Implementation of national blood conservation recommendations at an adult sickle cell center

Abstract

Background Due to the national blood supply crisis caused by the COVID‐19 pandemic, the American Society of Hematology proposed guidance to decrease blood utilization for sickle cell patients on chronic transfusion therapy (CTT). Little evidence exists to support the efficacy and safety of these blood conservation strategies. Study Design and Methods Through retrospective analysis, we sought to describe outcomes following implementation of these recommendations in 58 adult sickle cell patients on chronic exchange transfusions. The strategies employed included: relaxing the goal fraction of cells remaining (FCR) to 30%–50%, utilizing depletion exchanges in select patients, and transitioning select patients to monthly simple transfusions. We compared hemoglobin S%, hemoglobin values, and other laboratory parameters, acute care visits, and red blood cell usage during the first year of the COVID‐19 pandemic to the year prior using Wilcoxon signed rank test. Results Of 53 patients who remained on chronic exchanges during the pandemic, use of depletion exchange increased (15%–23%) and FCR increased (34.9 [SD 4.7] vs. 37.6 [SD 4.5], p < .05). These changes resulted in 854 units conserved without clinically significant changes to pre‐exchange laboratory parameters, including hemoglobin S%, or number of acute care presentations. In contrast, five patients who transitioned to predominantly simple transfusions, experienced difficulty maintaining hemoglobin S% less than 30 and worsening anemia. Discussion Our data suggest that in a blood shortage crisis, optimizing the exchange procedure itself may be the safest means of conserving blood in a population of adult patients with sickle cell disease.

Revisiting the benefits of isovolemic hemodilution red cell exchange for sickle cell disease

“…This retrospective crossover analysis of nine patients aims to add to the existing literature on IHD-RCE and address the equipoise regarding whether the benefits of decreased RBC usage per exchange and lower FCR/increased interprocedure interval can be observed at the same time, in the same patient. Our study also provides additional safety data on potentially higher-risk conditions, using greater Hct decreases than reported elsewhere, 3,5,6 while using normal saline replacement exclusively.…”

“…Given the challenges of the pandemic, there has been increasing interest in how we can optimize blood utilization in SCD while continuing to maintain appropriate therapeutic goals. 2,3 A recent survey of RCE practice indicated that 40% of respondents use IHD 4 ; as more centers consider adopting this practice, they will need to have a clear, realistic understanding of how much benefit to expect. This retrospective crossover analysis of nine patients aims to add to the existing literature on IHD-RCE and address the equipoise regarding whether the benefits of decreased RBC usage per exchange and lower FCR/increased interprocedure interval can be observed at the same time, in the same patient.…”

Doing more with less: Patient blood management meets sickle cell disease management

“…By allowing for a higher FCR, the patient will require fewer donated RBCs. In this month's issue of TRANSFUSION , the study by Jones et al provides evidence that using depletion/exchange and tolerating a higher FCR, while being mindful of patient comorbities, likely does not have a significant clinical impact on sickle cell patients who are compliant with their scheduled regimen 20 . In addition, because the replacement fluid volume typically needed for the depletion is low relative to total plasma volume (about 6%), in some patients, the use of normal saline instead of 5% albumin can be considered while still meeting therapeutic targets 21 …”

“…Jones et al 20 demonstrated that increased use of depletion/exchange and increasing the FCR resulted in the conservation of over 850 units of RBCs at their center and caused no clinically significant changes to targeted laboratory parameters. For the five patients who transitioned to simple transfusion, there was an increase in the HgbS fraction along with increased anemia.…”

“…In this month's issue of TRANSFUSION, the study by Jones et al provides evidence that using depletion/exchange and tolerating a higher FCR, while being mindful of patient comorbities, likely does not have a significant clinical impact on sickle cell patients who are compliant with their scheduled regimen. 20 In addition, because the replacement fluid volume typically needed for the depletion is low relative to total plasma volume (about 6%), in some patients, the use of normal saline instead of 5% albumin can be considered while still meeting therapeutic targets. 21 At our center at the University of Illinois at Chicago, our transfusion service orders 24,000 ml of RBCs or approximately 80 units of Rh C, E, and K1 negative units every month from our blood supplier to support the over 50 patients who receive chronic RCE.…”