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

2. 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

3. 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

4. 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

5. 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 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)

6. 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: ).
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)

8. 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)

9. Downtime form
Granulocytes

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

12. 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!!!

13. 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.

14. 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)