How do blood banks know when a patient should get irradiated blood, if the patient's doctor forgets to order the blood to be irradiated? Page 2

ADDENDA Apr. 19, 2006

12. A transfusion medicine physician at an academic medical center in Pennsylvania reports that his hospital uses irradiated blood products for all patients who need transfusion, so that they do not have to rely on those who order the products to know (and inform the blood bank) that irradiated products are indicated.
    
    
13. A Consultant Hematologist for the National Blood Service in the UK reports that in his opinion there is no need to irradiate blood products merely because they need to be transfused to a pregnant patient.
    
    
14. Dr. Susan F. Leitman, Chief of the Blood Services Section, Department of Transfusion Medicine at the National Institutes of Health (attribution used with permission) reports that she is not aware of a case of TA-GVHD having occurred in a pregnant woman, nor is she aware of a mechanism whereby pregnancy alone would confer a degree of immune suppression sufficient to increase the risk of TA-GVHD. She wonders if the physician who ordered irradiated RBCs as reported in the case above and in the ADDENDUM of Apr. 17, 2006, might have done so with the goal of protecting the fetus (as opposed to the mother) from TA-GVHD risk, and therefore confused the well-documented incidence of TA-GVHD following intrauterine transfusion with a 'hypothetical' risk of TA-GVHD from a maternal transfusion. However, the risks do not overlap since a fetus is not at risk of TA-GVHD from passenger lymphocytes transfused to its mother. Dr. Leitman acknowledges that all blood product transfusions are irradiated at the NIH, as that institution practices 'universal irradiation.' However, she adds that in an institution not practicing universal irradiation, she would not recommend irradiation of cellular blood products merely because a transfusion recipient is pregnant. With regards to the use of CMV seronegative blood for a pregnant woman, at the very least she would want to know the CMV serostatus of the mother before this was considered. She is also of the opinion that there is no specific indication for leukocyte reduction of units transfused during pregnancy, in an institution which is not practicing universal leukoreduction. Dr. Leitman agrees that providing phenotype-compatible red cell units to sickle cell disease patients is a medically justifiable practice, whenever possible. Finally, it is interesting to her that the CMV negative, phenotype-compatible blood product order (see case report) was generated by the transfusion service (per their policies) and not by the ordering physician, making it sound as though the ordering physician may not even be aware of these practices. At the NIH, the transfusion medicine staff meet bimonthly with the major sickle cell treating physicians to review odd or unusual cases and to review and refresh transfusion and apheresis guidelines.

ADDENDA Apr. 23, 2006

15. At the Los Angeles County+USC Medical Center, a pregnant sickle cell disease patient who needs a transfusion would routinely receive leukocyte reduced (CMV low risk) red cells, since essentially all RBC units used at that facility are leukocyte reduced. Furthermore, a pregnant sickle cell disease patient would receive donor RBCs that are matched to the patient's C, E, K phenotype. The LAC+USC blood bank does not routinely provide irradiated RBCs for pregnant patients, unless specifically requested (and justified) by the patient's physician. Furthermore, RBC units used for adults with sickle cell disease are not screened for hgb S, unless specifically requested (and justified) by a clinician who wants to quantify and trend a patient's hgb S levels (such as by serial hemoglobin electrophoresis).

ADDENDA May 25, 2006

16. A colleague who works in the UK at the Leeds teaching hospitals reports that their blood bank receives data directly from pharmacy as to which patients are receiving the following drugs, which qualify the patient to receive irradiated cellular blood products:

Fludarabine phosphate (Fludara®)
Cladribine (Leustatin®)
Alemtuzumab (Campath®)
Other purine analogues

Their local practice is based on the recommendations of the UK SHOT program which said in 2003 'Prevention of TA-GvHD in patients receiving purine analogues is the responsibility of prescribers, but can and must be supported by the pharmaceutical industry and pharmacists and by suppliers of laboratory IT systems. All patients should receive an information card and leaflet and haematologists must ensure that there is an effective system of flagging special transfusion requirements in the laboratory. Referrals for shared care must include timely communication of all relevant information.' In the 2004 SHOT report it says 'Robust systems for noting patients' special requirements should be developed together with a policy of empowering patients to be more aware of their own special needs.'

ADDENDA June 16, 2006

17. A colleague in Jefferson, New York reports that his hospital transfusion service uses a commercial computer/software system which allows the operator to insert a special need (such as irradiated cellular products) for a patient. If the special need is not fulfilled (i.e., a non-irradiated product is selected for a patient with a special need for irradiated products, either at product selection or release) the computer will require a password to actively override the system in order to release the product. The respondent reports that they have had very good experience with this system and that it can be used to indicate a specific patient must receive special phenotyped blood products as well as CMV antibody negative products, etc.

ADDENDA Dec. 29, 2007

18. A Blood Bank Supervisor, at a Medical Center in Jacksonville, Florida reports that she is aware of at least one facility that stocks only irradiated blood products to avoid using a non-irradiated unit for a patient who needs irradiated blood products. Her question is "Are others doing this?"

ADDENDA Jan. 10, 2008

19. In response to the question posed in addendum #18 Dr. Paul Holland (attribution used with permission) reports he is aware of three hospitals which only stock irradiated red cells and platelets to ensure that patients at risk of T-A G-v-H D only get irradiated blood components. The three centers are 1) the Clinical Center at the NIH, 2) MD Anderson Hospital in Houston, and 3) Childrens' Hospital of Philadelphia. Also, according to Dr. Holland, in Japan, all units are irradiated because of the limited HLA diversity of their population.

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