Red Blood Cell Exchange Procedures Research Articles

Hemapheresis Clinic Scheduling Quality Improvement Project

Abstract Introduction/Objective Outpatient (OP) Red blood cell exchange (RCE) therapy is used to treat patients with severe manifestations of sickle cell disease. Like any blood transfusion, a patient must have an active type and screen, drawn 24 to 72 hours prior to scheduled RCE procedure. UIH Hemapheresis clinic performs several types of apheresis procedures treating sickle cell disease, kidney transplant rejection and autoimmune disorders. Outpatient clinic staff perceived that most RCE procedures are scheduled disproportionately between Wednesday through Friday, which creates an unbalanced schedule that is lighter on Monday and Tuesday, and heavier Wednesday through Friday. The study's objective was to determine if there is a significant difference between the number of outpatient procedures scheduled on the different days of the week. If significant differences are identified, processes may be improved to schedule a more balanced OP clinic week. Potential benefits may include a more balanced patient to nursing staff ratios which can improve patient care and more efficient RBC utilization which can ease workload across multiple cross-functional departments such as nursing staff, reference labs and in-house blood bank staff. Methods/Case Report The UIH Epic Hemapheresis Clinic schedule was searched to identify how many total OP procedures, including RCE, were scheduled each day of the week between 01AUG2021 – 31JUL2022. Only OP procedures occurring in complete five-day weeks were included. Weekends and weeks having clinic closures for holidays were excluded Results (if a Case Study enter NA) Our study show that the lowest number of OP RCE (mean 1.4) and total number of OP procedures (mean 2.6) were on Monday. Wednesday is the busiest day with overall averaging 3.5 total procedures (Standard Deviation: 1.56). However, Friday is the most variable, with the largest SD for both RBCX (SD 1.4) and Total number of procedures (SD 1.7). Conclusion Contributing factors to low procedure volume on Monday are likely multifactorial. Some patients may prefer not to come to the hospital on Saturday for type and screen, while some may forget they need labs. Transportation issues are another factor. One intervention the clinic has implemented is automatic appointment call reminders. Staff encourage patients or caregivers to sign up for the EPIC MyChart app which also notifies patients of upcoming appointments. Future studies need to be conducted to address other bottlenecks within the scheduling workflow and to determine ways to optimize patient appointment adherence.

Use of Conventional Transfusion Thresholds Contributes to Ongoing Iron Overload Issues in Patients with Homozygous (SS) Sickle Cell Disease

Introduction: Homozygous sickle cell disease is characterized by chronic anemia which contributes to a clinical course characterized by recurrent pain crisis episodes. These episodes are usually managed with the use of packed red blood cell products. Randomized data is currently available that supports lower transfusion thresholds in non-sickle cell related conditions including but not limited to patients undergoing orthopedic procedures, cardio-vascular interventions and those needing intensive care. Due to lack of similar randomized trials in patients with sickle cell disease, recommendations from other trials are applied to patients with sickle cell diseases as well. However, this has the potential of worsening iron overload states that patients with sickle cell disease usually suffer from. Methods: Patients with homozygous SS sickle cell disease were evaluated with regarding to transfusion support given during hospitalization for vaso-occlusive pain crisis episodes. The hemoglobin threshold that was used for deciding whether or not to give packed red cell transfusion was studied in patients who were previously getting periodic red blood cell exchange procedures for chronic sickle cell related pain. Serum ferritin levels during the period of exchange transfusion support was compared with levels during simple transfusions. 8 patients were selected from the cohort of patients with homozygous sickle cell disease who had been receiving elective packed red blood cell exchanges. Patients with ferritin levels persistently remaining above 1000 ng/ml were then evaluated with regard to transfusion thresholds used for simple transfusion support during hospitalization for pain crisis episodes. Results: Six patients had persistently high ferritin levels. Thresholds for simple transfusion in this group were studied. A total of 30 units of packed red blood cells were found to be transfused over a 6-month period. During this period only one patient required an exchange transfusion session. 2 out of 30 units were given for a Hgb level above 7 g/dl. The majority, representing 24 out of the total 30 pack red blood cell units were given above a Hgb threshold of 6.0 g/dl. Only 4 units were given using a Hgb threshold less than 6 g/dl. Mean ferritin level before and after the period of simple transfusion support was 6097 ng/ml and 6076 ng/ml respectively. Mean Hgb level in while on exchange transfusion was 7.4 g/dl and it was 6.9 g/dl in those receiving a simple transfusion protocol. Conclusions: Transfusion threshold used in patients with homozygous SS sickle cell disease appears to be similar to patients without sickle cell disease. Current practice based on studies including TRICC and TRISS is to keep the Hgb level above 7 g/dl. This has been shown to be safe and in fact even improves patient outcomes. However, in patients with sickle cell disease this may not be appropriate since their baseline Hgb levels are lower to begin with. Also, transfusions don't appear to improve Hgb levels considerably. These patients also tend to have iron overload at baseline which likely will not improve unless all transfusions are limited. Therefore, applying a lower transfusion threshold would be recommended to avoid acute transfusion related issues and long-term iron overload problems in patients with SS disease.

Algorithm-based selection of automated red blood cell exchange procedure goals reduces blood utilization in chronically transfused adults with sickle cell disease.

Automated red cell exchange (RCE) is a common treatment for patients with sickle cell disease (SCD). Two key parameters are used to determine the volume of blood for RCE to reduce sickle hemoglobin (eg, HbS): fraction of cells remaining (FCR) and target hematocrit. We evaluated how the calculated FCR-using the manufacturer's algorithm-impacted blood utilization and incidence of acute care encounters. Retrospective chart review was conducted of 15 adults with SCD who underwent chronic RCE from July 1, 2015 to August 31, 2019. Blood utilization and acute care encounters were compared across three time periods: (a) when a fixed FCR of 30% was used (12 months); (b) transition period during which physicians made ad hoc changes to the FCR (25 months); (c) algorithm phase when a procedural FCR between 30% and 50% was selected using an algorithm generated by the manufacturer's built-in software to target a HbS fraction of 8% post-procedure (12 months). Wilcoxon signed rank test was used to determine statistical significance. Median blood utilization per procedure decreased from 2398 mL (interquartile range [IQR]: 2271-2759 mL) during the fixed FCR phase to 1887 mL (IQR: 1495-2241 mL) during the algorithm phase (P < 0.001). Similarly, median number of units transfused decreased from 10 (9-11) to 7 (5-9) during the respective phases (P < 0.001). Visits to the emergency department were 1 (0-4) in the fixed FCR phase and 0 (0-3) in the algorithm phase. Algorithm-based selection of a procedural FCR significantly reduced blood utilization (~21%) without appearing to increase acute care encounters.

PMD2 HEALTH OUTCOMES ASSOCIATED WITH DIFFERENT TRANSFUSION MODALITIES IN SICKLE CELL DISEASE

To avoid and overcome significant sickle cell disease (SCD) complications, treating physicians have different therapeutic options including several chronic transfusion modalities such as simple blood transfusion (ST), manual blood exchange procedure (MBE) or automated red blood cell exchange procedure (RBCX). The objective of this study was to determine the impact of different blood transfusion modalities and their ability to avoid and overcome SCD patient complications. The main study method was physician reported patient health outcomes. The study relied on a double blinded cross-sectional survey amongst 53 treating physicians based in the US. Together, these physicians yearly routinely treat 5,989 SCD patients out of an estimated total population of 100,000 SCD patients in the US. The impact of chronic blood transfusion modalities on SCD complications was measured on 14 disease complications. Chronic automated RBCX largely outperformed simple blood transfusion and manual blood exchange in terms of SCD patient complication reduction. Complication reduction for RBCX was found to be 56% higher versus manual exchange and 46% higher vs simple blood transfusion. Compared to the next best transfusion alternative (simple transfusion or manual exchange) RBCX was reported to have a significantly (p < 0.01) positive impact (% reduction) on the following disease complications: acute chest syndrome (-24%), stroke (-45%), silent infarction (-54%), renal failure (-38%), priapism (-62%), iron overload (-50%) and severe infection (-32%). Automated RBCX is likely to reduce the incidence of multiple SCD complications. Physicians access to multiple transfusion modalities at their facility will decrease the patient burden of disease and potential long-term consequences of SCD most by utilizing automated RBCX whenever possible.

A brief review of common mathematical calculations in therapeutic apheresis.

Apheresis is defined as the removal of blood from the body, its separation into constituent components, and removal or manipulation of one of these components prior to intravascular return with or without the addition of replacement fluid. Patients undergoing therapeutic apheresis often have multiple comorbidities, potentially affecting their hemodynamic status. Thus, a thorough understanding of apheresis principles and calculations is required for the performance of safe, efficacious, and successful procedures. The performance of simple transfusions or red blood cell exchange procedures is additionally complicated by the difficulties inherent in the procurement of compatible blood products, and the emphasis on minimizing exposure to unnecessary blood products. It is essential that apheresis physicians be able to accurately evaluate the risks/benefits inherent in the procedural options and efficiently stratify patients to the optimal therapeutic modality. The formulas requisite for performing therapeutic apheresis calculations are herein reviewed.

Comparison of Spectra Optia and COBE Spectra apheresis systems' performances for red blood cell exchange procedures

BackgroundSpectra Optia (Terumo BCT, Lakewood, CO) was FDA approved for red blood cell exchange (RBCx) procedures in January 2014 and is expected to replace COBE spectra (Terumo BCT) very soon in the USA. The performance characteristics of these devices for Isovolemic Hemodilution (IHD-RBCx) procedure were compared in this study. MethodsA total of 114 IHD-RBCx procedures from 19 patients were analyzed. For every patient, three procedures on each device with similar pre-procedure hematocrits were compared. Pre and post procedure laboratory parameters compared were hemoglobin S (HbS), hematocrits (Hct), platelet counts and fraction of cells remaining (FCR). Statistical analysis was performed using t-test adjusted by the Holm-Bonferroni method to reduce family-wise error rate. ResultsThere were no significant differences between these two devices in regards to HbS, Hct, FCR and platelet counts (p = > 0.05). However, rinseback volume (124.2 ± 8.9 ml) and normal saline replacement volume during IHD phase (296.1 ± 97.2 ml) were lower in Spectra Optia as compared to COBE Spectra (337 ± 33.8 ml and 326.6 ± 105.2 ml, p value <0.001 and 0.030 respectively). Spectra Optia had a longer run time (107.1 ± 15.9 min vs 123.8 ± 19.6 min, p value <0.001) overall. ConclusionsPerformance characteristics of Spectra Optia for HbS, Hct and FCR were similar to COBE Spectra for IHD-RBCx. IHD-RBCx procedure on Optia required less normal saline replacement volume and rinse back volume but with overall longer procedure run time.

Automated Erythrocytopheresis for Relief of Priapism in Sickle Cell Hemoglobinopathies

Priapism, a complication of male patients with sickle hemoglobinopathies, has been managed by a variety of surgical and nonsurgical forms of therapy that often are unsuccessful. The application of automated erythrocytopheresis (red blood cell exchange) by continuous-flow and semicontinuous-flow procedures appears to offer distinct advantages in the treatment of complications resulting from sickle hemoglobinopathies. The successful application of erythrocytopheresis for the relief of priapism in a patient with hemoglobin SC disease is presented and probably represents the first case reported on the use of automated red blood cell exchange procedures in the treatment of this condition. Data and results of automated erythrocytopheresis in 4 additional patients are presented. The advantages and disadvantages of erythrocytopheresis in the treatment of priapism (and other complications of sickle hemoglobinopathies) are discussed and the method is compared to other modes of therapy.