An observational study of red cell transfusion in specialist palliative care Dear Sir-We wish to report our findings of an observational study of red cell transfusion practice in specialist palliative care. This was conducted in two specialist palliative care inpatient units in the United Kingdom. The combined catchment population was one million and, in the period analysed, there were 944 admissions. One hundred transfusion episodes occurred and 73 individual patients received transfusions. Fifty-four (73.9%) patients received a single transfusion with the remaining 19 (26.1%) receiving multiple transfusions. Thirty-five (47.9%) patients were male and the mean age was 66.5 years (range 37-102 years, SD 13.56). Seventytwo (98.6%) patients had a malignant diagnosis. Prostate cancer was the most common primary tumour and occurred in 19 (26.3%) patients. There was a high proportion of patients with gastrointestinal cancer and lung cancer; 13 (17.8%) and 11 (15.1%) respectively. The most common site of metastases was bone, present in 32 (44%) patients. Low haemoglobin (Hb) level was documented as a trigger, either solely or in conjunction with other reasons, in 73 (73%) transfusions. Anaemia was deemed the only reason for transfusion in 26 (26%) cases. Haematinics (B12, folate, ferritin or combination) were checked in nine (9%) transfusions. The mean pre-transfusion Hb was 7.9 g/dL (range 4.3-11.4, SD 0.95) and mean post-transfusion Hb was 10.0 g/dL (range 7.2-13.0, SD 1.29). The mean number of units transfused was 2.2 (range 2-4 units). A response to transfusion was recorded in 38 (38%) transfusion episodes with 31 (31%) having a positive response. The transfusion decision was not documented as being discussed with either patients and/or relatives in the majority of cases (78%). The mean number of days between the last transfusion and death was 47 days (range 2-293 days, SD 57.1). Ten (13.7%) patients died within seven days of transfusion.
Type II heparin-induced thrombocytopenia (HIT) is a rare but well-recognised and potentially life-threatening complication of unfractionated heparin therapy, and has been reported in association with heparin locks for central venous lines. We report a case of type II HIT complicated by iliofemoral deep venous thrombosis and pulmonary embolism in a 43-year-old woman in the course of plasma exchange for myasthenia gravis. A Gamcath central venous line had been inserted femorally due to poor peripheral venous access, and this was locked with heparin 5000 U/ml between procedures. Twelve days after initial heparin exposure, she presented with new-onset thrombocytopenia, a painfully swollen right leg, and pleuritic pain. Deep venous thrombosis and pulmonary embolism were confirmed radiologically, and serology for heparin/PF4 antibodies was unequivocally positive. The line was removed, and she was successfully managed with intravenous lepirudin, switching to warfarin on platelet recovery. This case demonstrates that Type II HIT can occur in association with heparin line locks in the course of plasmapheresis, despite previous reports of successful use of plasma exchange to treat Type II HIT.
Anaemia is a common side-effect of malignancy and cancer therapy. Both red cells and erythropoietin will improve anaemia; however, the scarcity and risks of allogeneic blood transfusion need to be carefully considered against the expense and benefits of recombinant human erythropoietin. Both treatment options have significant economic implications and the definitive evaluation from NICE must be awaited with much interest.
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