Refusal to use Rh positive platelets for an Rh negative male undergoing coronary artery bypass surgery

A colleague reports a distressing situation in which a thoracic surgeon refused to accept ABO compatible Rh positive single donor pheresis platelets for the intraoperative transfusion of an over 50 year old Rh negative male during coronary artery bypass surgery. At the time the platelets were requested there were no Rh negative platelet products available. The thoracic surgeon allegedly claimed that Rh "incompatible" platelets were not acceptable for cardiac surgery patients and that the administration of Rh Immune Globulin would adversely affect the patient's blood pressure. Furthermore, for this specific cardiac surgeon, the hospital's open heart procedure manual states that for Dr. X, "only exact ABO/Rh matched platelets are acceptable". The surgeon reportedly refused to accept the Rh positive platelets and required the blood bank to obtain Rh negative platelets, which required a delay of more than 4 hours before Rh negative platelets could be transferred from another facility. The inquiring colleague wonders if others have had similar experiences.

The following responses have been received.

ADDENDA Mar. 25, 2004

1. A transfusion medicine physician in Pennsylvania reports that from a purely scientific standpoint, it is unlikely that Rh-positive apheresis platelets would cause anti-D alloantibody formation, and in a male patient the concern would be lower.  The idea that Rh immune globulin would adversely affect the blood pressure, or the surgical outcome in CT patients, is not supported by anything in the peer-reviewed literature.
   
   
2. A colleague from Barcelona, Spain, is of the opinion that one need not delay a medically necessary transfusion of Rh positive platelets, if a male patient is Rh negative. The Spanish colleague says that this is a clear situation where Rh positive platelets could be transfused to an Rh negative patient and that NO anti-D immunoprophylaxis is needed. He offers the following main reasons to support his position:
   • the low red cell content in pheresis platelets that are manufactured with modern apheresis devices
   • the low probability to develop anti-D in this clinical situation
   • even if a male patient developed an anti-D following an Rh positive platelet transfusion, which is very rare following transfusion of pheresis platelets, one need not worry about hemolytic disease of the newborn.
   He adds that if the transfusion is of pooled platelets from Rh(D) positive donors to an Rh(D) negative recipient, in such cases, the gender, age and immune status of the recipient should be considered.
   
   There are several recent references about this topic as well as previous discussions by the CBBS e-Network Forum.
   • Transfusion 2002;42:136-8 (editorial)
   • Transfusion 2002;42:173-6
   • Transfusion 2002;42:177-82
   • Transfusion 2003;43:893-8
   • Transfusion 2003;43:173-6
   • Transfus Med Rev 2003;17:57-68
     
     
3. A colleague at the Texas Heart Institute reports that they often use Rh positive platelets in male patients undergoing cardiac surgery. The policy also applies to females older than 50 years of age. The responding physician has not experienced difficulty with complications attributable to this practice in the form of frequent alloimmunization or other untoward effects. Their surgeons and cardiologists are satisfied with the outcomes. Further, the responding colleague is quite concerned about poor outcomes, i.e., excessive bleeding, in patients experiencing delay in provision of platelet therapy due to platelet Rh-matching requirements.
   
   Editor's Note: In addition to the replies that are posted above, several colleagues have submitted similar comments, including anecdotal (and frustrating) experiences during which clinicians refused to use blood products that were not identical in blood group/type with the patient, even when such refusal placed the patient in harm's way. This suggests a need for improved physician education regarding the use of Rh (and ABO) non-identical transfusions. Do colleagues have effective educational materials that they might be willing to share?

ADDENDA Apr. 3, 2004

4. An experienced transfusion medicine physician in Florida reports that the study by Schmidt PJ, Leparc GF, Samia CT, Use of Rh positive blood in emergency situations.  Surg Gynecol Obstet 1988;167:229-33, which was done some years ago and published in a surgical journal, may be germane to the discussion about using Rh positive platelets in surgery, during local shortages of Rh negative blood products.

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Ira A. Shulman, MD
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W. Tait Stevens, MD
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Elizabeth M. St. Lezin, MD
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