1. Dallas, TX November 2–4, 2012 GRANUOCYTE TRANSFUSIONS

2. Dallas, TX November 2–4, 2012 THERESA SULLIVAN, RN,CNS MID-LEVEL PROVIDER DEPARTMENT OF LEUKEMIA MD ANDERSON CANCER CENTER HOUSTON,TEXAS

3. Dallas, TX November 2–4, 2012 OBJECTIVES At the end of this session the participant will be able to: 1.List the criteria required for granulocyte transfusion. 2.Discuss the granulocyte collection process.

4. Dallas, TX November 2–4, 2012 History of Granulocyte Transfusions 1959-1961 Collecting, processing and transfusing of platelets cut death rates from hemorrhage in children with acute leukemia. 1960-1962 Focus now to infection – Granulocytes (WBC’s) collected from CML patients are transfused to pediatric leukemia patients.

5. Dallas, TX November 2–4, 2012 History of Granulocyte Transfusions 1962- July 1965 Collaborative effort with George Judson of IBM, Robert Eisel and Dr. Freireich to develop a blood cell separator. July 1965 Clinical tests start on developed separator. Dr. Freireich moves to MDACC.

6. Dallas, TX November 2–4, 2012 History of Granulocyte Transfusions 1966 New and improved NCI-IBM blood cell separator offered for field trial, MDACC gets 1of 3. 1974 Use of HES and steroids bring granulocyte collection process to forefront again.

7. Dallas, TX November 2–4, 2012

8. History of Granulocyte Transfusions 1995 Advent and use of G-CSF enabled higher yield of granulocytes (WBC’s) to be collected. 2011 Approximately 950 granulocyte transfusions collected at MDACC. 2012 MDACC plans comparative study of prophylaxis vs. therapeutic use of granulocyte transfusions.

9. Dallas, TX November 2–4, 2012 Indications for Granulocyte Transfusions Life threatening bacterial infection in a setting of prolonged neutropenia. (ANC<5) Life threatening fungal infection in a setting of prolonged neutropenia. Deteriorating condition with known infection and “correct” antibiotics. Improvement in infection for BMT option.

10. Dallas, TX November 2–4, 2012 Neutropenia Risk Category ANC 0 - none within normal limits 1 - mild > 1500 - < 2000/mm3 2 - moderate > 1000 - < 1500/mm3 3 - severe > 500 - < 1000/mm3 4 - life threatening < 500/mm3 NCI- CTC 3.0

11. Dallas, TX November 2–4, 2012 Neutropenia Direct relationship to the degree of neutropenia and risk of infection. Direct relationship to the duration of neutropenia and risk of infection.

12. Dallas, TX November 2–4, 2012 Process of Granulocyte Collection Identify possible donors Family members/ friends preferable Screening process for donors Standard blood banking screening Obtain and inject G- CSF 600 mcg by 8pm evening prior Decadron 8 mg orally Minimum side effects to donor

13. Dallas, TX November 2–4, 2012 Process of Granulocyte Collection Granulocytes (WBC’s) donated- 8am 1 1/2 body volume processed 2 1/2 - 3 hour duration 2 arm procedure Males can donate 5x every other day Females can donate 4x every other day

14. Dallas, TX November 2–4, 2012

16. Process of Granulocyte Collection Granulocytes ready for infusion by early afternoon All granulocytes irradiated Half life of granulocytes is six hours Transfuse within 2 hours of collection No good way to store granulocytes

17. Dallas, TX November 2–4, 2012 Process of Granulocyte Collection Use of COBE/Spectra continuous flow blood cell separator. Aim of Yield minimum 4 x 10(10) cells average 8 x 10(10) cells No need for ABO compatibility most RBC’s are taken out No need to be CMV negative

18. Dallas, TX November 2–4, 2012

20. Granulocyte Infusions Transfuse over 1-2 hours Premedicate: 650 mg acetaminophen po 25 mg diphenhydramine IV 50-100 mg hydrocortisone IV Meperidine for rigors prn Give 2 hours apart from Amphotericin B preparations Monitor patient for possible reactions

21. Dallas, TX November 2–4, 2012

22. Possible Reactions/ Nursing Interventions Fever, chills r/o granulocyte reaction Intervention: Hold transfusion Repeat premedications Give meperidine If better can restart after 30 minutes.

23. Dallas, TX November 2–4, 2012 Possible Reactions/ Nursing Interventions Dyspnea r/o fluid overload vs. WBC migration range from overload/pulmonary edema/ARDS Intervention: Furosemide IV, breathing treatment Slow infusion rate Possible intubation

24. Dallas, TX November 2–4, 2012 Possible Reactions/Nursing Interventions Pain at infection site i.e. chest pain, lesions Intervention: analgesics

25. Dallas, TX November 2–4, 2012 Evaluating Response Disappearance of fever Clearance of positive cultures Improvement in physical findings Improvement in imaging (CT, CXR) Improvement in performance status

26. Dallas, TX November 2–4, 2012 Case Study 10/12/10 26 yr old married female with relapsed ALL s/p allogeneic transplant. Admit for fever and increasing counts. Start Methotrexate and Peg L- asparaginase. 10/16/10 c/o facial pain with sinus pressure. CT c/w acute sinusitis. Seen by ENT, frozen section—fungal hyphae. 10/20/10 Ambisone, caspofungin started then posaconazole 10/22/10 Granulocytes started. Debridement #1.

27. Dallas, TX November 2–4, 2012 Case Study 10/31/10 Debridement # 2, biopsy still positive. 11/15/10 Debridement # 3, no evidence of fungus per ENT 11/21/10 SCT evaluation, two goals met: Decrease blast < 10% and control of fungal infection

28. Dallas, TX November 2–4, 2012 Case Study Received total of 35 WBC transfusions over eight week period. Tolerated well Able to do some transfusions outpatient 12/10/10 Begin cord transplant regimen 12/19/10 Date of infusion of stem cells

29. Dallas, TX November 2–4, 2012 Future Comparative study to determine if standard of care prophylactic antibiotics plus prophylactic white blood cell transfusions decrease the rate of infection compared to prophylactic antibiotics alone

30. Dallas, TX November 2–4, 2012 THANK YOU!

31. Dallas, TX November 2–4, 2012 QUESTIONS ?