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  1. 1. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Table of ContentsWebcis Access 2Blood Bank & Apheresis rotation: Outline 2Blood Bank & Apheresis rotation: Resident Responsibilities 3Blood Bank & Apheresis rotation: On Call 4Blood Bank & Apheresis rotation: Miscellaneous 6Blood Bank Call Documentation 7Blood Product Preparation 10Transfusion Reaction Work-up 11Transfusion Audit criteria: Platelets 13Transfusion Audit criteria: FFP 14Transfusion Audit criteria: Cryoprecipitate 15Rh (D)+ pRBC transfusion in Rh (D)- patients 16Coagulation Factor Concentrates 16Activated Factor VII (Novoseven) 17Rh Immune globulin administration: ITP & Obstetric patients 19Apheresis: Nursing Schedule/Coral Nursing Contact Information 21Apheresis: Indications and Evaluation 21Apheresis: Complications 23Apheresis: Medications Used 24Apheresis: Common Procedures 25Peripheral Blood Stem Cell Harvest: Utility of the Sysmex HPC parameter 28Core Laboratory & Other Laboratory Services 31 Protocols/GuidelinesIndications for CMV-Neg Blood product transfusion 33Indications for Granulocyte transfusion 35Definition & Indications for work-up of Platelet refractoriness 36Massive Transfusion: ABO-non identical Solid Organ transplant in AB recipients 37Bld Transfusion: ABO/Rh(D) non-identical BMT/HSCT 37Anti-A/B Titration & Bld Transfusion: ABO Incompatible Kidney Transplantation 39Anti-A/B Titration & Bld Transfusion: ABO Incompatible Heart Transplantation 42Anti-A/B Titration & Bld Transfusion: ABO Incompatible Liver Transplantation 46 FormsApheresis Checklist 49Retrospective Red Cell Audit 50Anti-A/B Titer Request 51Granulocyte Request 52Platelet Refractoriness Work-Up form 53 MiscellaneousCUMC Clinical Pathology/Blood Bank/Apheresis Internet Resources 54Phone numbers: Patient Floors 57Phone Numbers: Pathology Dept and Operating Rooms 59 1
  2. 2. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York GETTING WebCIS COMPUTER ACCESS FROM HOSPITAL AND HOME:To get Access in Hospital: See Gwen White at 5-1938 in VC 5-570 for WebCIS access (call ahead)To get Access from Home: 1. Install VPN Network on home computer (virtual network from home) by going to "Hospital and Departmental Resources" on the WebCIS homepage, then scroll to bottom and click on "VPN" and follow the instructions for installing the software. The VPN software is already installed on the CP Call Laptop Computer and can be used for home access to the internet. 2. See Gwen White at 5-1938 in VC 5-570 for SecurID Card (call ahead). Blood Bank & Apheresis Rotation OutlineSchedule • The Blood Bank (BB) resident and NYBC fellow (when rotating at CUMC) will divide the service, such that one is covering component calls (pager: 8-5838) immunohematology, and transfusion reactions for 2 weeks, while the other is covering therapeutic apheresis/stem cell processing (pager: 8-2754) for 2 weeks, and then switch responsibilities every 2 weeks. • If the BB Resident is alone on the rotation, he/she will cover both components of the service (component calls, immunohematology, and transfusion reactions AND therapeutic apheresis/stem cell processing). If the services are both busy, the BB resident will deal with the most emergent issues first. • Weekly Conference Schedule: Monday 10:00am: CP Call Conference (HP4-415) 4:30pm: CP Sign-out Conference (HP4-415) Tuesday 10am: CP Call Conference (HP4-415) 12:30pm: CP Journal Club/Special Topics Conference (PH3-329) 4:30pm: CP Sign-out Conference (HP4-415) Wednesday 10am: CP Call Conference (HP4-415) 4:30pm: CP Sign-out Conference (HP4-415) Thursday 9-11am: Hematology-Oncology Rounds (Milstein 5GS) 10am: CP Call Conference (HP4-415) 3:30pm: Transfusion Medicine Case of the Week (HP4-415) 4:30pm: CP Sign-out Conference (HP4-415) Friday 10am: CP Call Conference (HP4-415) 12:30pm: CP Didactic Conference (PH3-329) 4:30pm: CP Sign-out Conference (HP4-415) ** The resident is expected to be onsite from 8:30 AM- 5:00 PM** 2
  3. 3. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Blood Bank: COMPONENT Resident Responsibilities 1. Enter ALL component calls in components computer. 2. Enter ALL ongoing component calls below in preparation for daily sign-out at 4:30 PM (i.e. OR cases, factor deficient patients receiving factors, etc) 3. Prepare the following for the daily morning CP Call Conference: a. Patient list with current patients with recurring issues on component call or apheresis b. OR cases of interest (i.e. Pay attention to the high volume component users: LVAD, open heart surgery, liver and heart transplants. Also be aware of patients with interesting antibodies, transplant cases) c. Review the cases from the previous night that did not meet our criteria and are logged into the Laptop by the on-call resident. These cases should be worked up and presented at the morning conference. In addition, if there is enough time prior to conference, the BB Resident/fellow should review the cases in which products were released between 11pm and 8am, when the resident is not called for approval. These cases should be retrospectively reviewed and presented at the morning call conference. 4. Record emergency component releases below and also save information to separate “Emergency Component Releases” word document. When going off service, this document should be passed on to the new component resident. 5. Review and record the daily inventory (pRBCs & platelets) in the afternoon in preparation for daily sign-out at 4:30PM. 6. Enter information for transfusion reactions that have occurred below (name, MRN, type of reaction, and if patient is ok to receive more products). 7. Enter ALL transfusion reactions in the components computer. 8. Ensure that the “Transfusion Reaction Preliminary Report Form” for transfusion reactions from overnight and the day shift have been submitted to a supervisor. 9. For transfusion reactions that occurred at the Allen Pavilion the “Transfusion Reaction Preliminary Form” should be given to Dawn so that it can be sent by courier to the Allen Blood Bank Supervisor (Lucille Vizcayno). 10. Ensure that all transfusion reactions are entered into COPATH by the resident who took the call, regardless of whether the call was from overnight or the day shift. 11. It is the responsibility of the Pathology resident who is on the blood bank rotation and covering components to ensure that all transfusion reactions are entered into COPATH. 12. Complete the weekly “Retrospective Red Cell Audit”. “Retrospective Red Cell Audit” should be reviewed with the attending at Friday morning 10 AM rounds. 13. Back up components database once every week on USB drive (with Dawn). Please return USB drive to Dawn once it is backed up. 14. The NYBC Fellow and the Blood Bank resident on service will divide up the weeks appropriately to present at the weekly “Transfusion Medicine Case of the Week” Conference at 3:30 PM on Thursday afternoons. The case can be presented with handouts, powerpoint, or simply by verbal presentation.END OF DAY CHECKLISTHave you?[] entered ongoing component calls?[] reviewed and updated the inventory?[] recorded emergency component releases?[] followed up transfusion reaction paperwork?[] updated the “Retrospective Red Cell Audit”? 3
  4. 4. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Blood Bank: APHERESIS Resident Responsibilities 1. Maintain daily apheresis list. 2. Complete the “apheresis checklist” for each new patient. 3. Ensure that patient labs have been drawn, resulted, and reviewed, and that the patient has been examined prior to apheresis. Inform your TM attending when the procedure has begun so that the patient can be seen during apheresis. 4. The rotating resident should check with the Hemotherapy unit to check if there will be any cases after 5PM. If the apheresis cases are not completed, you are expected to be in the HP4/Blood Bank area until all cases are finished. Also have the names and procedures for the following day prepared for sign-out at 4:30 PM. 5. When going off service, the schedule for the following Monday must be ready for Friday sign-out at 4:30 PM and should be passed on to the new apheresis resident. 6. The apheresis list for the weekend must be ready for Friday sign-out at 4:30 PM. 7. Copath note should be entered within 24 hours of the procedure.END OF DAY CHECKLISTDo you?[] have the information for patients whose procedures are not completed today?[] have the information for tomorrow’s/weekend patients?[] have entered pending apheresis copath notes? Blood Bank: SUPERVISING Resident Responsibilities 1. Ensure that the apheresis and component residents are aware of their responsibilities. 2. Assist apheresis resident with writing orders. 3. Assist apheresis and component residents with working up advanced/complex component and apheresis issues. 4. Ensure that components are ordered for procedures for the next day/weekend. 5. Review daily component calls and determine what calls are appropriate/necessary for 4:30 PM sign-out. 6. Ensure that component and apheresis residents are prepared for sign-out at 4:30 PM. ON-CALL Responsibilities 1. The on-call resident or fellow covers both pagers (8-5838 and 8-2754) during off hours (5:00 PM- 8:30 AM/Weekends/Holidays). 2. Weeknight call starts at 5 PM and ends at 8:30 AM the following day. The resident on call is responsible for signing the pager over in the evening and the day resident is responsible for signing the pager over in the morning. 3. Weekend call begins at 5 PM on Friday, continues through Saturday and Sunday, and ends at 8:30 AM on Monday morning. 4. Routine Blood Bank audit calls end at 11 PM. However, you will be called after 11 PM for the other blood bank issues. For example, transfusion reactions, request for washed cells, emergent apheresis, blood type switching and other consultation will be referred to the resident when needed regardless of time. 4
  5. 5. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York5. Therefore, your beeper should be kept ‘ON” and carried with you even after 11 PM when you are on call. The resident must sign out the pager by calling the operator (at 212-305-2323 or by logging on to the online paging website) if in the autopsy suite or an area where you cannot be paged.6. The BB Resident/fellow who is on-call is responsible for covering the Blood Bank and Apheresis/Stem Cell Processing Services at CUMC and the Blood Bank at the Allen Pavilion (the contact person at the Allen Pavilion is Charlotte or Freda (212) 932-4235 or extension 4-4235.7. The BB Resident/fellow on call for the weekend will be responsible for preparing weekend cases for presentation at the Blood bank morning conference at 9:30 AM on Monday. During the week, if the on-call BB Resident has other clinical responsibilities, they may sign out the cases to the BB Resident/fellow covering during the day by 9am, so that the BB Resident/fellow has the information ready to present at the morning call conference. However, if there are no conflicting clinical responsibilities, the on-call BB Resident is expected to attend and present their cases.8. The faculty members in transfusion medicine and laboratory medicine provide appropriate attending back up. 5
  6. 6. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York MiscellaneousAnswer all of the Blood Bank pages within ten minutes of receiving the page. All decisions shouldbe made and conveyed to the laboratory within twenty minutes. • If a decision or action will be delayed for longer than twenty minutes, it may be useful to call the Blood Bank and inform them of your plan and approximately when you will finalize a decision. This step in communication will help the laboratory staff communicate with the nurses and physicians, who are often requesting the blood multiple times while the resident investigates the appropriateness of the request. The product will not be released without the resident’s approval.The “Ten minute rule”If you are traveling, can’t get go to a phone (e.g. subway), or if you are too busy to answer thecall, the blood bank will release the product according to the “ten minute rule.”If the blood bank does not hear from you within ten minutes, they will release the components • If you are traveling from CPMC to home, I would recommend the following:  Call the Blood Bank Front Desk and let them know you will be traveling home.  Keep your pager on so that you are aware of any Blood Bank activity (a cell phone is helpful if you can troubleshoot over the phone, but a cellular phone is not required).  Call the blood bank front desk when you get home to learn of any pending problems and to check whether components were released according to the “ten- minute” rule. A retrospective review of the released components should be made if components were released. • If you are sick or unable to cover the service that you are expected to cover, first make an effort to approach another resident to arrange coverage for the time that you will not be available. If this period of time is going to be lengthy, please contact the Chief Resident in Clinical Pathology or the attending in charge of your rotation. It is irresponsible and inexcusable to leave a service uncovered by a resident physician without properly arranging coverage or notifying the attending of the service.A log book of all transfusion requests is kept at the front desk.A Communication log book (black & white marble notebook) is also kept at the front desk. Youcan write a telephone number where you can be reached, log in requests to the New York BloodCenter, and write standing orders.The residents keep a log of calls in the CP Laptop Computer as a legal document of the callsreceived. All calls made to you should be entered in this database. Often, this is the onlydocumentation of the process behind our decisions.The laptop should be handed off during sign-out to the On-Call resident and then back to the dayresident.If you have a problem with a technician, clinician or other hospital staff, document the problem byoutlining the events. Report the problem to the Chief Resident, attending or BB supervisor. 6
  7. 7. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Blood Bank Resident/Fellow Documentation for Component Calls  The vast majority of calls you will receive will be from the blood bank front desk and will be concerning the requests by physicians at the medical center for platelets or plasma products (FFP, cryoprecipitate or coagulation factor concentrates). o Our blood bank has a policy of screening the use of these components using a set of transfusion audit guidelines, or “triggers.”  For example, our trigger for allowing the tech at the front desk to release a dose of platelets to a bleeding patient is a platelet count of less than 50. If the platelet count is 50 or above, the tech will page you and ask for your approval to release the product.  A set of audit criteria is shown later in this guide.When you speak with the tech at the front desk, document the following information in the CPLaptop Computer: o Time of Page o Patient Name o Patient Medical Record Number o Patient Location o Name of the requesting physician o Beeper Number of requesting physician o Type and amount of product requested o Brief, concise, relevant clinical history o Relevant lab values and blood type o Presence or absence of bleeding (the source of the bleeding, if patient is bleeding) o If and when the patient is scheduled for surgery or an invasive procedure. o It may be useful to find out what medications the patient is taking (e.g. effect on platelet function), if the patient is on antiplatelet agents (aspirin, Reopro), if the patient had received vitamin K yet, or if the patient is receiving UFH or LMH.  After getting the relevant information, lookup the patient’s history and other clinical information on WebCIS or call the physician requesting the product and gather the relevant clinical information and laboratory values.  Blood type, antibody workups and transfusion history can be obtained online through CoPath, Wyndgate, and Webcis.  If you do not have access to a computer at home, you may get laboratory information from the front desk technicians. However, please be aware that they are often overworked and can’t help you do an extensive laboratory lookup. However, they should provide most of the information you need to make a decision. If you need additional laboratory information, call the Core Lab and ask the technicians or the supervisor to help you.  A decision should then be made as to the appropriateness of the product requested. o If you agree with the request, APPROVE the products by calling the lab back and letting them know. Document this in the on call laptop. o If you disagree with the indication for the components, then discuss with the requesting physician and explain why. 7
  8. 8. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York  If you can convince them of your plan for transfusion, then call the desk and tell them that the products are NOT APPROVED. Often, we make alternative products or amounts available. If you are not sure of the appropriateness or if the requesting physician does not agree withyour plan for transfusion, then involve the attending on call. You are encouraged to request or even add on additional tests to clarify the clinical situation.A fibrinogen level, D-dimer assay, or a mixing study can go a long way in choosing the correctproducts. You can add on tests by calling the Core Lab at 5-2732 or paging the shift supervisorat #86859. You are also encouraged to see the patient at the bedside and review the chart. Assessingbleeding yourself can give you a good feel for the clinical situation and communicates to theclinician that you are interested and willing to invest time into the case. o If you disagree with the indication for the components, then there are a few options: 1. Call the attending on-call and discuss the case with them. If the attending refuses to release the product, notify the requesting physician and explain the reasoning and let them know that your attending is willing to speak with them about the case. Notify the front desk that the product is NOT APPROVED. 2. Alternatively, if the attending decides to release the product, you should tell the blood bank to release the product with or without our approval. - If you release without approval (when the clinician really insists on having the product against the blood bank recommendations), subsequent review by the hospital’s transfusion committee will take place (this is the so-called “level 3 review”). Format for Resident Blood Bank Laptop Entry 1. Date and Time of Page 2. Date and Time of Event Occurrence (if applicable) 3. Name and Medical Record Number of Patient 4. Patient Location 5. Name and contact number of treating physician 6. Brief Clinical History 7. Statement of Problem a. Request for products not meeting audit criteria b. Request for special products or procedures c. Difficult crossmatch or irregular antibodies d. Authorization for deviation from normal procedure (e.g. Rh conversion) 8. Pertinent laboratory and other ancillary data 9. Documentation of Discussion with treating physician 10. Recommendations made and plans for additional investigation 11. Final action taken 12. Follow-up information on additional investigations or clinical outcome. 13. Indicate whether the case was discussed with a particular attending and record their name.Example: 8
  9. 9. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkFollow and Complete all fields in the “Blood Bank Entry Form” on the Access Database on the CPCall Laptop Computer. In the history field, your note may look something like the following:40 year old woman with Hepatitis C cirrhosis admitted today for abdominal pain and ascites. Arequest for 4 FFP was made with a PT 16.4. The patient is not bleeding and is scheduled to haveparacentesis today. Other relevant data include Hgb 10, Plts 80,000, PTT 32, fibrinogen 220. Ispoke with Dr. Smith who says that he would feel more comfortable with a PT in the normalrange. I explained that a PT corresponded to adequate levels of coagulation factors. In addition,the patient would be given approximately a liter of fluid, addition a risk of volume overload.However, he insisted on the product. After speaking with Dr. J. Fink, I emphasized the bloodbank position and Dr. Smith agreed to proceed without the products, but will call immediately ifthe patient runs into any bleeding problems. The 4 FFP were NOT APPROVED. This case wasdiscussed with Dr. Kaplan at 11pm. 9
  10. 10. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Blood: Time for Testing & Preparation:Prior to blood issue, the blood bank performs a serological work-up (see Chapter 15 of theTechnical Manual 16th ed). This work-up can be relatively quick (15-30 minutes) or can take muchlonger. The table below is meant to be used as a general guide on the minimum time requirementfor testing/procuring blood. Time pRBC product Available <5 minutes Group O, Uncrossmatched 15 min after blood ABO-group specific, arrives in BB Uncrossmatched 1 hr (Stat) or 4 hrs ABO-group specific, (Routine) after blood crossmatched (Neg arrives in BB Antibody screen) Several hours ABO group-specific, antigen-negative, crossmatched in a patient with antibodiesOther Blood Products: 30 min 10 units Cryoprecipitate 10 min (if previously 4-6 units FFP thawed); 30 min to thaw 10 min (non-aliquoted) 6 units (1 apheresis) 30 min (aliquoted) PlateletsIn cases of emergency requests (for uncrossmatched blood), the requesting MD will have to sign theemergency blood release form at the BB front desk. 10
  11. 11. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Transfusion Reaction Workup ***FILL OUT THE PRELIMINARY TRANSFUSION REACTION FORM AND GIVE IT TO A BB SUPERVISOR RIGHT AWAY*** ***TRANSFUISON REACTION NOTE SHOULD BE IN COPATH WITHIN 48 HRS OF RESIDENT BEING PAGED ABOUT THE REACTION*** ***TRANSFUSION REACTION PAPERWORK CANNOT BE TAKEN OUT OF THE TM OFFICE (MAKE PHOTOCOPIES IF NEEDED)***• The blood bank front desk will notify you of reported transfusion reactions after the initial workup has been completed (i.e. DAT, clerical check, and visual check for hemolysis).• Document the following information in the log book when you receive the call: o Patient Name o Medical record number o Blood type o Type of product that was transfused (e.g. Leukofiltered, packed red cells) o Amount transfused o Patient’s symptoms o Timing of symptoms with transfusion o Pre and Post vital signs o Results of our laboratory workup o Clerical check, DAT from pre- and post-transfusion patient blood samples, Hemoglobinemia on pre and post-transfusion blood samples, Urine Sample for hemoglobinuria o Premedication given o Therapy initiated after the reaction and the follow-up information about the effect of the therapy• Call the floor and speak with the nurse or doctor reporting the reaction. Obtain a medical history, transfusion history (prior pregnancy and transfusions, irregular antibodies), and the events leading to the suspected transfusion reaction. A template for this purpose can be found on the Transfusion Medicine section of our CP website. Make sure they send the bags of component, transfusion slips, transfusion reaction report forms, and a post- transfusion blood sample and urine to the blood bank for work up, if they have not already done so. You are also encouraged to see the patient at the bedside and review the chart. This will give you a good feel for the clinical situation and communicates to the patient and the clinician that you are interested and willing to invest time into the case.• Try to come up with a diagnosis based on the information you have gathered, and use your clinical judgment. The most important thing is to rule out an acute hemolytic transfusion reaction. Decide if it is worthwhile to culture the units. If you believe that there may have been an acute hemolytic transfusion reaction (e.g. transfusion of ABO- incompatible RBC), contact your attending.• Interpretation and recommendations can be reserved until all laboratory testing is complete and the case has been review with an attending. In general, an extensive recommendation on treatment is not warranted at the time of the workup. In most cases, however, the clinician will want to know whether the additional units of red cells or other component can be infused.• The transfusion reaction documentation should be put in the CP Call Laptop Computer and printed for the following morning’s conference with all the required information. At 11
  12. 12. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York the conference, the case can be discussed and reviewed. After presenting the transfusion reaction, give Dawn the information so that she can accession the case in CoPath and type in the note that you have printed from the CP Call Laptop Computer.Transfusion Reaction Flowchart 12
  13. 13. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York 13
  14. 14. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkTransfusion Audit Criteria for Platelet Concentrates A. Transfusion without reference to platelet count o Massive transfusion (> one blood volume in < six hours) B. Platelet count < 100 x109 and: o Baby on ECMO o Intracranial hemorrhage o Scheduled for neurosurgery o Pulmonary hemorrhage C. Platelet count < 50 x109 and: o Active bleeding o Scheduled for imminent surgery o Scheduled for invasive procedure (central venous line, Swan-Ganz catheter, biopsy, lumber puncture, bronchoscopy, laryngoscopy) o Premature infants at risk for intracranial hemorrhage o Neonate (0-28 days) with ongoing bleeding D. Platelet count < 15 x109 All patients except those with: o Autoimmune thrombocytopenic purpura o Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome 14
  15. 15. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkTransfusion Audit Criteria for Fresh Frozen Plasma A. Transfusion without reference to laboratory tests o Thrombotic thrombocytopenic purpura/Hemolytic uremic syndrome o Massive transfusion (> one blood volume in < six hours) o Known factor XIII deficiency with active bleeding B. Moderately prolonged PT (> 20 sec) and: o Active bleeding o Scheduled for imminent surgery (< 4hrs) o Scheduled for invasive procedure (central venous line, Swan-Ganz, biopsy, lumber puncture, bronchoscopy, laryngoscopy) C. Severely prolonged PT (>45 sec, INR>5) and: o All patients D. Prolonged PTT (>55 sec), known history of factor deficiency, and: o Active bleeding o Imminent surgery or other invasive procedureCoagulation Screening Tests: Results and Factor Levels Activity (%) PT INR PTT 100 13.0 0.95 29.0 50 16.5 1.28 44.2 40 18.8 1.52 54.2 30 21.6 1.82 74.2 20 28.6 2.63 117.3 10 >50 >180 15
  16. 16. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkTransfusion Audit Criteria for Cryoprecipitate A. Transfusion without reference to laboratory tests o Production of fibrin glue o Known factor XIII deficiency with active bleeding or scheduled surgical/invasive procedure o Uremic bleeding refractory to DDAVP and dialysis B. Hypofibrinogenemia (fibrinogen < 100 mg/dl) and: o Active bleeding o Scheduled for imminent surgery (< 4 hrs) o Scheduled for invasive procedure (central venous line, Swan-Ganz catheter, biopsy, lumber puncture, bronchoscopy, laryngoscopy) C. Fibrinogen < 40 mg/dl o All patients 16
  17. 17. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Transfusing D+ pRBCs in D- patientsYou will be paged by the blood bank when a Rh(D)-Neg patient needs blood at a time of limited Rh(D)-Neg inventory. These tend to occur more during the summer months and Dec-Jan when there aresystem-wide blood shortages. These are treated on a case-by-case basis taking into consideration thepatient’s age, sex, clinical condition, anticipated future blood transfusion needs and our D- inventory.Discuss the case with your TM attending and the patient’s physician. Be sure to discuss the future riskof sensitization. See page 20 for the dosage protocol for females exposed to Rh+ platelet products. Coagulation factor concentratesThe resident will be paged by the blood bank for clotting factor requests to ensure that the patient isreceiving the appropriate product at the proper dose. The severity of an acute bleed will determine thetarget plasma level of the relevant clotting factor. These patients should also have a hematologyconsult. Look up our special heme/coag lab work-up for factor and inhibitor levels, if any. It is alsoimportant to discuss factor inventory with the blood bank supervisor/manager, especially if the patientwill require treatment over the several days.The CUMC nursing manual discusses how coagulation factor concentrates/blood derivativesshould be administered (essentially, it directs the nurse to follow directions from the packageinsert). A copy of this nursing manual can be found here.Commonly used Factor concentrates (see page 54 for links to package inserts of commonly usedproducts): a) Factor VIII: In the absence of an inhibitor, an easy to remember rule of thumb: Factor VIII levels will increase 2% for every 1 unit/kg infused. Assuming a starting plasma level of 0%, a 100% factor VIII level can be achieved by giving a 50 IU/kg IV bolus. The maintenance dose is half the loading dose and is dosed q12 hours. The severity of bleeding/ invasive procedure will determine the target levels to be achieved. Typically, targets for mild, moderate and severe hemorrhage are 30%, 30-50% and 80-100% respectively. Both recombinant and plasma derived factor VIII are stocked in the blood bank. b) Factor IX: Factor IX has somewhat different pharmacokinetic properties (increased extravascular distribution) and half-life than factor VIII. In the absence of an inhibitor, an easy to remember rule of thumb: Factor IX levels will increase 1% for every 1 unit/kg infused. Assuming a starting plasma level of 0%, a 100% factor IX level can be achieved by giving a 100 IU/kg IV bolus. The maintenance dose is half the loading dose and is dosed q24 hours. Target factor percentages for mild, moderate and severe hemorrhage are similar to those for Factor VIII. Both recombinant and plasma derived factor IX are stocked in the blood bank. c) Von Willebrand factor/Antihemophilic Factor complex: Humate P is used for the treatment of von willebrand disease. Note that Humate P vials are actually labeled with both von Willebrand Factor units and Factor VIII units (~ 2:1 vWF: fVIII; exact levels vary by lot). Loading dose is typically 40-60 units/kg and Humate P is dosed q8-12 hours. d) Patients with inhibitors: Very infrequently you may encounter a patient with factor inhibitors. Most of these patients have inhibitors to factor VIII. A few options including FEIBA (Factor VIII 17
  18. 18. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York inhibitor bypass activity) and activated Factor VII (Novoseven) are available. Use of these drugs occurs typically with the level of inhibitors >5-10 Bethesda Units. Discuss dosing with the TM attending and hematology fellow/attending (see below for more information on activated Factor VII). Activated Factor VII (Novoseven) Typical indication to be met and discussions to be had: • Severe uncontrolled bleeding despite transfusion of 2 rounds of routine components (6U plts, 6U FFP, 10U Cryo x2 and pRBCs). Note that novoseven will not help arrest a purely surgical bleed. • A hematology consult is required in non-emergent situations. • Discuss prothrombotic risks of Novoseven. This is particularly relevant in patients with CAD, h/o thrombosis, ECMO/VAD, DIC/Obstetric patients. Make sure that the requesting MD understands and accepts these risks and document this in the on call computer. • Recommend correction of acidosis if pH<7.2. • Encourage continued transfusion of blood products so that there is enough substrate to form a clot • Follow up on patient status after novoseven administration. Evaluate bleeding/number of blood products used. PT should correct with FVIIa.  General Dosing Guidelines (Refer to Flowchart below for more details) • SEVERE UNCONTROLLED BLEEDING: - 35-90 mcg/kg • CONGENITAL FACTOR VII DEFICIENCY: - 15-30 mcg/kg • BLEEDING IN A PATIENT WITH FACTOR VIII OR IX INHIBITOR: - 90 mcg/kg. q2 hours until hemostasis is achievedNovoseven has an in vivo half life is 2-3 hours. Bloodbank supplies vials of 1.0, 2.0 and 5.0 mg. 18
  19. 19. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Treatment Guidelines For The Use of Recombinant Factor VIIa Bleeding Patient Known Documented Factor VIIa Severe bleed Congenital (by CT/MRI)90-120 µg/kg YES hemophiliac with NO TIME secondary to trauma? VII an inhibitor or FOR Intracranialq 2-3 hrs until STANDARD High risk for ICH? Deficiency. - known acquired THERAPY Factor VIIa hemorrhage hemostasis, FVIII, IX, X, XI Liver failure? Need for within prior 6 then titrate invasive monitoring? 20 µg/kg inhibitor hrs Life threatening NO bleed? -Platelets Quantitative/ TIME FOR -DDAVP RESPONSE TO Factor VIIa known -Amicar YES STANDARD 80 µg/kg x 1 qualitative THERAPY -Dialysis dose platelet (uremia) -FFP disorder? -Cryo -Cryo -Platelets NO NO RESPONSE -RBC -Fluids Factor VIIa 35-90 µg/kg Prolongedq 2-3 hrs until INR (>5.0) hemostasis, requiring rapid NO RESPONSE. then titrate reversal? (And no identifiable RESPONSE. surgical source of Appropriate bleed). Factor VIIa 35- monitoring 90 µg/kg. If no hemostasis in 1 hr, (PTT, PT, INR, repeat dose x 1 and CBC) consider re-exploration. SEVERE BLEEDING. **NOTE: FACTOR VIIa SHOULD BE USED MINIMAL 1.) Vitamin K 10 mg IV or SQ WITH CAUTION IN PATIENTS WITH ANY OF BLEEDING. 2.) Factor VIIa 20-50 µg/kg THE FOLLOWING: Vitamin K 10 mg IV q 2-3 hrs until hemostasis 1.) CAD or SQ 3.) FFP 15-20 mL/kg 2.) DIC 3.) RECENT CARDIAC SURGERY 4.) H/O ARTERIAL or VENOUS THROMBOSIS 5.) CEREBRAL VASCULAR DISEASE 6.) CURRENT ECMO or VAD USE. 4-12-05 19
  20. 20. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Rh Immunoglobulin (RhIg) administrationA. Idiopathic Thrombocytopenic Purpura:A hematology consult is requiredWe use WinRho SDF to treat ITP patients (IV administration)Adult ITP dosage:50-75 ug/kg (250 – 375 IU/kg) for acute (i.e. 1st dose – can be split over 2 days)25-60 ug/kg (125 – 300 IU/kg) for subsequent dosesPediatric ITP dosage:Same as in adults. However subsequent doses are not usually needed.If hemoglobin is <10g/dL, use 25-40 ug/kg (125 – 200 IU/kg)Important Note:Patient should be Rh positive (D+) and non-splenectomizedB: Suppression of Rh isoimmunization:1. Obstetric patients:We use RhoGAM to treat obstetrical patients (IM administration)1 vial of RhoGAM= 300ug = enough RhIg to neutralize 15mL of red cells (or 30cc of whole blood).Our RhoGAM protocol: BB receives cord blood & Fetal Screen Sample from D- mother Cord blood: D+ Cord blood: D+ Cord blood: D- Fetal Screen: Neg Fetal Screen: Pos 1 RhoGAM vial 2 RhoGAM vials No further action issued issued K-B test ordered K-B results back- Additional RhoGAM issued,] if indicated (see below)The Kleihauer-Betke (K-B) test can be used to quantitate the amount of fetal-maternal bleeding.This test is based on the principle that in the presence of acid, fetal red cells will maintain normal 20
  21. 21. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New Yorkstaining characteristics whereas adult red cells will appear as “ghosts.” The number of fetal redcells present in the sample is determined by manual counting and is expressed as a percentageof the total red cells.To calculate the number of vials of Rhogam required, the following rule-of-thumb is used:# Vials RhIg required = (Maternal blood volume (in cc) x K-B%)/3000. Round-off to theclosest integer +1 vialExample: 70 Kg female; Fetal screen: Pos; K-B=0.4%# Vials RhIg required= (4900cc x 0.4%)/3000= 0.65. Round-off to 1.0 +1= 2 vials issuedThe table provided below can also be used for RhIg dosing. Dose % Fetal Cells Vials to Inject µg (mcg) IU 0.3 - 0.8 2 600 3000 0.9 - 1.4 3 900 4500 1.5 - 2.0 4 1200 6000 2.1 – 2.6 5 1500 75001. Based on maternal blood volume of 5000 cc2. 1 vial of 300 µg is needed for each 15 cc of fetal red cells or 30 cc of fetal whole bloodFrom Technical Manual, 16th Ed. Roback, JD et al.2. Rh- female patients > 4 months of age through childbearing years exposed to Rh+platelets:We use RhIG to treat Rh- patients exposed to Rh+ platelet products to suppress Rhisoimmunization. RhIG is recommended for the suppression of Rh isoimmunization in Rh(D)negative female children and female adults in their childbearing years transfused with Rh(D)+platelets. A 300 μg (1500 IU) dose will suppress the immunizing potential of approximately 17 mLof Rh(D)+ RBCs.Approximate number of RBCs in platelet products: Single Donor Platelet Unit ~ 0.5mL RBCs Apheresis Platelets (6 unit dose) ~2-3mL RBCsDosage:Administer 1 vial (300 μg) of rhogam within 72 hours after exposure to Rh(D)+ platelets. APHERESISNURSING SCHEDULE: 21
  22. 22. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York NYP-CUMC Apheresis Nursing Schedule: Monday - Friday: 9am – 9:00pm; Sunday 9am-4pm Saturday and off-hours  Must call Coral Blood Services: 800-483-4888, or 914-968-5188/5000 (Rose- Nurse Mngr), or 914-562-3020 (cell) Call attending to confirm that this is an emergency and cannot be scheduled during regular hours.What do I do when I get a call requesting Apheresis treatment? Is apheresis indicated? Elicit a detailed history from the requesting MD and assess if apheresis is the appropriate modality of treatment for the patient. The American Society for Apheresis (ASFA) has published guidelines reflecting the current thinking regarding the efficacy of apheresis for various clinical entities. Diseases are assigned to one of four categories based on available studies in the literature (ASFA 2007 guidelines): Category I: Standard acceptable therapy Category II: Sufficient evidence to suggest efficacy usually as adjunctive therapy Category III: Inconclusive evidence of efficacy or uncertain risk/benefit ratio Category IV: Lack of efficacy in controlled trials Discuss the case with your TM attending, and if the decision is made to go ahead with apheresis, discuss the following with requesting MD. **** THE RESIDENT SHOULD FILL OUT THE APHERESIS CHECKLIST FOR EVERY NEW PATIENT AND PRESENT IT TO THE ATTENDING**** 1. Referral form/Consent/Orders: Ask referring MD to fill out the apheresis Referral form. The apheresis resident should obtain an Apheresis Consent prior to initiating the procedure. Also, include a blood product consent form if FFP or pRBCs are to be used as prime or replacement fluid. You will need to order the blood product from BB. You will also need to write apheresis orders calculating exchange volumes using the Plasma exchange worksheet or RBC exchange worksheet, as appropriate. 2. Patient location: Inform referring MD that apheresis will NOT be performed in the emergency room. Patient will need a hospital bed in order for apheresis to be initiated. 3. Vascular Access: If the patient has a functional graft/fistula (used for dialysis), it may also be used for apheresis. In patients without a graft/fistula, a rigid dual lumen catheter needs to be placed to support the high flow rates (60-110 cc/min) used in automated apheresis procedures. It is important to inform the contracted apheresis nursing service on the type of access. If an internal jugular or subclavian line is placed (by a service other than IR), it needs to be radiographed prior to the procedure and a note indicating that it is OK to use for apheresis should be placed in the patient chart. Dual lumen catheters may be accessed using sterile precaution by apheresis and dialysis staff only. They may NOT be used for blood draws or to administer medications/transfusions by the floor staff. Mahurkar catheters are available in the apheresis unit at all times and on the shelf by the resident desk. Weight (Kg) Catheter Size 22
  23. 23. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York <10 7 FR MedComp 10-20 8 FR MedComp or 8 FR Mahurkar 20-50 9 FR MedComp or 10 FR Mahurkar >50 9 FR MedComp or 11.5 FR Mahurkar Adult 13.5 FR Mahurkar, Adult PermCath, Adult VasCath Transfusion Needles Pediatrics 22 gauge for kids 24 gauge for neonates/preemies Adults 16/18 gauge for high risk ante/post partum 18/20 gauge for adults (19 gauge Huber (non-coring) needle for ports)4. Request appropriate laboratory testing: The typical apheresis patient should haveCBC, BMP, iCal, Coags, Fibrinogen, Serum albumin and protein performed. Requestadditional testing when appropriate (e.g. LDH, smear review in TTP)5. Medical Evaluation: A physical exam must be done during the initial consultation afterreceiving the appropriate referral form. Correction of abnormal electrolytes (e.g. calcium),abnormal blood cell indices (e.g. Hct<25, Plt<50), should be done prior to initiatingapheresis. An interim history and physical should also be obtained prior to each therapythereafter.6. Medications: There is a higher incidence of hypotensive events associated with use ofACE inhibitors. Ideally, the patient should be off of ACE inhibitors for 24hrs prior toapheresis. Patient should be switched to a non-ACE medication for control ofhypertension as long as the patient is on apheresis treatment. In addition, there is verylimited data on drug removed by apheresis. Recommend to the requesting MD thatwhenever possible medications (esp. once daily meds) be administered post-plasmapheresis. IVIg and rituximab should always be administered post-plasmapheresis.7. Body Weight/Blood Priming: Typically, patients need to be >20 kg for RBCexchange or plasmapheresis and >10 kg for stem cell harvest. In pediatric patientspriming the apheresis set with a 1:1 pRBC-5% albumin mix should be considered whenthe extracorporeal volume exceeds 15% of the Total Body Volume. Apheresis disposableset volumes are provided below: Spectra Disposable Set Volume Set (cc) Plateletpheresis 131 cc Plasmapheresis 170 cc RBC exchange 170 cc 23 WBC set 284 cc
  24. 24. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York 8. Attending Physician Evaluation: Review patient history, physical exam, lab values, medications and treatment plan with TM on-call attending. 9. Procedure: The resident/fellow must be present in the medical center, accessible by pager, and able to return immediately to the procedure location if requested (within 5-15 minute response time) when the procedure is taking place. 10. Write consult note in CoPath: If you are on-call for the weekend and the case has not been accessioned, then write the note as a Microsoft Word document that can then be put in CoPath on the following workday.Note on electrolyte changes with plasmapheresis: Plasmapheresis is not expected tosignificantly change plasma concentrations of sodium, potassium, bicarbonate, chloride orglucose. Levels of ionized calcium and magnesium are decreased during plasmapheresis. COMPLICATIONS OF APHERESISComplications of Apheresis1. Citrate-induced hypocalcemia • Always measure ionized calcium prior to procedure because albumin-calcium complexes may falsely elevate the total calcium level • Treatment for paresthesias Calcium carbonate tablets PO and milk based products and/or Blankets and heating pads Decrease flow rate to 50-60 cc/min • Treatment for total body tingling/numbing, chills, +Chvosteks Increase WB:ACD-A ratio to 18:1 Decrease flow rate to 50-60 cc/min Stop procedure, if necessary Calcium gluconate IVP • Treatment for irregular pulse, hypotension, seizures Call attending Stop procedure Calcium gluconate IVP Saline to KVO2. Depletion of coagulation factors • Fibrinogen acts as an ideal solute and two-thirds of it is removed by 1 plasma volume exchange. Consider cryoprecipitate transfusion when fibrinogen levels are <100.3. Effects of blood component (FFP/PRBC/Cryo) infusion • Call your attending • Complications of transfusions (e.g. transfusion reaction) • Discontinue blood component and order transfusion reaction work-up4. Allergic reaction leading to anaphylaxis 24
  25. 25. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York • Call your attending • Treatment for Hives: Benadryl 25-50 mg PO Benadryl 25-50 mg in 50cc NS IVSS over 15-30 min -if <100 lbs then use 25 mg Solumedrol 125 mg in 100cc NS IVSS • Treatment if reaction continues after Benadryl or if patient starts to have pharyngeal edema, wheezing, or acute respiratory distress Epinephrine 1:1000 in 0.5cc subcutaneous, may repeat in 10-15 min5. Hemorrhage • Stop procedure • Call your attending6. Fluid Imbalance • 15% of TBV should not be exceeded in extracorporeal circulation • Treatment for vasovagal/syncopal reactions: Trendelenberg position, elevate feet/legs Cold compresses/cloths, offer bedpan, stimulate patient Expand blood volume with IV bolus of fluids (NS, crystalloid)7. Problems with vascular access • Placement associated issues- pneumothorax • Infection- culture access site if there is purulent discharge • Clotting • Extravasation/hemorrhage • Cardiac arrhythmias8. Hyperventilation/Anxiety • Offer cold compress, encourage deep slow breathing • If hypotensive, place in Trendelenberg position and give saline bolus9. Back Pain/ Bone Pain/ Abdominal Pain/ Fever • G-CSF can cause all of the above symptoms. Abdominal pain may be secondary to splenic rupture, a potentially serious complication.10. Serious problems- call security (5-2222), cardiac arrest/trauma (5-3333), fire (5-4444), asappropriate.Commonly Used Medication Orders • Tylenol 650 mg PO PRN for fever (325 mg PO for kids) • Calcium carbonate 650 mg PO, 1-2 tablets every 15 minutes X 4 PRN for citrate toxicity • 10% Calcium gulconate (1 amp = 10mL): Only MD’s can give IV push Otherwise, hang 1 amp of 10% calcium gluconate diluted in (at least) 50cc of 0.9% NS • Benadryl 25 or 50 mg PO; Benadryl 25-50 mg in 50cc NS IVSS over 15-30 min • Solumedrol 125 mg in 100cc NS IVSS if hives not improved with IV Benadryl COMMON APHERESIS PROCEDURESTherapeutic Phlebotomy • Common Indications: 25
  26. 26. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York 1. Hereditary Hemochromatosis 2. Primary or Secondary Polycythemia (The viscosity of blood increases exponentially >10gm/dl) 3. Stroke or Symptomatic consequences of increased hematocrit • Pre-procedure evaluation: Hemocare- point of care testing (Hb) Labs: CBC • Orders: You will typically Phlebotomize 450-500cc on each occasion to achieve a target hematocrit requested by the patient’s physician (usually 45-47%) with at least 5-7 days in between each procedure for best tolerance. Note: Patients with cyanotic heart disease only tolerate removal of 200-250 cc -These patients require an increased PRBC mass. Target Hct should be 52-57% -They may need fluid replacement -Syncopal episodes occur if too aggressivepRBC Transfusion • Common Indications: 1. Symptomatic Anemia 2. Sickle cell disease • Pre-procedure evaluation: Transfusion consent Labs: CBC • Orders: Transfuse 1-2U PRBCs over 3-4 hours After transfusion of 1U pRBC in older patients/patients with cardiac decompensation/volume overload, diuresis may be considered before proceeding with further transfusionsRed Blood Cell Exchange • Common Indications: Acute Chest/CNS ischemia/Priapism/Multi-organ failure secondary to Sickle cell disease • Pre-procedure evaluation: Apheresis consent Blood product consent Labs: CBC, BMP, ionized Ca, Coag, Fibrinogen and HbS % • Orders: Type of replacement fluids: pRBCs (Hgb S negative) Replacement volume according to equation (RBC exchange program) No rinse back: You do not want to give the patient the Hgb S in the machine back to them and you want to maintain isovolemia. Aim for end Hgb level 27-30% Goal is to get FRC (fraction of red cells remaining)=0.25-0.3 (or 0.4 if there is not enough blood available, i.e. Patient has antibodies and there are only a certain number of units available and not enough to bring the patient to FRC of 0.3)Note on Manual Red Blood Cell Exchange: In cases where the patient is an infant or childweighing less than 20 Kg, and requires red cell exchange (for sickle cell disease/ Hyperbilirubin-emia), they should be manually exchanged with reconstituted whole blood (pRBC and FFP that isABO compatible). The patient should have a pediatric hematology consult. The hematologist 26
  27. 27. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New Yorkmust specify the desired hematocrit and volume when placing requests for reconstituted blood.Typically, a two blood volume exchange (~170cc/kg) is performed. Reconstituted blood should beused within 24 hours of preparation, after which it will be discarded by the blood bank.Plasmapheresis • Common Indications: 1. Myasthenia Gravis (MG) 2. Gullian-Barre Syndrome (GBS) 3. TTP 4. Humoral Rejection of solid organ transplants • Pre-procedure evaluation: Apheresis consent form Blood product consent form, if applicable Labs: CBC, Coags, Chem7, ionized Ca, serum albumin/protein • Orders: Typically you can replace ½ the plasma volume with saline and ½ with albumin (err on the side of more albumin in 250 cc increments) except in TTP (see below), GBS (see below), and in special circumstances (with coagulopathy/low serum albumin and protein/ anasarca) Thrombotic Thrombocytopenic Purpura: - Replace all plasma volume with FFP. - Ask clinician to always order “CBC+Retic” instead of CBC so that platelets are counted in the more accurate optical light scatter method. Schistocytes can be mistaken as platelets in the standard impedance method of detection and may result in a spuriously high platelet count. Guillain Barre Syndrome: - Process 250cc/kg of body wt over 8-13 days qod (5-6 procedures). - Patient should be exchanged with 5% albumin only (no normal saline) due to autonomic instability in GBS. Renal Transplant Rejection: - Typical schedule is 3 treatments qod followed by reevaluation (repeat antibody titers/biopsy/monitoring serum creatinine) - Prior to commencing treatment, request HLA/ABO antibody titers, as appropriate. HLA titers can be requested from the Immunogenetics laboratory using the form designated for this purpose. -IVIg should be administered AFTER plasmapheresis Plasma fibrinogen levels should be followed closely and cryoprecipitate should be transfused, if indicatedLeukapheresis • Common Indications: 1. WBC > 100,000, with myeloblasts without symptoms of hyperviscosity 2. Symptomatic Hyperviscosity with high WBC 27
  28. 28. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York • Pre-procedure evaluation: Apheresis consent form Calculate blood volume based on height and weight Labs: CBC, Coags, Chem7, ionized Ca • Orders: Process 1.5-2 total blood volumes (usually 2 BV)Platelet Depletion • Common Indications: 1. Platelet count > 1,000,000 • Pre-procedure evaluation: Apheresis consent form Labs: CBC, Coags, Chem7, ionized Ca • Orders: Process 1.5-2 total blood volumes Get post-procedure CBC to determine plt count and transfuse PRBCs if hematocrit is low Peripheral Blood Stem Cell Harvest (PBSCH) • Pre-procedure evaluation: 28
  29. 29. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Apheresis consent form Labs: CBC, Coags, Chem7, ionized Ca Specifically look for evidence of infection/sepsis (fever/sinus pain/ headaches/ diarrhea/URI etc) and ask about abdominal pain (splenic rupture). • Orders: -Process 20 L in adults qday to target dose (usually 5 X 106 CD34/kg based on wt of recipient) -Process 480 cc/kg for pediatric cases -Replacement fluid is saline prn - Pediatric primer: If indicated, reconstitute 150cc of pRBCs (irradiated, leukocyte poor) in 150cc of Albumin to obtain a Hct of 30% Get post CBC and transfuse platelets, if necessary; Deliver product to stem cell processing labThe Sysmex automated hematology analyzer in the CUMC core laboratory is capable ofidentifying a cell population representing hematopoietic progenitor cells (HPC) based on cell size,intracellular characteristics, and differential resistance to lysis. Dr. Joseph Schwartz’s group hasperformed a study comparing this Sysmex HPC parameter with preharvest CD34+ counts todetermine whether Sysmex HPC enumeration can aid in determining the optimal time of PBSCcollection. They also looked at the utility of WBC counts in predicting pre-harvest peripheral bloodCD34+ counts. These results are presented below, and may be used in preharvest peripheralblood CD34+ prediction and early initiation of leukapheresis (Use of the Hematopoietic ProgenitorCell Parameter in Optimizing Timing of Peripheral Blood Stem Cell Harvest. AnandPadmanabhan, Ronit Reich-Slotky, Jeffrey S. Jhang, Shatrina Dael, Tamara Crowder, Adriana I.Colovai and Joseph Schwartz, Vox Sanguinis, 2009).Table 1. Summary of results: HPC-CD34 ROC analysis: 29
  30. 30. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkTable 2. Summary of results: WBC-CD34 ROC analysis: Group N HPC*> Sensitivity Specificity PPV NPV AUC 83 90 0.911 All data 60 23 94 72 0.942 Adult Autologous 39 30 86 100 100 73 Pediatric- NB 7 16 100 100 100 100 1.000 0.800 Pediatric Non-NB 8 44 67 100 100 83 Allogeneic-Pediatric & Adult 6 15 80 100 100 50 ** Group N WBC*> Sensitivity Specificity PPV NPV AUC 6 55 100 0.829 All data 0 37 100 53 3 0.846 Is HPC>Threshold Value? Adult Autologous 9 37 64 100 100 52 Pediatric- NB 7 4.5 100 100 100 100 1.000 Pediatric Non-NB 8 5.3 Yes No67 80 67 80 0.533 Allogeneic-Pediatric & Adult 6 37 80 100 100 50 ** Legend: Start PBSC Collection Is WBC> Threshold Value? NB- Neuroblastoma; PPV- Positive Predictive Value; NPV- Negative Predictive Value; AUC- Area Under the Curve; ROC- Receiver operating characteristic curve *- Threshold that optimally predicts peripheral Yes No blood CD34+ count >20cells/µl; **- Insufficient data for ROC curve generation. Note: WBC count may NOT be used to predict CD34 counts in Peds-Non NB patients given the low AUC. Start PBSC Collection Enumerate CD34 The following algorithm should be followed for peripheral blood CD34 prediction: Is CD34> Threshold Value? Yes No 30 Start PBSC Collection Defer PBSC Collection
  31. 31. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York CORE LAB AND OTHER LAB SERVICES• The 5% of calls you get that aren’t related to transfusion medicine are mostly from the Core Lab, where the supervisor may call you to look at a peripheral blood smear with blasts/malaria or a body fluid (CSF, pleural fluid, ascetic fluid) with unidentifiable cells (? malignant) 31
  32. 32. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York• The hematology supervisor should only call you for patients with first-time blasts. You should not be paged for patients with a known diagnosis of leukemia and confirmed blasts. Check on WebCIS to make sure this is the case. For suspected new cases of leukemia it is important that you look at the slide in a timely manner (as soon as possible, but at worst within 3 hours of the call) and inform the clinician. It is important to inform them as soon as possible about blasts so that the patient is admitted and not sent home. Although hematopathology and flow cytometry may not be available on the weekend or off-hours, you can at least tell the clinician to send the patient’s peripheral blood to hematopathology for evaluation and flow cytometry on the next working day.• The following requires the CP On-Call Resident (not NYBC Fellow) to come in for immediate review: o Ring forms on peripheral blood smear (Malaria/Babesia) o Peripheral blast if an immediate read is clinically indicated. (Unless the patient has a known diagnosis of leukemia, contact the clinical team for pertinent history. If warranted, come in to review smear.)• The hematopathology fellow carries a pager (8-3845) on the weekends. He/she can be called in emergency situations to review slide and/or discuss the case. Also, flow cytometry may be ordered as a send out test over the weekends if deemed appropriate by the hematopathology fellow. Blasts• The hematology tech will perform a differential on the slide in question and will leave it in the resident’s basket in the Core Lab for review. It is useful to collect the following information: o Clinical information (primary diagnosis) including reason for admission o Location (e.g. Emergency Room versus 5GS) o Attending physician (e.g. Dr. Bar-David versus Dr. Diuguid) o The Sysmex scattergram output• Review the Scattergram and then look at the slide under the microscope. You can perform your own differential if you wish – the tech can show you how using the Sunquest computer system as a counting device. o If you agree with the differential, write on the sheet that you agree and sign the sheet. Include your beeper number, the date and the time. o If you do not agree with the differential, write your corrections on the sheet and sign as above. o If you are not sure of what you are looking at, page the clinical lab attending on call and ask for help or show it to HemePath. o Speak with the Supervisor on duty and have your interpretation added to the specimen as a comment. Other Slides for Review  Very rarely you may be called to identify parasites (malaria, for example) on a blood smear. Proceed as indicated above. You only need to identify whether Plasmodium species are present in the on call setting and help determine the level of parasitemia present. It is not required that you be able to speciate the 32
  33. 33. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York type of malaria (i.e. falciparum, vivax, malariae, ovale). Follow up with Gelpi in Parasitology on the next working day about Malaria/Parasite cases. Make sure to inform Dr. Della Latta of the case. CSF and Body Fluids  For body fluids, gather relevant clinical information and laboratory data. Relevant laboratory data includes the fluid and peripheral blood glucose, total protein, triglycerides, LDH, and call count and differential.  Review the Wright-stained smear. After you have assessed the slide and filling out the Body Fluids review form, show it to the cytopathologist on the non- gynecology cytology service. The Cytology attending will help to describe what should be written on the Clinical Lab sign-out and let you know if further workup is required.  Speak with the Supervisor on duty and have the interpretation added to the specimen as a comment.  The technicians in the Core Lab should have also made two unstained slides. Write up a requisition form or copy the body fluid form from the Core Lab and send it along with the two unstained slides to Cytology for Pap staining, if the Cytologists would like to work up the case further.  Body fluids should be reviewed during normal hours (M-F 8-5). If called for an abnormal body fluid slide review while on call notify the patient’s clinician of the situation and that the slide will be reviewed with the cytopathologist during the next working day. Physician Complaints  A small percentage of calls are from clinicians who have a question concerning a lab test. Answer the question if you can. If you can’t, page the clinical lab attending on call. Examples of possible calls include: Can I order a soluble liver antigen or a mast cell tryptase? Which test is better? Why am I getting a abnormal value on one assay and a normal one on another?  You will also get paged to investigate delays in processing, lost specimens, and mislabeled specimens. Often there are angry and frustrated clinicians on the other end of the telephone. Be as helpful as you can. Remember, if they are speaking to you they have already spoken to a ton of people who couldn’t solve their problem. Have them investigate while you investigate. For example, have them check the pneumatic tube system and make sure the sample was actually sent to the labs. In the meantime you can start the search for it in our lab. GUIDELINES/PROTOCOLS Request for CMV-Negative Blood Products(NOTE: ALL BLOOD PRODUCTS ISSUED FOR ROUTINE REQUESTS ARE CMV SAFE(LEUKOCYTE-REDUCED) 33
  34. 34. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkStep 1: Are CMV-negative blood products indicated?Our Indications:All Infants <4 mo of age.All Intrauterine TransfusionsAutologous BMT/PBSCT when the patient is CMV negative.Allogeneic BMT/PBSCT when both patient and donor are CMV negativeLung Transplant when both patient and donor are CMV negativePediatric Cardiac patients with DiGeorge syndromeStep 2: Looking up CMV status in WEBCISGo to “Lab summary”Then go to “others”Scroll down to “Viral Serologies”Select “all”This will reveal all viral serologies ever run on the pt—look for CMV testingIf you see an entry under CMV, note down date serology was done. Then go to “Laboratory” andscroll down to appropriate date and note IgM and IgG titers.NOTE: Titers under “CMV” in lab summary lists only one titer (IgG or IgM) but does not tell youwhich titer this is.If there are no CMV serologies in webcis, and the patient is known to the Stem cell laboratory,call them to find out if they have performed CMV serologies on the patient (Stem cell lab sendsout sample to the NYBC). The stem cell laboratory can be reached at 5-4446 (Mon-Fri8AM-5PM).Step 3: Obtain donor status, if relevant from clinical team or WEBCIS notes. If patient is CMVnegative and donor’s CMV status is unknown, CMV negative products are approved until suchtime that donor CMV status can be accurately ascertained.What if there are no CMV titers in WEBCIS?If there are no patient CMV titers, ask requesting MD to send out CMV antibody titers ASAP.Inform Blood Bank tech that CMV-negative blood products are approved for 3 days. At the end ofthis 3-day period, if any further blood products are requested for the patient, the BB resident willbe paged by techs. CMV titers should be back at this point and should aid in making a finaldecision. Communicate decision to BB tech so that they can input this information in Wyndgate.If MD states that he/she does not know donor cmv status in lung transplant cases, call lungtransplant coordinator Theresa Daly 47771 (87600) for CMV status.CMV Negativity/Positivity:“CMV negative” patient status is defined as negative CMV IgM AND negative CMV IgG. Note:positive IgM indicates acute infection.Most commonly, the “CMV positive” patient has negative IgM but positive IgG titersTesting Information:Site: Specialty Laboratory 34
  35. 35. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkLocation: BHS-02Phone (212) 305-9116Availability Mon-Fri, 8 AM - 4 PMCMV IgG is performed 3 times per week; CMV-IgM is performed 2 times per weekVolume & Container: Send 2ml blood in Gold Top TubeReference RangesCMV IgG: No antibody detected: <4 Equivocal: 4 to <6 Antibody detected: 6CMV IgM: No antibody detected: <0.70 Equivocal: 0.70 to <0.90 Antibody detected: 0.90 Request for Granulocyte TransfusionGeneral guidelines for use of Granulocytes:11. Pediatric or adult patient with severe neutropenia (ANC ≤ 500/μL)2. Fever for 24 to 48 hours with persistent morbidity3. Documented bacterial or fungal infection4. Unresponsive to appropriate antibiotics for 48 hours5. Reasonable hope of marrow recoveryInstructions and Information: 35
  36. 36. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York11. Administration 1a. There MUST be an Eclipsys order placed to the Blood Bank prior each day of granulocyte transfusion. One order for 3 granulocytes transfusions is NOT acceptable. b. Appropriate orders should be written in the patient’s chart in advance so that nursing and house staff are aware of the transfusion. c. Granulocytes will be: 2i. ABO/Rh specific and fully crossmatch compatible (high red cell content); there MUST be an active type and crossmatch sample in the Blood Bank; ii. irradiated to prevent transfusion associated graft-versus-host disease iii. Regardless of CMV status of donor and/or recipient, the Blood Bank always obtains CMV negative granulocytes. The products will not be labeled as “CMV negative” due to testing not being complete at the time of issue (see #4) 3d. Premedicate 1 hour prior to granulocytes with diphenhydramine 1 mg/kg (max 50 mg) and hydrocortisone 1 mg/kg (max 50 mg) e. give through a standard blood filter (170 μm) over 1-2 hours22. Dosage: Note that granulocytes are collected at NYBC from a stimulated donor (withsteroids). In general, the product has a low yield of granulocytes (usually less than 1 x 1010 PMN)3. Storage and Timing 1a. Products are stored at room temperature and expire 24 hours after collection b. Optimal administration is within 6 hours of collection to minimize loss of chemotaxis c. Granulocytes MUST be picked up and transfused as soon as possible after arrival. The Blood Bank will not send them through the pneumatic tube system.34. Urgent Medical Need 1a. The risk of infectious disease transmission is essentially similar to any other blood product except that donors are only tested for infectious disease markers on the day of collection. Thus, due to the expiration time of the product, the products are issued prior to the release of infectious disease marker testing results under urgent medical need. Please note that granulocyte donors have been tested for infectious disease markers and found negative/non-reactive within the last ten days.45. Adverse Reactions 1a. Granulocyte transfusions have the same risk of adverse reactions as any other blood product and should be monitored closely; systemic reactions or fever may be treated with acetaminophen 10 mg/kg (max 650 mg), meperidine 1 mg/kg and additional diphendyramine and hydrocortisone as necessary56. Continuation (based on clinical judgment and the patient’s response) 1a. Reasons for discontinuing granulocytes include: 2i. Neutrophil recovery (ANC > 500 for two days)/ clinical response ii. Exhaustion of available donors iii. Severe transfusion reactions iv. Futile deterioration of patient’s condition 3b. Granulocyte donors undergo a procedure with moderate risk for complications. In order to prevent exposing healthy donors to unnecessary risk, Ped Hem/Onc fellows and/or Ped Hem/Onc/BMT attending must let the Blood Bank know as soon as possible if granulocytes are no longer indicated (via Granulocyte request form) Platelet Refractoriness Work Up Information/ConsultationGeneral Indication for Platelet Refractoriness Work-up:1. A patient is regarded as refractory to platelets if he/she fails to show an acceptableincrement in platelet count after transfusion on at least two separate occasions.2. Increment is normalized by calculating the Correct Count Increment (CCI): CCI = (Posttransfusion [15-60min] PLT count – Pretransfusion PLT count) x BSA (m2) 36
  37. 37. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New York Number of platelets transfused (multiples of 1011) An apheresis platelet bag has approximately 4x1011 platelets; BSA in a 70kg male is ~2m2 CCI can be calculated on the CCI excel sheet on our Transfusion Medicine websiteSevere refractoriness is defined as a CCI <5,000; Moderate refractoriness as CCI <7,500,and mild refractoriness as CCI <10,000.3. All non-immune causes of refractory thrombocytopenia including consumption, drug-related and sequestration by the spleen should be considered in the differential diagnosis.Instructions and Information:A request for anti-HLA/anti-PLT antibody testing must be ordered on Eclipsys. Then:1. Fax the ordering clinician the “Platelet Refractoriness Work-Up” form. They will fill itout with all appropriate information and fax it back to the blood bank.2. Utilizing the information provided on the form, calculate the one-hour post-transfusionCCI for the two trials provided.3. If >7,500 STOP here.4. If <7,500, examine the clinical history provided on form for other, non-immune causesof thrombocytopenia.5. If no other clinical causes can be determined, ask the following questions: • Were “fresh” platelets used in transfusion? By fresh, we mean platelets that are about 3 days old. This may not always be possible. • Were ABO-matched platelets transfused? When assigning platelets to a patient, we prioritize release of those that are about to expire, with ABO- matching as a secondary concern. Matching for ABO may increase platelet circulation time. • This information is available in our Blood Bank computer system.6. If the two alternatives in (5) have not already been tried, or you/your attending don’tbelieve this is practical based on inventory, approve testing to be sent out to the NYBC.7. Results of testing will tell us if an immune mechanism is responsible for plateletrefractoriness. The immune nature of the reaction will be further classified as mediatedby anti-HLA or anti-PLT antibodies.8. For either anti-HLA or anti-PLT antibodies, platelet crossmatch may be performed onunits to help identify cross-match compatible units.9. If anti-HLA antibodies are present in the patient, you may consider using HLA-matched platelet transfusions. This requires an HLA-type from the patient (if available,the results will be in the Suciu-Foca lab-56941). AB RECIPIENTS: SOLID ORGAN ABO-COMPATIBLE BUT NON- IDENTICAL TRANSPLANTATION- BLOOD TRANSFUSION GUIDELINES IN MASSIVE HEMORRHAGEThese transplants typically do not come to the attention of the BB resident/fellow, unless somesort of ABO switching is being contemplated. For example in a massively bleeding AB hearttransplant recipient, the decision may be made to transfuse >10 A-type pRBCs followed by A-type FFP, because of low AB FFP inventory. However this may be a problem if the heart is from a 37
  38. 38. The Official Guide to Laboratory Medicine On Call Columbia University Medical Center Department of Pathology New York, New YorkB-type donor. In the specific example presented, it may be a better choice to transfuse B typepRBCs and follow with B type FFP in order not to increase the risk of AMR in the donor heart dueto passively transfused isohemagglutinins in plasma. Therefore, before switching the ABO typefor transfusion, the resident/fellow should ascertain ABO type of the donor and only then decideon the future course of action. ABO NON-IDENTICAL BMT/HCST: BLOOD TRANSFUSION GUIDELINESTransfusion of red cell containing products based on Rh (D) status of recipient and donor: RECIPIENT DONOR Rh (D)-POS Rh (D)-NEG Rh (D)-POS Select Rh (D) pos Select Rh (D) neg pRBC, platelets pRBC, platelets Rh (D)-NEG Select Rh (D) neg Select Rh (D) neg pRBC, platelets** pRBC, platelets** After the patient has engrafted and front types as Rh (D)-positive, Rh (D)-positive red cellcontaining products may be issued.Modified from Chapter 25. Transfusion Support for Hematopoietic Transplant Recipients.Technical Manual, 16th Ed, Roback, JD et al. 38