On February 28, 2001, a member requested help in crafting a policy/procedure to address the use of Rh negative RBC's during emergency and massive transfusion situations. In the inquiring member's opinion, conservative transfusion practices and/or the reluctance to transfuse Rh positive RBC's to Rh negative (or Rh type unknown) patients unless/until the Rh negative inventory is depleted seems to be an overuse or misuse of a seemingly limited resource. The member requests that the e-network share policy/procedures with respect to the following:

1. Under what circumstances of urgent orders for uncrossmatched blood, do you:
   ......issue group O Rh negative RBC's only?
   ......issue group O Rh positive RBC's only?
   ......issue either group O Rh positive or group O Rh negative RBC's depending on age and sex of the patient?
   
   
2. If/when you find you've transfused group O Rh positive RBC's to an Rh negative patient, how do you proceed? Do you
   ......monitor the patient for development of anti-D?
   ......administer Rh immune globulin?
   ......some other approach?
   
   
3. Do you impose a limit on the number of uncrossmatched group O units that you will 'ordinarily' issue to a given patient (i.e. maximum of 2 units before issuing group specific units)?
   
   
4. Is it feasible and permissible to stock both group O Rh positive and group O Rh negative RBC's in the same location at the same time, for example in the ER, group O Rh positive RBC's intended for males, group O Rh negative RBC's for females, in order to maintain a ready supply for urgent transfusion situations?
   
   
5. In the case of anticipated 'heavy' RBC usage for known Rh negative, anti-D negative patients, under what circumstances would you or do you switch from transfusing Rh negative RBC units to transfusing Rh positive RBC units?
   
   
6. Do you limit in some way the number of Rh negative RBC units available for that patient prior to switching?
   
   
7. How does your policy differ with respect to age and sex of the patient?
   
   
8. If the prevalence of anti-D in transfusion recipients is so low (<1%), is it still appropriate to plan to utilize a scarce resource (group O Rh negative RBC's) to meet the urgent transfusion needs of the entire population when relatively few Rh negative patients might actually benefit?
   
   
9. Why not issue group O Rh positive RBC's to this population of patients, thereby conserving scarce group O Rh negative RBC's for known group O Rh negative patients.
   
   
10. Can you suggest/supply a model policy (your own?) or recommend specific references for such a policy?

The following comments were received.

1. A member stated that while waiting for cross matched blood to be available, emergency transfusion needs can be met in various ways, depending on the clinical status of the patient and the equipment available. This member believes that most patients can tolerate an acute decrease in hemoglobin and therefore oxygen carrying capacity, provided resuscitation of their intravascular fluid volume occurs in an adequate amount and in a timely fashion. Crystalloid or colloid solutions may be infused to increase intravascular volume and stabilize the vital signs, although overzealous administration of to normalize blood pressure may be disadvantageous in certain patient subsets (e.g., penetrating torso injuries). If the patient has cardiac disease, pulmonary disease or cerebrovascular disease, and acute anemia will pose increased risk, or if there is not time to wait because the patient is in extremis, then either group specific or group 0 Rh-negative red cells can be administered while awaiting a formal crossmatch to be performed.
Group 0 Rh-positive Red Blood Cells for males or postmenopausal females can be transfused in this setting as well. Administration of uncrossmatched blood has been shown relatively safe, in part related to the low incidence of unexpected antibodies observed during cross match in patients with (1 percent) or without (0.1 percent) a previous history of transfusion. Administration of Group 0 Rh-negative blood may lead to hemolysis if multiple units of Group 0 Whole Blood (containing anti-A and anti-B antibodies) have been transfused to patients with Group A or B blood; this concept has led to the recommendation that one should not switch back to the patient's blood type after administration of two units of Group 0 Whole Blood. However, modern blood banking strategy does not allow for the use of Group O Whole Blood unless the patient is tested and shown to be group O. Until the patients blood group is known, blood banks should not release whole blood. The patient can be switched back to his or her inherent type specific blood after subsequent testing by the blood bank indicates it is safe to do so. The passively transfused anti-A and anti-B antibodies are seldom a problem after Group 0 Red Blood Cells are transfused, especially if the Red Blood Cells are preserved in an additive solution.

2. A second member commented that there may be a threshold for the number of group O units transfused above which you would not switch away from group O RBCs back to the patients genetic ABO group, because too much incompatible ABO antibody has been transfused. The anesthesiologists at this member's institution seem to consider the transfusion of 6 group O units as the threshold above which you should stay with group O blood. Although this member has seen other institutional policies where they will not switch away from group O blood once the patient has received 12 units. This member suspects that with the use of Adsol (or similar additive solution systems) units, a threshold of 12 units would be realistic.

3. A third member submitted her hospital PROTOCOL:

"Uncrossmatched 0 positive packed red cell units are to be issued to trauma patients who are male or to females older than childbearing age instead of uncrossmatched 0 negative packed red cell units:
..When the number of 0 negative units in inventory falls below ten,
..When the patient is an 0 neg male and the need is for more than ten 0 negative units.
..When six units of 0 negative have been issued to a Code Yellow male patient and no specimen has been received for type specific blood.
..When the blood suppliers cannot supply more 0 negative and there is a continuing need for 0 negative blood.
..When both in-patients and trauma 0 negative patients need blood.

The 0 Negative blood supply shall be reserved for women of childbearing age or younger, and for in-house patients known to be 0 negative. The Transfusion Service Director is to be consulted when there is a need to switch, or in time constraint circumstances, to be notified when time permits."

4. The Editor & Moderator's facility has this to add: The Los Angeles County + University of Southern California Medical Center (LAC+USC) houses one of the busiest emergency departments in the country. The level one trauma center cares for nearly 28% of all the trauma cases in the County of Los Angeles, including nearly 4,000 trauma registry cases per year. Immediate transfusion support with group O, Rh negative RBCs is available and used by about 4-5% of these trauma cases. (During times of severe group O, Rh negative shortages, male patients in need of emergency/immediate transfusion support may receive group O, Rh positive RBCs instead of O negative.) If a LAC+USC emergency or surgery physician determines that an emergency transfusion is medically indicated, group O, Rh negative RBCs can be available within seconds This immediate access is possible by maintaining a blood bank refrigerator stocked with group O RBCs (usually group O Rh negative) in the Emergency Department and within selected surgical areas. Each refrigerator is monitored by the blood bank and stocked with 6-8 units of group O Rh negative RBCs (Rh positive RBCs are stocked during Rh negative shortage periods). The preferred preservative system for these RBCs is AS, since AS-RBCs flow more freely than CPDA-1 RBCs. Nurses prefer AS-RBCs because this product does not need to be diluted and therefore can be administered through a straight intravenous line and surgeons prefer to transfuse blood products, which flow like whole blood. The Mayo Clinic has shown that AS-RBCs have flow characteristics similar to whole blood. Each RBC unit stocked in an emergency refrigerator is conspicuously labeled to indicate, "Emergency Blood Release. Blood issued without complete compatibility testing," and given an identifying letter or number (i.e. unit T, unit XX, etc.) When opening an emergency refrigerator door, an alarm sounds in the blood bank which signals a technologist to pick up the designated phone. This phone automatically calls the phone located adjacent to the opened emergency refrigerator. The transfusionist who answers the phone is asked to provide the following information: the identifying unit number and the name and hospital identification number of the intended, recipient patient. The technologist then fills out paperwork documenting the request, the ordering physician's name, the unit identifying number, and the patient's name and hospital identification number. The technologist requests that a blood specimen be drawn and sent as soon as possible to the blood bank for the usual testing. The blood specimen is sent via a pneumatic tube (six inch diameter tube) directly to the blood bank laboratory. A technologist performs stat ABO/Rh determinations and an antibody screen. Additionally, a technologist begins crossmatch testing on tubing segments retained in the blood bank from the O negative emergency units which were transfused. If antibody screening detects an unexpected red cell alloantibody, the patient's physician is immediately notified and the specificity of the antibody is determined so that units lacking the corresponding antigen can be selected and antiglobulin crossmatching of can be performed.

ADDENDA June 10, 2005

5. A tertiary care medical center in Ohio is building a new emergency department with 70 - 80 beds including both pediatric and adult level I trauma. This will be an essentially freestanding facility, although there will be tunnel access to the hospital including its ORs. The physical distance between the planned new facility and the blood bank has raised some questions about blood availability for trauma patients. The transfusion medicine service medical director at the facility wonders whether it is reasonable to consider, in addition to the storage of group O RBC units in this new ER, also plasma and platelets under the assumption that with the trauma I patients and their distance to the ER the docs will want to stabilize the patient as much as possible prior to transport. She would like to know if other large ERs keep not only group O RBCs, but also thawed plasma and platelets on hand in the ER.

ADDENDA March 2, 2006

6. Editor's Note: Colleagues may find the comments at:

• Weiskopf RB, Webb M, Stangle D, Klinbergs G, Toy P. A Procedure for Rapid Issue of Red Cells for Emergency Use. Arch Pathol Lab Med. 2005 Apr;129(4):492-6
• Wong KF, Kwan Comment on A Procedure for Rapid Issue of Red Cells for Emergency Use. Arch Pathol Lab Med. 2006 Feb;130(2):145; author reply 145-6.
• Weiskopf RB, Toy P. In Reply A Procedure for Rapid Issue of Red Cells for Emergency Use. Arch Pathol Lab Med. 2006 Feb;130(2):145; author reply 145-6.

to be relevant to the present discussion.

ADDENDA Jan. 3, 2007

7. The medical director at a level I trauma center in Central California (University Medical Center in Fresno; attribution used with permission of the submitting colleague) asks if colleagues at other trauma center hospitals would comment on local performance standards for their blood suppliers for STAT deliveries. He is particularly interested in what colleagues feel are reasonable physical distance and "commit times" for the STAT delivery process to trauma hospitals. For example, is there likely to be a significant difference in STAT delivery performance if a trauma facility is 11 miles from the supplier versus only 5 miles? Dr. Slater reports that his preliminary survey of other centers suggested considerable variability in physical distances and STAT delivery commit times among trauma centers and their contract blood suppliers -- and these often were not highly correlated with one another.

ADDENDA July 16, 2007

8. A transfusion medicine physician in Boston reports that recently his hospital treated a patient who arrived in such critical condition to the E.R. that the patient was almost immediately transported to the OR. The ER was informed that the patient was acutely decompensating during transit from another hospital. The ER simultaneously notified the OR and began the process to assign a medical record number. The OR was aware that the patient was coming but did not know the patient's medical record number and asked for blood products STAT. The transfusion service was informed that this case represents an exceptional circumstance in which it is not always possible to know the medical record number of the patient, and finding (or assigning) the medical record number may cause medically harmful delays. The inquiring Bostonian is concerned with the risk inherent in releasing essentially untagged units. As a consequence of the aforementioned case, his blood bank has been asked to develop a policy to permit the emergent release of RBCs for a patient who has no known medical record number. He wants to know if other hospitals have developed policy and procedure to permit the issuance of blood products for a patient whose identification is unknown and the patient has no ID on their person. If other blood banks have such policy and procedure, how does this work and have there been problems.

ADDENDA July 20, 2007

9. In response to the query of July 16, 2007 from the transfusion medicine physician in Boston, a transfusion medicine physician at the New Mexico Health Sciences Center reports that being a level I trauma center, the hospital uses pre-printed trauma-alert names, numbers, and barcodes. Every critically-injured patient that enters the trauma center is given an identification packet containing a unique trauma-alert name/number which may be merged with the patient's real ID at a later date. When this happens, the blood bank is involved to ensure that current type and screen procedures are not compromised by the "change" in name. Regardless of whether the a trauma-alert number is present on the patient, the trauma bay has emergency O Neg blood on site, and may administer this when needed. When this is used, they contact the blood bank with the patient information for documentation and so that the stock can be replenished. They reportedly are currently in the process of implementing the Neoteric refrigerator tracking system to issue blood remotely for emergencies and non-emergencies at 7 sites in the hospital, including the trauma bays (see press releases HERE and HERE). This will enable additional tracking of who removes the blood, and which patient it is for. In rare instances, it may be necessary to issue blood when a patient ID is not available. Due to the computer networking of the neoeteric system, the blood bank will know immediately that emergency blood has been issued and who retrieved it--if there is no ID then follow-up can happen in "real-time.

ADDENDA August 10, 2007

10. A medical director of a Canadian tertiary care hospital is attempting to standardize policies for emergency red cell release for medical centers in their region. The physician read with interest comments in this discussion regarding the acceptability of releasing group O positive RBC's to males of unknown Rh status, or to post menopausal females. The question is how does a transfusion service define "child bearing age"? In the inquiring physician's center they cannot expect to be informed of an adult female patient's menopausal staus in an acute scenario. It seems reasonable to set an age cut-off. What is the norm in other institutions; age 50, age 55, or older? This question is of practical importance in an era of improved reproductive technologies which might cause this age cut-off to creep higher.

ADDENDA June 13, 2008

11. A colleague in Australia wonders what is the practice at other institutions with regards to switching back to using Rh negative blood products, after giving Rh positive products to an Rh negative trauma victim. Her question applies to trauma patients requiring multiple transfusions over several days/ weeks when there is a shortage of Rh(D) negative RBCs. If Rh(D) positive RBCs needed to be transfused to a Rh(D) negative (male) recipient, what would be an acceptable timeframe to continue transfusing Rh(D) positive RBCs before reverting to Rh(D) negative RBCs?

ADDENDA July 16, 2008

12. A respected transfusion medicine specialist from Southern California writes: "There is no easy answer to this. Rh-D negative units should be given to the patient as soon as the Rh negative red cell supply permits. However, if bleeding continues, or if the patient needs to be taken back to surgery, Rh positive red cells still may need to be issued depending on the clinical demand and the Rh negative red cell supply. A transfusion medicine specialist should make a decision regarding the Rh type of the red cells to be issued for each transfusion episode. Obviously, the patient must have a screen for red cell antibodies performed at least once every three days as long as he or she continues to need transfusion.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Assistant Editor & Moderator