A colleague in New York reports that the general blood administration policy at their institution recommends that during a non-emergency RBC transfusion, the rate of infusion should be slow during the first 15 minutes in order to limit the volume of blood given while observing the patient for signs of a reaction. On the other hand, their dialysis unit does not follow this general policy. Rather, they administer multiple RBC units in a short period of time without a preliminary slow infusion rate. The inquiring colleague is curious to learn whether other institutions have addressed this issue in their SOPs. Do dialysis units follow general institutional blood administration policy or are dialysis units exempt from such guidelines because of how the blood is given to the patient via the dialysis machine? Do any facilities have specific policies for blood administration during dialysis?

The following comments have been received.

ADDENDA Dec. 14, 2004

1. A colleague at a hospital in a Sunbelt State reports that they used to have to deal with the same issue, in that the dialysis staff would infuse RBC units rapidly, because it was convenient to do so. In fact, they would infuse the RBCs so rapidly that in the opinion of the responding colleauge, if any error had occurred, at least two entire units of RBCs would be transfused before the patient would have a chance to demonstrate any of the early symptoms of hemolysis. After several fruitless discussions with their dialysis staff, the Transfusion Service Medical Director met with the Medical Director of the Renal Service. Once the latter understood the basis of the transfusion service concerns, support for a more measured rate of transfusion was agreed upon, and compliance is no longer an issue.

ADDENDA Feb. 24, 2005

2. A physician who specializes in the treatment of hemoglobinopathies and who practices is in Northern California at a pediatric care hospital comments that in his opinion there is not much difference between rapid blood transfusions during a dialysis procedure versus during a therapeutic erythrocytapheresis. He acknowledges that during an erythrocytapheresis his policy is not to slow down the apheresis procedure for each unit of RBC that is administered. He is wondering why there should be a problem with rapidly infusing blood during the first fifteen minutes during a dialysis treatment, but not during an apheresis treatment and vice versa. He continues saying that although the patient is monitored continuously during apheresis exchange for plasma or for blood the flow rates and volumes exchanged exceed the rates that would be considered safe for a manual straight transfusion or manual exchange transfusion.  During red cell exchange the flow rates are constant and there is no slower rate each time a new unit is infused during a run. There should be SOP’s for these procedures warning of the possibility of transfusion reaction when a new unit is started in the middle of the run. The Northern California physician believes that nurses and physicians who provide therapeutic apheresis services are aware of the inherent danger of this procedure and may be more diligent in patient and product identification. Having said the aforementioned comments, he acknowledges that he has seen one acute hemolytic transfusion reaction in a patient who had a known Le^a antibody and was issued one Le^a positive unit for a four-unit red cell exchange transfusion. The transfusion service did not think Lewis antibodies were a contraindication to the transfusion of this unit. Most of the unit had been transfused before it was realized that the patient was having an acute hemolytic transfusion reaction. The patient had a transient decrease in renal function but there were no other effects and there was complete recovery. Laboratory values as shown in the attached table (PDF File).

ADDENDA Feb. 25, 2005

3. A Technical Supervisor at a hospital in Arizona agrees with the above physician. She states that since (in her experience) pheresis exchange is not an everyday procedure, the staff monitoring the pheresis patient are extremely vigilant for all the adverse events that may occur. On the other hand dialysis is an 'everyday event' in most hospitals, and with familiarity comes a certain degree of 'relaxation'. She cautions that the sort of lapses that can allow an ABO-incompatible transfusion accident to occur during an emergency situation are just as likely to happen during an 'everyday event' (such as dialysis).

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