2024 FSA Podium and Poster Abstracts

P104: MANAGEMENT OF A PATIENT WITH EXTREMELY LIMITED COMPATIBLE BLOOD PRODUCT AVAILABILITY
Joshua Raber, MD; Nathalie Abitbol, MD, MBA; University of Miami

Introduction/Background: Surgical procedures with anticipated blood loss require pre-operative planning which includes laboratory evaluation to ensure blood availability. When antibodies are present, blood preparation may be challenging. In rare cases, compatible blood may not be available within the region.

Methods: We describe the case of a 27-year-old African American female with a history of chronic rhinosinusitis and nasal polyposis who presented for sinus surgery due to persistent symptoms of nasal congestion and hyposmia refractory to medical therapy. Preoperative complete blood count and metabolic panel were within normal limits; type and screen was positive for Anti-U antibody. Given extremely limited compatible blood availability, the blood bank labeled her with an allergy to “Red Blood Cells.” As surgical blood loss was anticipated, in the setting of multiple nasal polyps, we describe the coordinated perioperative management with the surgeon, blood bank, and anesthesiologist to safely care for this patient.

Results: Laboratory results revealed her blood type as O Rh-negative. An antibody screen was performed and was positive for Anti-D and Anti-U alloantibodies. Direct Coombs testing for IgG and Complement were both negative. After discussing with our institution’s blood bank, it was determined that neither U-negative blood products were available within our institution nor our institution’s network of blood banks. Considering the difficulty in allocating compatible blood products, which could take weeks, and in the setting of the patient’s discomfort and impacted quality of life, the decision was made by a multidisciplinary team (surgeon, anesthesiologist, and hematology) to proceed with the planned procedure using a hemodilution strategy with the aim to abort and stage the procedure if/when intraoperative blood loss were to reach one liter. In the operating room, after induction and intubation and prior to surgical incision, the patient had a second peripheral IV placed and was hemodiluted with lactated ringers 1500 mL and albumin 5% 500 mL. Throughout the procedure, the patient received an additional 900 mL crystalloid, totaling 2400 mL. The surgeon completed the surgery in one stage, with an estimated blood loss of 600 mL. The patient was extubated and taken to PACU in stable condition. 

Discussion/Conclusion: Perioperative blood management is essential in cases of anticipated surgical blood loss. In this case, the development of the Anti-U alloantibodies is a rare immunohematological problem possible in ~1% of African Americans resulting in an extremely limited compatible blood product availability. This patient had laboratory studies within normal limits and didn’t require preoperative transfusion, allowing for a hemodilution approach combined with the option of procedure staging. Besides allogenic blood transfusion, blood management options include perioperative autologous blood transfusion, acute normovolemic hemodilution, and cell salvage.

With advancements in blood banking technologies, allogeneic blood transfusion rates have increased worldwide, though met with a reduction in donations resulting in a shortage of supply, further straining the availability of rare blood units. Therefore, blood conservation strategies, especially in cases where finding suitable blood products proves challenging, along with staging procedures when surgically possible, remain effective and valuable options for patients at risk for significant blood loss.