Managing repeat blood donors who have adverse donor reactions on multiple occasions

A nine gallon whole blood donor and repeat platelet pheresis donor reports that he recently experienced a rather severe reaction while undergoing an automated donation of platelets and RBCs which he attributes to the anticoagulation used during the collection. He acknowledges having had mild to moderate 'anticoagulation' related donor reactions in the past and he generally asks the donor staff to adjust downwards the amount of anticoagulation used during an automated collection, as a prophylactic strategy to prevent a reaction. He generally spaces his donations 8-9 weeks apart.

On the day leading up to his most recent combined RBC+Platelet donation he reports in his own words the following: "Breakfast was a 12 ounce smoothie made from frozen berries, whole milk, yogurt, and banana. I had lunch with me at work, but unfortunately had to leave to go purchase a used car. Spent 5 hours test driving, inspecting, getting a second opinion, negotiating, feeling typical "should I buy or not" nervousness, figuring out what to do with my old (and dead) car, etc. Also stress from time constraints and need to get my wife's car back to her at work in time for her to drop me off for the apheresis appointment. Around 3:40 I managed to swing by McDonald's (the need for food overcame the guilt of going to McD) to pick up a 20 piece Chicken McNugget and a large orange juice. Ingested majority of the chicken nuggets (my wife had a few) and the OJ. Made it to the Blood Bank by 4:05 PM."

At the time of his most recent donation he reports the following, also in his own words: "I would guess that the procedure started around 4:55 PM. Standard single-needle procedure, combined platelet and RBC, estimated procedure time of 51 minutes. I made sure to eat some Tums (12-14), that there was a hot blanket for the needle site to help keep the draw pressure up, that I had a pillow in the lumbar region, etc. I forgot, however, to remind the technician to lower my anticoagulation level. I noticed milder than normal anticoagulation symptoms during the majority of the donation, but towards the end when the machine shifted from platelet to RBC, I started to notice an increase in symptoms to more normal levels for me. Normal symptoms for me are moderate tingling in the hands, jaw cramping if I try to chew on something (I have to be careful if I wait too late to start eating the Tums since the cramping can be rather uncomfortable and chewing on the Tums is a sure trigger), and sometimes mild tingling in the feet. As the rinseback started, the symptoms started to skyrocket. By the time rinseback had completed, the technicians indicated that I appeared very pale and had already started placing ice packs on my chest, ankles, and behind my neck. I did not pass out or lose visual or auditory contact with the world. I did, however, experience extreme tingling in the entire body from the neck down. My hands cramped in a position I have seen in people with cerebral palsy. My arms, hands, legs, and feet all experienced rigidity. An attempt was made to get me some juice, but I decided against it after the first sip as it was too hard from a reclining position to defend against it going down the wrong pipe. I would estimate that I was in this state for roughly 10 minutes before the symptoms started to ease. I aggressively maintained verbal and visual contact with the technicians, discussing things like previous experiences and my vague recollections of the role of Ca+ channels in nerve impulse transmission, in an attempt to distract myself, maintain a positive attitude, and ensure that I didn't lose conciousness. Part way through, I discovered that, although I didn't think I could move my fingers and I couldn't feel them through the tingling, I could actually make limited range movement with them and could verify this by watching them. Once the symptoms started to lift sufficiently that I had motor control and proprioception, I ate a Viactiv Calcium Chew and drank a chocolate milk, and then started eating some crackers. When I felt strong enough to stand, I moved to a sofa, where I sat reading and munching while waiting for my wife to pick me up."

Given the foregoing experience, he wonders what blood bankers suggest he should do. He has expressed that he is highly motivated to continue being a blood donor, and he would like to remain an automated collection donor. However, since he has had repeated reactions during automated collections, he wonders if he should limit his donations to being a regular whole blood donor. Were he to continue automated donation, what steps would you recommend he and the blood bank take to increase the margin of safety?

The following comments have been received.

ADDENDA June 11, 2006

1. A well-known apheresis research team at a large institution in Maryland replies that many plateletpheresis donors experience uncomfortable citrate-related symptoms during donation, and that in some cases these events may impact willingness to return for future donations.  Randomized studies performed by this team demonstrated that prophylactic administration of oral calcium carbonate tablets (2 to 4 gm, or 4 to 8 tablets of 500 mg each) 30 minutes prior to donation slightly improved ionized calcium levels during donation, but had a trivial impact on clinical symptoms.They do not feel that prophylactic oral calcium can be relied upon to prevent severe citrate reactions. In contrast, a recently completed clinical trial showed dramatic symptom reduction and improved platelet yields using prophylactic intravenous calcium administration during plateletpheresis (Journal of Clinical Apheresis 2006; 21(1):2-3). The investigators recognize that widespread implementation of prophylactic intravenous calcium administration during plateletpheresis is not likely to happen soon.  They point out that the donor described below experienced a severe tetanic reaction, and that this donor was known to be sensitive to citrate. They strongly recommend that collection facilities not rely on donors to remind the staff to reduce the rate of citrate administration based on a prior history of citrate reactions.  They recommend that the donor's file be amended to contain a permanent instruction to run future donations at a slow whole blood flow rate, perhaps 15-20% lower than the usual rate used by the center, and that the anticoagulant ratio should be adjusted as well, to the lowest ratio of anticoagulant to whole blood allowable at that center.

ADDENDA June 19, 2006

2. A transfusion medicine physician in the Midwestern US recommends that the donor under discussion schedule an appointment with the medical director of the blood center where he donates, if he has not already done so. The medical director and the donor should discuss the reactions, possible means to prevent or lessen them, and what donation strategy would work the best. If the respondent was the medical director, s/he would certainly want to do whatever s/he could to keep this dedicated person donating, whether as an "automated" component donor or whole blood donor. From a personal perspective as a multi-gallon donor, the respondent physician acknowledges that s/he was also quite sensitive to citrate infusion in the past with some of the automated collection instruments that were available then, although symptoms were not nearly as severe as what the donor under discussion reports. S/he had to switch back to being a whole blood donor for several years until a combination was found of the right instrument and apheresis operators who could figure out and prevent the problem before it started. The respondent now donates plasma & platelets 3-4 times/year with no problems and concludes that "although we are always in need of blood donations, the well-being of our donors always comes first. I'd encourage this donor to review his options with the blood center medical director and keep on donating components or whole blood, if that is deemed safe for him to do."

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