Is it ever acceptible to intentionally transfuse ABO-incompatible RBCs?
The section supervisor of a rural transfusion service located two and a half hours from the closest blood supplier reports that typically, being located this distance from their supplier is not a problem, because their inventory levels allow for sufficient time to have blood delivered by stat transport before depleting their entire supply. However, currently due to a regional blood shortage situation, the blood supplier is at critically low levels, and their inventory levels in the Transfusion Service are critically low. The section supervisor asks the e-network to please consider the following scenario, that she reports is TRUE!!! and actually happened at her facility An eighteen year-old male (group O, Rh positive) was in a motor vehicle accident and arrived in their ER with massive bleeding. After transfusion of 12 units of RBCs their supply of group O Rh positive and group O Rh negative RBCs was completely depleted. The physician wanted the laboratory to prepare for transfusion of 'least incompatible' group A RBCs for transfusion during surgery. The inquiring colleague reports that her first thought was that this might not be a good idea; however, after even more thought, she wondered if the patient's plasma levels of anti-A,B might be sufficiently decreased by this time that giving group A RBCs to the group O patient might actually be better than allowing the patient to literally bleed to death. The blood bank laboratory was not able to acquire a new blood specimen from the patient for compatibility testing at this point to determine if the anti-A,B reactivity was diluted, because the surgical team could not to provide the specimen. The decision to intentionally transfuse group A RBCs did not need to be acted upon, since the patient expired in surgery as the last few drops of group O RBCs were being infused. The inquiring blood banker wonders how other colleagues might have approached this problem, if the patient had lived and continued to bleed excessively, but group O RBCs continued to be unavailable.
In response to the above scenario and question, several replies were submitted. As one might expect, a wide range of opinions were expressed, some based on science and some based on emotion. Below is a representative sampling of these responses.
- A very experienced transfusion medicine physician who practices in Chicago at a major institution reported that according to his approach, if the patient were receiving FFP during the RBC transfusions, it would be advisable to switch to group A FFP. This would both dilute the patient's anti-A and neutralize the antibody to some extent with soluble A antigen in the transfused plasma, facilitating a switch to group A RBCs;
(one might also consider using A2 or other A subgroup RBCs, rather than using A1 RBCs)
. An approach of using group A FFP and ABO incompatible RBCs was published in 1988 for two group O liver transplants during shortages of group O RBCs (Yang S-L, Ballas S, et al, Transplant Proceedings 198820 (1 Suppl 1) 295-9). In the first case, they gave 7 U of FFP immediately preoperatively, gave 23 group O units during the initial hepatectomy phase, switched to 40 units of group A RBCs, then switched back to 20 group O RBC units. The patient got 87 FFP, all A. In the second case, they used 78 O units first, then switched to 93 A RBCs, then finished with 11 O RBCs, all while giving 208 units of A FFP, then did a 6-unit blood exchange the next day with O RBCs and A FFP. However, in the usual trauma patient, RBCs are more quickly available than FFP, since FFP must be thawed. So it might be difficult to give a large volume of group A FFP before a large number of RBCs are given. The Chicago physician would have to agree that if absolutely necessary, group A RBCs must be given, taking as much precautions as possible against hemolysis (hydration, diuresis, alkalinization of urine). Intraoperative red cell salvage would be very helpful too, if available. If diffuse coagulopathy were contributing to the hemorrhage, in his opinion recombinant factor VII (rFVIIa) could improve hemostasis.
Editor's note: rFVIIa is not currently FDA-approved for the medical indication suggested by the Chicago physician; thus the use of rFVIIa in that setting would be considered an off-label use of the drug.
- An opposing opinion comes from a West Coast blood bank technologist who reports that over 25 years ago she worked in a small rural hospital in Idaho where blood product deliveries came by airplane. The Idaho hospital's usual blood stock was just a few units of red blood cells. In emergencies they would call the surrounding hospitals and ask them to send blood with the State Police and take emergency donations at the hospital. In spite of shortage situations, she reports never having issued ABO-incompatible blood for any patient. However, she adds that, in her opinion, many patients DID die due to lack of blood. What made these deaths especially difficult was that the community was so small that many of the patients were known personally by the hospital staff. In spite of the above, she would not want to give someone ABO-incompatible blood and then have to work up the reaction. In her opinion, she does not think that a few units of ABO-incompatible blood would save anyone if they were that critical, and such a transfusion would only add to the confusion of why the patient expired.
ADDENDA Jan. 24, 2003
- A very experienced transfusion medicine physician in Ohio is of the opinion that it is acceptable to administer ABO-incompatible blood in the rare event where there is no other blood available and the patient is in critical need. She thinks the challenge is not 'if it acceptable', but rather, deciding 'when are the right circumstances'. When is it medically in the patient's best interest 'to pull the trigger, so to speak'. The latter is much more difficult to decide since the goal is always to keep the risk to benefit ratio in favor of overall benefit.
- A transfusion medicine physician and scientist, who has published scientific studies on the pathophysiology of incompatible transfusions reports that in his experience, the mortality rate from ABO-incompatible red cell transfusion is about 20%. While this is high it is less than the mortality from hemorrhagic shock. He thinks that no one should be allowed to bleed to death for lack of serologically compatible red cells. In his opinion, if he were ever in the situation he would give AB plasma if possible then go to group B red cells and finally group A or AB red cells. He would also give IVIG when the hemorrhage is controlled. Finally he would do an exchange with compatible red cells as soon as they become available.
- A transfusion medicine physician in Sacramento reports that if faced with a scenario like that described above he would have done the following (verbatim): "(i) ensured that the surgery/anesthesia team were using an intraoperative salvage device, if available; (ii) confirmed that, before providing group A or B RBCs to the patient, volume repletion (with colloids and crystalloids) had been pushed to the utmost, and that no alternative but to give incompatible RBCs existed; (iii) made certain, as soon as it appeared likely that we were going to run out of group O RBCs, that all plasma transfusions received thereafter by the patient were of the same ABO type as the incompatible RBCs the patient was about to receive (or, better yet, group AB, if such plasma were available), so as to reduce further the amount of ABO-incompatible plasma the patient would have on board; (iv) prioritized the use of "least-incompatible" RBCs (preferably, at first, group A2) for the patient, since it would be most important to prevent the patient's impending exsanguination, rather than be paralyzed by the (admittedly very real) possibility s/he would develop an acute hemolytic transfusion reaction; and (v) begun treating the patient, immediately before the first ABO-incompatible RBC were transfused, with hyperhydration, and (probably) kept his urine alkalinized."
ADDENDA Jan. 27, 2003
- A physician in the Bethesda, Maryland area offers two other options to consider, when facing a group O patient who is bleeding to death in an area with limited supplies of group O banked blood:
- Emergency collection of group O whole blood, preferably from a 'pedigreed' donor, released and transfused prior to infectious disease testing due to emergency. If collection kits and testing serum were available this could be accomplished within 30 minutes.
- If advance planning was made, use of a hemoglobin-based oxygen carrier, as recently published by Gould SA et al. The life-sustaining capacity of human polymerized hemoglobin when red cells might be unavailable. J Am Coll Surg. 2002 Oct;195(4)445-52; discussion 452-5.
Editor's note: The above hemoglobin-based product (PolyHeme) is not yet FDA-approved. Also, please re-visit the recent e-network forum discussion on a related aspect of this issue ("Where do hospitals store 'oxygen therapeutics' solutions?) Feel free to comment on the storage of hemoglobin-based oxygen carriers in that discussion. e-Network Forum members from institutions that have participated in the above or related studies are particularly encouraged to respond.
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Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator
W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator
Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator
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