A resident’s guide to granulocyte transfusions Last updated 6/3/2016

The consultation: convey this information to the clinical team Indications: Patient should be neutropenia (ANC<500) Refractory to medical management Reversible bone marrow recovery Efficacy: Studies show no difference in outcomes (mortality and resolving infection), but limited power In these most recent RING study, donors were stimulate with G-CSF, whereas at SHC, they are not (so we may have poorer efficacy) Risks: Infectious disease testing will not be complete by time unit needs to be transfused Associated with pulmonary complications when administered with amphotericin (recommend spacing out 12 h) Premedication with Tylenol, Benadryl, Steroids

The consultation: gather this information from EPIC/clinical team Diagnosis/type of infection(s)/WBC count Patient blood type and screen (granulocytes need to be ABO compatible due to high concentration of RBCs) CMV status How many days they plan on transfusing? How they will monitor for improvement? If it isn’t working, or patient placed on hospice, stop granulocyte transfusions

The consultation: extra steps to ensure adequate communication Since this is usually a complicated consultation, would recommend: Resident/fellow speak to the team in person, can take this opportunity to give them the 3 forms they need (see later slides and “forms” pdf). Resident/fellow write a note in EPIC (see sample EPIC note doc). Even incomplete notes can be viewed by the clinical team You can put in a note with info for the clinical team(s), even if it cannot be signed right away. Be careful to be accurate

Logistics – communicating with SBC Resident/fellow will contact TS/SBC attendings & special donations (Cynthia Evora,Elaine Sugawara, Jan Webster, Regina Driscoll) Should be done ASAP so special donations can begin to search for a donor (call and email Cynthia) Special donations will want to know T&S, CMV status, what days the transfusion is need to determine how many donors they should try to recruit Special donations will also ask for the attending physician’s contact information (pager, phone, fax) Why do they want a phone and fax? B/c they want to send the emergency release blood products form to the clinical team We found it easier just to have special donations fax the form to us in TS, and we will give it to the team (along with the two other forms they need)

Logistics - Forms (4 in all, 3 to get to the clinical team) 1) Authorization of emergency release of unprocessed blood components form This form needs to be filled out by the clinical team, and then get sent back to SBC Can be directly faxed between SBC and clinical team (SBC fax number: 650- 225-7729). TS resident/fellow can facilitate Get form 09pF83 from SBC (call and ask it to be faxed to TS) and bring to the clinician Return form to SBC Needs to be signed by the attending physician of the primary team Only 1 form need for all transfusions Indicates that infectious disease testing has not been completed yet SBC targets low risk donors (platelet donors who have donated within the past month)

Forms – how do we instruct the clinical team to order the granulocyte unit? Not orderable in EPIC, need to use downtime procedures (need both daily) 2) Downtime form (fill out each day the want the transfusion) 3) Call slip (send to transfusion when they want the unit)

Downtime form Granulocytes

4) Only form that is for internal record keeping – not for clinical team!

Other things to keep in mind Please remember to log a medical exception daily: Granulocyte unit infectious disease testing not yet complete Need to be transfused within 24h Why is unit labeled CMV untested? B/c infectious disease testing not yet complete, they can’t put this sticker on, but SBC recruits donors with neg CMV serology Do not need a separate CMV untested exception Stored at 20-24°C for up to 24 hrs without agitation Giving Rh positive unit to Rh negative patient – consider RhIG (consult with MD) Unit is irradiated to prevent TA-GVHD CANNOT BE LEUKO-REDUCED!!!

Open communication Call the team daily (e.g. in afternoon around 3-4 pm) to ensure they want to proceed with the next day’s granulocyte transfusion If they want to cancel, resident/fellow will call SBC and special donations ASAP so donor does not take high dose steroids the night before.

Granulocyte transfusion on Sunday The problem: difficult to arrange collection on Sunday at SBC The solution: collect 2 U on Saturday Transfuse first unit on Saturday Transfuse second unit early Sunday before 24 h expiration time (or consider transfusing both units on Sat)