POTD: Blood Transfusions in Immunocompromised Patients

You have a chemo patient who’s been feeling weak and was sent by their oncologist to the ED for further evaluation. They look pale, maybe a little tachy, but otherwise stable. A preliminary VBG comes back with a Hct of 10%…what do you do?

Let’s talk about blood transfusions in the immunocompromised patient! Shout out to Dr. Allie Kornblatt for the clinical question!

Irradiation

What is irradiation?

Process to inactivate lymphocytes in the RBC product. 

Why is it important?

Viable donor lymphocytes can attack recipient cells in individuals who are unable to mount an immune response against them, causing transfusion-associated graft-versus-host disease (ta-GVHD). Ta-GVHD can target all hematopoietic cells as well as other tissues, leading to bone marrow aplasia and other complications that are ultimately fatal.

Who should get irradiated blood?

• Recipients of intrauterine or neonatal exchange transfusion; premature neonates

• Individuals with congenital cell-mediated immunodeficiency states

• Individuals treated with specific types of potent immunosuppressive therapies (purine analogs, antithymocyte globulin [ATG], certain monoclonal antibodies); this may include those being treated for non-Hodgkin lymphoma (NHL) or other hematologic malignancies

• Recipients of hematopoietic stem cell transplant (autologous or allogeneic)

• Individuals with Hodgkin lymphoma (any stage of disease)

• Individuals at risk for partial HLA matching with the donor due to directed donations, HLA-matched products, or genetically homogeneous populations

Additional Considerations

Blood ultimately has a reduced shelf life and may have a delay in arriving to the patient for transfusion.

Leukoreduction

What is leukoreduction?

Removal of leukocytes from the red cell product.

Why is it important?

These cells are present due to co-purification and do not provide any known benefit to the recipient and can potentially cause immunological mediated effects, infectious disease transmission, and repercussion injury. Some countries require universal leukoreduction of cellular blood components (RBCs and platelets), but this is not mandatory in the United States.

Who should get leukoreduced blood?

• If cost wasn’t a factor, EVERYONE should get leukoreduced blood!

• Patient’s that suffer from frequent febrile nonhemolytic transfusion reactions, especially if fever in these patients (e.g. immunocomprised) necessitates inpatient evaluation for occult infection

• Patient’s awaiting organ or bone marrow transplantation and have a history of platelet refractoriness caused by Human leukocyte antigen (HLA) alloimmunization

• Decrease the risk of postoperative infection and occult bacterial contamination

• Patient’s with cardiac injury to prevent reperfusion injury

Additional Considerations

They have no role in preventing ta-GVHD.

CMV-Seronegative Red Cells

What are they?

RBC components that test negative for the presence of CMV using serologic methods (antibody testing).

Why is it important?

Certain immunocompromised individuals who are themselves CMV-negative may be at risk for serious infection if they receive a CMV-positive unit of blood. 

Who should get CMV-seronegative blood?

• Solid organ transplant recipients

• Hematopoietic stem cell transplant (HCT) recipients

• Low birth weight neonates

• Individuals infected with HIV

• Pregnant women

References

https://www.uptodate.com/contents/practical-aspects-of-red-blood-cell-transfusion-in-adults-storage-processing-modifications-and-infusion?search=irradiated%20blood%20products&sectionRank=1&usage_type=default&anchor=H15&source=machineLearning&selectedTitle=1~150&display_rank=1#H2822609644

POTD: Esophageal Disorders

Question:

An elderly male comes to the ED with worsening epigastric and retrosternal chest pain, nausea, and forceful vomiting after eating some spicy food and consuming a small amount of alcohol with dinner. The most recent episode included a small amount of bright red blood.  The pain has progressively worsened, and he now has pain while swallowing and mild shortness of breath.  The patient has had dyspeptic symptoms in the past, which he self-treated with over-the-counter antacids.  He does not use tobacco or illicit drugs.  He appears pale, diaphoretic, and in moderate distress.  Temperature is 38 C (100.4 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 24/min.  Neck veins are flat.  Dullness to percussion and decreased breath sounds are present over the left basal area.  Abdominal examination reveals epigastric tenderness and decreased bowel sounds.  Stool occult blood is positive.  Upright chest x-ray reveals a small pleural effusion of the left lung, and ECG shows sinus tachycardia; the imaging results are otherwise unremarkable.

Which of the following is the most likely cause of this patient's current condition?

A) aspiration pneumonitis

B) erosive esophagitis

C) esophageal perforation

D) mallory-weiss syndrome

E) perforated gastric ulcer

The answer is (c). Vomiting + bleeding = mallory-weiss, but vomiting + PAIN + L pleural effusion = Boerhaave’s. Boerhaave’s can lead to mediastinitis (from gastric contents entering sterile sites) and lead to a left pleural effusion with accompanied pneumomediastinum. Fever can take >4 hours to develop. Mortality from mediastinis can double if not properly treated within 24 hours of diagnosis. Make sure to start broad spectrum antibiotics and obtain an emergent thoracic surgery consult!

Why L sided pleural effusion?

The mid esophagus lies next to the right pleura while the lower esophagus abuts the left pleura. Rupture occurs most commonly in the left posterolateral wall of the distal third of the esophagus with extension into the left pleural cavity.

References:

UWorld.com

Inservicetrainingprep.com

POTD - Trauma Tuesday - Pregnant trauma

Trauma in the pregnant patient 

Considerations:

- What's good for mommy is good for baby!! Resuscitate mom!

- Viable fetus typically at 23-24 weeks (fundus above level of umbilicus)

- Trauma incidence in up to 7% of pregnancies

- leading cause of death in reproductive females

- leading non-obstetrics cause of death in pregnant women

Assess ABCDEs first like every trauma!!!

Airway considerations -  prepare for difficult intubation (increased soft tissue edema, larger breasts, weight gain, increased aspiration risk)

Breathing - increased basal O2 requirement, fetus highly sensitive to maternal hypoxia (aim to keep Sp02 above 95%), Chest tube placement if indicated should be 1-2 intercostal spaces higher (almost in the axilla!!! a gravid uterus pushes everything superiorly)

Circulation - fluid and bloods as per ATLS, Placenta highly sensitive to vasopressors (be careful regarding placental ischemia), IVC compression from a gravid uterus can decreased CO by 30% --> decompress IVC by rolling patient to LL decubitus or just towards left side.  Defibrillation of mother has small fetal risks (mother being dead is a higher risk to the fetus).  

Complications:
Uterine Rupture:  typically 2/2 direct abdominal trauma during 2nd half of pregnancy, Sx: maternal shock, abdominal distention/peritoneal signs, abnormal uterine contour on palpation, abnormal fetal lie, palpable fetal parts, fetal ascent, abnormal fHR tracing

Placental Abruption: most common cause of fetal demise in blunt trauma to pregnant mother, U/S not sensitive for this pathology, Sx: abdominal pain, uterine tenderness to palpation, vaginal bleeding (in up to 70%, may be absent if bleeding into retroperitoneum), uterine tonicity or contractions, fetal distress on monitor (decels, loss of variability).

Preterm Labor: 2x risk of preterm labor after trauma

Labs: CBC, BMP, T and S, d-dimer, fibrinogen, coags, Rh factor

Imaging: FAST, further imaging as indicated by injuries/suspicion of clinician.  Imaging should not be delayed or deferred 2/2 concern for fetal radiation exposure in the trauma setting!!!!  

If mom is stable, fetal monitoring/tocometry!  think VEAL CHOP (variable = cord compression, early = head compression, accelerations = okay, Late = placental insufficiency.

Treatment Dispo:

- Nonviable fetus (less than 23-24 weeks of age, fundus below umbilicus) - treat as standard trauma patient, consider RhoGam 50 mcg for Rh negative patient to prevent alloimmunization 

- Viable fetus (greater than 24ish weeks old) - consider RhoGam 300 mcg in Rh negative patient.  Avoid pressors which can compromise uterine and placental bloodflow and secondarily fetal SpO2.  Decreased pressure on IVF --> left lower decubitus position or roll patient 30% to left (like on a backboard if C-spine immobilized).  Tocometry monitoring 4-6 hours if no further risk factors of fetal loss.  Toco monitoring x 24 hours + if risk factors for fetal loss/placental abruption exist.

This leads me into the reason for this email:  The resuscitative hysterotomy, formerly called the perimortem C-section, but name recently changed to reflect that this procedure is good for both mother and fetus!  Potentially life saving for both as it decreases some burdens of pregnancy on maternal circulation, volume status, respiratory status, as well as it makes the newly delivered infant accessible for resuscitation, medication/fluid/blood administration, CPR, etc.  A fetus inside a mother is much harder to resuscitate.  

- Best outcome when performed within 4 minutes of Cardiac Arrest. (this patient is already dead at this point, you cannot make them worse, it is time to throw the kitchen sink)

- only attempt if gestation age is known at or above 24 weeks or if uterus appears gravid enough (fundal height above umbilicus).  

- Bare minimum supplies necessary: prep stick, Scalpel, Large scissors, hemostat, sterile gauze and then hopefully a close by OR, OB surgeon (to put patient back together again), Pediatrics to resuscitate the fetus and ICU/trauma ICU setting for patient if they make it.  A c-section or abdominal ex-lap tray is available in many ERs, and a emergency thoracotomy kit (in most EDs) will have most necessary tools.  Suction, sterile garb and copious betadine also helpful.  

I highly recommend watching some videos (Scott Weingart's: https://vimeo.com/59516684) as attached below but here are very basic steps:

1. Widely cleanse the entire abdomen with betadine (betadine bath)

2. midline vertical incision using scalpel from xiphoid to pubis

3. Sharp or blunt dissection through anterior abdominal wall until abdominal cavity is entered

4. retract abdominal walls laterally and bladder inferiorly to expose uterus

5. Make small vertical incision at uterine fundus, insert two fingers to and lift uterus wall away from fetus

6. use scissors to extend incision to the anterior reflection of the bladder, if encounter an anterior placenta, incise directly through it sharply.  Be careful to avoid major vessels laterally.

7. Manually grasp and deliver fetus from uterus

8. Clamp and cut umbilical cord and hand off infant to Peds/NICU/2nd provider

9. Remove placenta with gentle traction.  Do not yank.  

10. Closure depending on maternal response to resuscitation.  Closure should occur in the OR.

Remember everybody that this is all occurring during CPR!!!  Keep those compressions going throughout, but efficacy of CPR should improve if this procedure is successful.

Sources:

https://coreem.net/core/peri-mortem-c-section/

https://wikem.org/wiki/Trauma_in_pregnancy

https://wikem.org/wiki/Resuscitative_hysterotomy

https://lifeinthefastlane.com/ccc/perimortem-caesarian-section/

http://emcrit.org/emcrit/peri-mortem-c-section/