Transfusion Management and Exchange

Transfusion in Sickle Cell Disease

Neill Westerdale (CNS Adults)

Luhanga Musumadi (CNS Teenagers & Young Adults)
Objectives of Transfusion in
SCD

Improve oxygen
carrying capacity

Remove sickle cells

& viscosity

Stop autologous
RBC production
 Methods for transfusion
Acute complications – exchange
transfusion
 Acute chest syndrome

 Acute stroke

• Priapism

 Pregnancy

 Pre-operative
 Exchange transfusion
Manual transfusion
 Advantages
 Cheap
 Out of hours service
 Little training required
 Disadvantages
 Slow
 Labour intensive
 High iron loading
 Poorly tolerated by
patients
 Messy > infection
Automated transfusion
 Advantages
 Quick
 Less labour intensive
 Little iron loading
 Less volume shift
 Lower S% achievable
 Disadvantages
 Expensive equipment
 On call service costs
 Training
 How to do an exchange
transfusion
 Manual exchange  Automated
exchange
(Erythrocytapheres
is)
Venous access -
peripheral
Femoral Line Insertion
 NICE + X ray
guidance vascular
X ray
 Consent

 Cannulation

 NBM for sedation

Considerations
 >DVT

 >Infection

 > Pain (local and

oral analgesia)
How to do an automated
exchange
How to do an automated
exchange
How to do an automated
exchange
How to do an automated
exchange
How to do an automated
exchange
•Pre Bloods FBC, HbS
%, U&E, LFT, Bone
profile, X-match,
clotting, Ferritin (day
before)
• 6-8 units in an
adult
• 6-10 weekly
•Consent EBT and
femoral line
•Annual Virology
(hepatitis B,C and
HIV)
How to do an automated
exchange
•Height and weight
•Haematocrit
•Initial
•Replacement (57%)
•End Hct (33%)
•Fraction cells remaining (S %)
Current S% X 100 = FCR
Target S%

•Volume to exchanged
How to do an automated
exchange
• Over at least
one hour
• Need to slow
rate if patient
unwell
• 2-3 hours
•Pregnancy
•Previous vaso-
vagal
• Observations
every 20 minutes
How to do an automated
exchange
• Hypocalcaemia
• po or iv Ca
• Check Hb and S
% post tx
• Remove line
• Observe for 1
hour
Prepari ng p atie nts for an
EBT p rogram
 Informed consent: Provide literature / consider cognition issues in
CVA and younger patients, may require family involvement
 Address concerns regarding blood and virology risk (cultural and
religious influences)
 Assess access
 Introduce patient to Day Unit/Cobe machine/ Meet other SCD
patients on EBT program
 Gradual transition top up /automated – For Adolescents
 Speak to employer or educational establishment regarding regular
absences
 Ma naging a p atient dur ing
an E BT
 Emergency EBT the patient should be in HDU for
monitoring reasons
 Give oral analgesia opiate prior to femoral line removal if
appropriate
 Get patient to go to the toilet pre femoral line and EBT
 Ensure patient adequately distracted and comfortable)
TV music etc
 Hypovolaemia and vaso-vagal is common. Give
additional fluids via Cobe or orally (overnight observation
if severe)
 Acute crisis pain may increase as opiates will be washed
out by EBT
 Improvi ng Com pliance
with EBT programs
 Positive encouragement and reminders about the need for EBT
(team consistency)
 Issue letters with dates and time of next EBT and reminder
telephone calls/ texts
 Ensure line insertion is undertaken competently and if femoral under
x-ray guidance or ultrasound with sedation
 Address needle, femoral line and blood phobias involve
psychologist if available
 Address outstanding social issues (transport or childcare)
 Consider admitting night before if issues with travelling punctuality
and reliability
 Where possible be flexible exams and holiday times in particular
 EXCHA NGE S AT G STT

 HbSS =13
 HbSC =1

Indication
 12=CVA

 1=Lupus/hepatitis/severe SCD

 1=Vasculitis (mild SCD)

 Ex ch ang es a t GST T
Interval
 8-10 weekly =2

 8 weekly = 5

 6-8 weekly = 5

 6 weekly =1

 4 weekly =1

Target Hb
 Pre 8-11gdl

 Post 10gdl (11gdl x 1(HbSC)

 EX CHAN GES AT GS TT
Target pre S % Femoral line = 14
 1=60 %

 11 = 50 %

 2 =30 %

Target post S %
 4=20 %

 10=15%
 EXCHA NGE S AT G STT
8850
8450
8050
7650
7250
6850
6450
6050
5650
5250
4850 ferritin levels SCD
4450
4050 patients on EBT
3650
3250
2850
2450
2050
1650
1250
850
450
50
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Thank you to the Sickle Team at St Thomas’
Hospital:
Dr Jo Howard (Haematologist)
Dr Baba Inusa (Paediatrician)