Use of O positive RBC in Trauma

A Transfusion Service Supervisor at a medical center in Northern California asks if there is a generally accepted policy for administering RhIG after transfusion of Rh positive RBC to an Rh negative recipient. The Supervisor’s hospital transfuses male trauma patients with Group O, Rh positive RBCs until the ABO/Rh type is known. Her trauma department has questioned if these patients should be given RhIG after such transfusions.

This question raises two issues for discussion:

1. What RBC product (O positive or O negative) do you use for trauma patients before the ABO/Rh type is performed? Do you transfuse O negative RBC if available for all patients or do you issue O positive to start (especially to males)? The rate of anti-D formation in patients after exposure in a trauma environment is lower than healthy subjects (<30%)1, but can occur. Anti-D also may be present in previously transfused D negative patients.
   See previous discussions on CBBS eNetwork Forum:
• Policies for Ensuring An Adequate Supply of O Rh Negative Blood in Emergencies
• Management of transfusing Rh-positive RBCs to Rh-negative recipients in times of severe shortage
  
  
2. If O positive RBCs are transfused to an O negative recipient, do you consider giving RhIG prophylaxis to prevent anti-D formation?
   Editors’ note: Clinically significant hemolysis of transfused Rh positive RBC after administration of RhIG has been reported. Most authors agree that the use of RhIG should be weighed against the risk of hemolysis and should be considered only when alloimmunization to the D antigen is a significant clinical issue (such as females of childbearing age) ^1,2,3.

References:

1. Frohn C et al. Probability of anti-D development in D- patients receiving D+ RBCs. Transfusion 2003;43:893-898.
2. Ayache S, Herman JH. Prevention of D sensitization after mismatched transfusion of blood components: toward optimal use of RhIG. Transfusion 2008;48:1990-9.
3. Karp JK, Ness PM. Acute renal failure with hemolysis in a mismatched transfusion recipient treated with RhIG. Transfusion 2009;49:1269 (letter).

ADDENDA Aug. 28, 2012

3. Dr. Paul Ness, Director of Transfusion Medicine and Dr. Karen King, Transfusion Medicine at Johns Hopkins (attribution used with permission) respond to the issue of using O+ rbc in trauma:
   
   At Johns Hopkins, we routinely use O+ rbc for trauma recipients. The majority of our trauma recipients are male and the patients with significant trauma requiring massive transfusions often have major abdominal issues that are life threatening and make Rh sensitization in women who are unlikely to bear children in the future a secondary concern. The trauma team is aware that we would attempt to supply O- blood to a female recipient whom they believe might ultimately bear children but these requests rarely occur. These practices have been approved by our Transfusion Practices Committee with input from our obstetric colleagues. As better means to handle Rh sensitized pregnancies with advanced prenatal and perinatal procedures have been developed in recent times, Rh sensitization in a woman of childbearing age has become less of a concern for colleagues who specialize in high risk pregnancies.
   As the largest hospital in our metropolitan area encompassing Baltimore and Washington, we are also aware of the effect of our policies on other hospitals in the region. If the major trauma centers such as Hopkins or University of Maryland demanded O- blood for massive trauma patients, we would compromise an already precarious blood supply where O- inventories are commonly at unsatisfactory levels. We believe that the O- inventory issues in our area and around the country could be improved by rapid Rh(D) typing of patients with incomplete pretransfusion testing and avoiding the use of O- units routinely for trauma cases where the transfusion needs are less than we encounter in major trauma centers.

ADDENDA Sept. 6, 2012

4. Paul J Schmidt, MD, Transfusion Medicine Academic Center, Florida Blood Services (attribution used with permission) responds:
   To test the validity of the assumed need to stock O Rh neg routinely in an active emergency room, we provided 601 units of O Rh pos RBC to 262 consecutive, untyped patients in a regional tertiary care hospital. Only 20 of those patients were Rh neg, mostly male. There were no acute hemolytic reactions and no sensitizations of young females. The greater good of the community, including its patients who present as Rh Neg and cannot receive what they need, is compromised by wasting Rh neg because a rare patient MAY be harmed.
   
   Schmidt PJ, Leparc GF, Samia CT. Use of Rh positive blood in emergency situations. Surg Gynecol Obstet 1988;167:229-33.

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