting morbidities, previous reactionsHow problems would be handled, potential long term impacts
83 Alternatives to Transfusion Preoperative autologous donationErythropoietinIntraoperative conservation techniquesAcute normovolemic hemodilutionBlood salvage and reinfusionBlood substitutes are not an option!
84 Right of Refusal Consequences of refusal Must complete separate form Refusal to the Use of Blood or Blood Products
85 Scenario 935 year old woman with no PMH presents to the ED with fatigue, fever and petechiaeLab work reveals Hct 22%, platelet count 8K, LD 3100On peripheral smear, many schistocytesOf note: BP normal, HIV negative, pregnancy test negative
87 Definition of TTPFirst described in 1924 by Moschowitz in a 16 year old femaleClassic pentad of symptomsHemolytic anemiaThrombocytopeniaFeverRenal failureAltered mental status
88 Diagnostic CriteriaMany causes of microangiopathic hemolytic anemia (MAHA)For diagnosis of TTPMinimum criteriaMAHAThrombocytopeniaOther causes excludedOnly 34% of patients present with all features of pentad
90 Autopsy FindingsPicture courtesy of Dr. Mark Brecher
91 Classification of TTP Primary or idiopathic TTP Secondary TTP TransplantChemotherapyHIVDrugsConnective tissue disordersHormonal (pregnancy)
92 Normal Processing Activity ULvWFStimulation: histamine, Shiga Toxin, tumor necrosis factor-alpha, IL-8, and IL-6P-selectinWeibel-PaladeBody
93 Normal Processing Activity ADAMTS13 attaches A3 domains in the monomeric subunits of ULvWF multimers and then cleave Tyr Met peptide bonds in adjacent A2 domainsFluid shear stress may increase the efficiency of ADAMTS13 attachment and/or cleavage of ULvWF multimers
96 TTP Emergent plasma exchange (TPE) 1 PV daily 1.3 to 1.5 PV may be used in refractory patients or those severely affectedPlasma is replacement of choicePlatelet count >150 K (x 2-3 days)LDH “normal”Watch out for anemia (may need RBCs)FFP infusions if TPE delayed
97 ApheresisA Greek word that means to separate or remove
98 Apheresis Terms Therapeutic Procedures Cytoreductive Apheresis Plasma Exchange, TPE, or Therapeutic PlasmapheresisRed Cell Exchange or ErythrocytapheresisPhotopheresisImmunoadsorption
99 Methods of Separation Filtration Centrifugation Plasma removal only WBC removalPlatelet removalRed cell removalPlasma removal
106 Hyperviscosity Syndrome Whole blood viscosity related to Hct, RBC aggregation, plasma proteins, and interactions with the vasculatureWhen viscosity increases, fragile endothelium can be damaged
107 Hypervisocity Syndrome Waldenstroms Macroglobulinemia, IgM MyelomaViscosity poor correlation with clinical symptomsConcurrent anemia may confound diagnosisElevated total protein, total Ig, UPEP, SPEPHydration trail, chemotherapyCertainty of diagnosis : risk vs benefit
114 Pulmonary renal syndrome Goodpasture’s Syndrome (Category I)Wegener’s/ANCA (Category II)Daily with plasma (1 PV) until pulmonary hemorrhage subsides then every other day for a total of 6 – 9 procedures)5% albumin once risk of bleeding subsidesAnemia may require RBC transfusion
115 Goodpasture’s Syndrome Results from the presence of an IgG anti-glomerular/ alveolar basement membrane antibodies (detected by radioimmunoassay in over 90% of cases).It represents a Type II immune reaction (cytotoxic antibody mediated).Males are affected more than females (9:1)
116 Goodpasture’s Syndrome The majority of patients present in their mid-twenties withhemoptysis (75%- due to diffuse pulmonary hemorrhage),hematuria (due to glomerulonephritis),anemia, hepatosplenomegaly, and hypertension.Pulmonary symptoms will generally proceed the renal disease by weeks to months,many patients also have laboratory evidence of renal disease at the time of presentation (microscopic hematuria).
118 Anti–GBM/ Goodpasture’s Syndrome Lung/kidney damage mediated by anti-GBMTwo Goals: Two concurrent strategiesRemoval of anti-GBMTPESuppress its synthesisSelf-limited: 6-12 monthsCyclophosphamide + steroids (pulse)Azathioprine
119 Anti–GBM/ Goodpasture’s Syndrome PLAN for TPE: Recommendations vary4 TPE exchanges (of at least 1 plasma volume) 1st weekThen alternate days (qoD)Total of 6 –9 treatments over 2- 3 weeksFollowing titer pre and post exchangeImmunosuppresive drugs should be continued longerFollow serum IgG as a surrogate: <200 mg/dLConsider risk of Ig removal and increased risk of infection
120 Wegener’s Granulomatosis, ANCA, etc. Necrotizing granulomatous vasculitis, C-ANCA positive
121 ANCA, Wegener’s, other RPGN Patients presenting with RPGNAnti-neutrophil cytoplasmic autoantibodiesMPO or PR3 specificity+/-pulmonary hemorrhageDiffuse Alveolar Hemorrhage =DAH
122 ANCA/Wegener’s/RPGN With DAH Emergent TPE useful DAH can be fatal Daily TPE with FFP replacement to prevent dilutional coagulopathyOnce DAH subsides, complete TPE series qoDGenerally 7 TPE procedures over 2 weeks
124 Sickle Cell Disease Most commonly Hb SS Sickled RBC have shortened life-spans, leading to hemolytic anemia and microvascular occlusionsPatients can have vaso-occlusive eventsPain crisesAcute chest syndrome (ACS)StrokePriapismSplenic, hepatic, and renal dysfunction
125 Indications for Erythrocytapheresis Category I for life and organ threatening complicationsEMERGENTStroke: CVA or prophylactic chronic RBC exAcute Chest Syndrome with progressive respiratory insufficiencyURGENTPriapism : as adjunct when primary therapy failsPre-operative to minimize risk of SSD complications during anesthesia
126 Cerebrovascular Disease Incidence of Stroke: 6-10%11% of patients will have a CVA by age 2050% will have a second stroke within 3 years without intervention75% due to vascular occlusion25% from hemorrhage
127 Stroke Risk Factors Transcranial Doppler Measurement of Average VelocityNormal 130cm/secIncrease risk of Stroke > 200cm/secHigh velocity may cause narrow vessel to collapse or clot to form.
128 Benefits of Exchange Rapid increase in Hemoglobin A Euvolemia Simple Transfusion = HyperviscosityReduction in Fe LoadDrop in platelet countSuppression of hematopoeisis
129 Practical Considerations Determine goal :70% Hgb A, Acute chest70-90% Hgb A, strokeFinal HctBlood Units set up time consumingC, E, K negative, sickle trait negativeGet type & screen and Hb/Thal panel sent statCheck on patient RBC phenotype/prior blood bank records here and afar
130 Therapeutic Apheresis in Leukemia/ Thrombocytosis
131 Cytoreduction Acute leukemias: leukostasis Usually high blast % WBC when symptoms generally beginMyeloid >100,000Lymphoid >400,000Monocytoid > 50,000Sxs: pulmonary and CNSCategory I
132 Cytoreduction May be profoundly anemia due to marrow inflitration RBC transfusion may be requiredAnemia can lead to similar CNS sxs as hyperleukocytosisMay need to decrease WBC to safely transfuse
133 Cytoreduction Generally one time procedure May need to repeat if patient becomes symptomatic again or chemotx delayedCentral line usually requiredHetastarch used to increase WBC removal efficiency
134 ThrombocytosisSeen with essential thrombocythemia and polycythemia veraAt risk for thromboembolic events (plt count >^600K)Can have bleeding (plt count >1.5 million)Plateletpheresis is rarely used; must be used in conjunction with plt-lowering agentsCategory II
135 Resources Blood Bank Staff: 966-4011 TMS Attending/Fellow/Resident on call 24/7McLendon Lab WebsiteAlways welcome to do a rotation on TMS!