Sickle cell disease (SCD) patients require urgent red cell exchange (RCE) procedures for acute chest syndrome (ACS), demanding a coordinated effort of multiple clinical services. Execution of RCE is a multistep process from the time the procedure is requested to the time the procedure is initiated. A retrospective review of patients with SCD requiring urgent RCE for ACS and stroke from 2012 to 2017 was performed at a centralized hemapheresis service covering a multihospital healthcare system. A total of 30 urgent RCE procedures performed on 28 patients were evaluated. The time required for red blood cell (RBC) preparation was the longest step in the process (median 3.8 hours). Furthermore, RBC preparation time was longer for sickle cell patients with RBC alloimmunization compared with nonalloimmunized patients (8.6 vs 3.8 hours, P = .03). One mortality event occurred in Ab− group. This study identified potentially modifiable factors, which impact the time to implementation of RCE in one service area. It highlights the importance of a structured and coordinated approach for the efficient and timely delivery of this vital treatment modality.
Background Currently, low titer A plasma is used on a routine basis in bleeding trauma patients of unknown AB type. Three AB non‐bleeding apheresis patients are presented here who safely received a combination of AB and low titer A plasma during therapeutic plasma exchange (TPE). One control AB patient received AB plasma only. Methods Data was obtained retrospectively on number of procedures, volume replaced, total plasma, and A plasma volumes including hemolysis laboratory data. Average A plasma volume and % of A plasma out of total plasma volume used were calculated. Results Two female AB patients were treated for thrombotic thrombocytopenic purpura (TTP) with TPE and a third female AB patient was treated for microangiopathic hemolytic anemia. Patient 1 received a total of 12 procedures, 10/12 with AB+A plasma (average 916.3 ±84.6 mL). Patient 2 received a total of 12 procedures, 4/12 with AB+A plasma (average 1210.5 ±27.9 mL). Patient 3 received a total of six procedures, four out of six procedures with AB+A plasma (average 1009.8 ±80.3 mL). Patient 4, control, received AB plasma only. Percent of A plasma volume exchanged ranged between 23.8% and 47.8%. Haptoglobin, LDH, hemoglobin, and total bilirubin were monitored and trends were comparable with the control patient. The patients had a negative follow up direct antiglobulin test, adequate platelet recovery and a favorable clinical outcome with treatments. Conclusions TPE was effectively performed without evidence of increased hemolysis using up to 47.8% of low titer A plasma. This approach can reduce strains on limited supplies of AB plasma whereas providing a vital treatment alternative for AB patients undergoing TPE with plasma replacement.
Background Red blood cell (RBC) exchange for sickle cell disease presents unique difficulties due to RBC phenotyping, complex antibody work‐ups, large number of RBC units required, and vascular access considerations, any of which can delay the procedure. Multidisciplinary coordination and systemic processes ensure that monthly appointments remain on schedule. Study Design and Methods A high‐volume chronic RBC exchange program is described, highlighting the importance of multidisciplinary coordination and process improvement strategies involving initial referral, vascular access, order sets, and allocation of antigen‐negative or phenotypically matched RBCs. Results Approximately 50 outpatient RBC exchanges are performed each month with an 82% kept‐appointment rate. Specific factors for program success include open communication across services and improvements to referrals and standardized order sets. Conclusion A combination of multidisciplinary coordination and process improvement can ensure the success of a high volume RBC exchange program. Frequent communication of upcoming appointments between the referring hematologists, the hemapheresis clinic, transfusion service, and interventional radiology is critical. Advance notice to the immunohematology reference lab of upcoming appointments is needed to allow enough time for allocating antigen‐negative RBCs. Order sets can be leveraged to standardize and streamline RBC exchanges. Lastly, numerous mechanisms help patients compensate for the cognitive sequelae of stroke.
Background Consensus guidelines recommend that therapeutic plasma exchange (TPE) should be started within 4 to 8 hours after the diagnosis of suspected acquired thrombotic thrombocytopenic purpura (aTTP). This study aimed to audit the steps from diagnosis to initiation of plasma exchange at a centralized apheresis service. Methods A retrospective review of the electronic medical record and laboratory information systems from January 1, 2014 to August 31, 2017 was conducted to identify all patients with suspected aTTP undergoing TPE. Demographics, comorbidities, pertinent laboratory tests, and temporal TPE procedural data were collected. Results The median (5th‐95th percentile) time from request to initiation of TPE was 5.4 (3.2‐10.6) hours. TPE was initiated within 8 hours in 94 of the 108 patients (87.0%). The median (5th‐95th percentile) time from request to central venous access was 2.5 (0.5‐6.9) hours and from request to plasma product issuance from the blood bank was 3.4 (1.6‐8.1) hours. aTTP patients in whom TPE was initiated greater than 6 hours from request did not have worse outcomes compared to those with TPE initiation within 6 hours: in‐hospital mortality (2/14 [14.3%] vs 2/21 [9.5%], P = 0.66), median length of stay (9.0 [4.7‐44.1] vs 8.3 [3.9‐27.0] days, P = 0.76), and median number of days to durable platelet count recovery (4.5 [2.0‐9.0] vs 4.0 [2.0‐18.0] days, P = 0.66). Conclusions The 4 to 8‐hour target window from TPE request to initiation appears feasible for a centralized apheresis program servicing a large healthcare system.
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