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A transfusion medicine physician reports that her hospital in Michigan is considering irradiating all cellular products (RBC and Platelets) because the vast majority of patients at their hospital have medical conditions for which irradiated products are appropriate. They realize that if they were to follow such a protocol, some patients would receive irradiated units who do not currently receive such products. Based on her knowledge of non-related donor/recipient transfusions, she has a growing concern about microchimerism and possible effects long term, especially in elderly and trauma patients. She wonders if any facilities are irradiating all cellular products for all patients because of these or other concerns? The following comments have been received. ADDENDA June 27, 2007 1. A transfusion medicine physician in Calgary, Alberta, Canada, reports that in his experience the downside of irradiating all cellular blood products is earlier outdating of RBC and potential hyperkalemia in transfusion recipients. He reports having had two pediatric patients who developed hyperkalemic cardiac arrest in the OR while undergoing massive tranfusions relative to their blood volume. Fortunately both were successfully resuscitated. They attributed hyperkalemia largely to the use of irradiated RBC and are now careful to avoid the use of irradiated RBC in pediatric OR unless clearly indicated. They also attempt to supply RBCs less than 14 days old (whether or not irradiated) for all children going to surgery. Ideally, if irradiating RBC, this should be done close to the time of issue. In his hospital this is not always possible since they do not have their own irradiator and the units are irradiated by the blood supplier. Therefore, if issuing RBCs to pediatric OR that were irradiated > 5 days beforehand, they issue them additive-depleted. 2. A transfusion medicine physician in Boston reports that his hospital has been irradiating all cellular components for about 4 years for the reasons stated and others. He comments that they are not unique in doing this and he is aware of at least two other major hospitals that irradiate all of their cellular components. One reason is that there is more of a chance of missing a patient who requires irradiated blood components if one uses a selective irradiation approach. In fact, this contributed to a case of fatal transfusion asssociated graft versus host disease at his facility. Another concern is the potential of a patient accidently receiving a transfusion from a relative who donated at the hospital-based donor center. Also, in addition to the elderly and trauma patients, some young children may have undiagnosed immune deficiencies. Finally, drugs that potentially increase the susceptibility to transfusion associated graft versus host disease are sometimes being used in patient groups not previously considered at risk, such as patients with severe rheumatologic diseases. There are some issues that need to be considered when implementing such a policy. In general, they irradiate at the time of crossmatch and they usually have an inventory of irradiated RBC units, which develops when crossmatched units are not transfused. For massive transfusions, they will use this inventory but if this inventory is depleted and RBCs are urgently needed, they will transfuse unirradiated RBC units. For OR patients less than 1 year old they irradiate at the time of dispense to avoid transfusing high concentrations of extracellular potassium. |
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Please submit comments to the e-Network Forum. Ira A. Shulman, MD W. Tait Stevens, MD |
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