Reevaluation of the medical necessity of washed red blood cell transfusion in chronically transfused adults.

BACKGROUND: Washing red blood cell (RBC) units mitigates severe allergic transfusion reactions. However, washing reduces the time to expiration and the effective dose. Automated washing is time- and labor-intensive. A shortage of cell processor tubing sets prompted review of medical necessity for washed RBC for patients previously thought to require washing. STUDY DESIGN AND METHODS: A single-center, retrospective study investigated discontinuing wash RBC protocols in chronically transfused adults. In select patients with prior requirements for washing, due to a history of allergic transfusion reactions, trials of unwashed transfusions were performed. Patient demographic, clinical, laboratory, and transfusion data were compiled. The per-unit washing cost was the sum of the tubing set, saline, and technical labor costs. RESULTS: Fifteen patients (median age 34 years interquartile range [IQR] 23-53 years, 46.7% female) were evaluated. These patients had been transfused with a median of 531 washed RBC units (IQR 244-1066) per patient over 12 years (IQR 5-18 years), most commonly for recurrent, non-severe allergic reactions. There were no transfusion reactions with unwashed RBCs aside from one patient with one episode of pruritus and another with recurrent pruritus, which was typical even with washed RBC. We decreased the mean number of washed RBC units per month by 72.9% (104 ± 10 vs. 28.2 ± 25.2; p < .0001) and saved US $100.25 per RBC unit. CONCLUSION: Washing of RBCs may be safely reconsidered in chronically transfused patients without a history of anaphylaxis. Washing should be implemented judiciously due to potential lack of necessity and logistical/operational challenges.

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

BACKGROUND: 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. STUDY DESIGN AND METHODS: 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. RESULTS: 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. CONCLUSION: Algorithm-based selection of a procedural FCR significantly reduced blood utilization (~21%) without appearing to increase acute care encounters.