Dallas, TX November 2–4, 2012 GRANUOCYTE TRANSFUSIONS

Dallas, TX • November 2–4, 2012

GRANUOCYTE TRANSFUSIONS


THERESA SULLIVAN, RN,CNSMID-LEVEL PROVIDER

DEPARTMENT OF LEUKEMIA

MD ANDERSON CANCER CENTER

HOUSTON,TEXAS


OBJECTIVES

• At the end of this session the participant will be able to:

1. List the criteria required for granulocyte transfusion.

2. Discuss the granulocyte collection process.


History of GranulocyteTransfusions

• 1959-1961 Collecting, processing and transfusing of platelets cut death rates from hemorrhage in children with acute leukemia.

• 1960-1962 Focus now to infection – Granulocytes (WBC’s) collected from CML patients are transfused to pediatric leukemia patients.



• 1962- July 1965 Collaborative effort with George Judson of IBM, Robert Eisel and Dr. Freireich to develop a blood cell separator.

• July 1965 Clinical tests start on developed separator. Dr. Freireich moves to MDACC.



• 1966 New and improved NCI-IBM blood cell separator offered for field trial, MDACC gets 1of 3.

• 1974 Use of HES and steroids bring granulocyte collection process to forefront again.



History of Granulocyte Transfusions

• 1995 Advent and use of G-CSF enabled higher yield of granulocytes (WBC’s) to be collected.

• 2011 Approximately 950 granulocyte transfusions collected at MDACC.

• 2012 MDACC plans comparative study of prophylaxis vs. therapeutic use of granulocyte transfusions.


Indications for Granulocyte Transfusions

• Life threatening bacterial infection in a setting of prolonged neutropenia. (ANC<5)

• Life threatening fungal infection in a setting of prolonged neutropenia.

• Deteriorating condition with known infection and “correct” antibiotics.

• Improvement in infection for BMT option.


Neutropenia

• Risk Category ANC• 0 - none within normal limits • 1 - mild > 1500 - < 2000/mm3• 2 - moderate > 1000 - < 1500/mm3• 3 - severe > 500 - < 1000/mm3• 4 - life threatening < 500/mm3

NCI- CTC 3.0


Neutropenia

• Direct relationship to the degree of neutropenia and risk of infection.

• Direct relationship to the duration of neutropenia and risk of infection.


Process of Granulocyte Collection

• Identify possible donors

• Family members/ friends preferable

• Screening process for donors

• Standard blood banking screening

• Obtain and inject G- CSF

• 600 mcg by 8pm evening prior

• Decadron 8 mg orally

• Minimum side effects to donor



• Granulocytes (WBC’s) donated- 8am

• 1 1/2 body volume processed

• 2 1/2 - 3 hour duration

• 2 arm procedure

• Males can donate 5x every other day

• Females can donate 4x every other day





• Granulocytes ready for infusion by early afternoon

• All granulocytes irradiated

• Half life of granulocytes is six hours

• Transfuse within 2 hours of collection

• No good way to store granulocytes



• Use of COBE/Spectra continuous flow blood cell separator.

• Aim of Yield

• minimum 4 x 10(10) cells

• average 8 x 10(10) cells

• No need for ABO compatibility

• most RBC’s are taken out

• No need to be CMV negative




Granulocyte Infusions

• Transfuse over 1-2 hours

• Premedicate: 650 mg acetaminophen po 25 mg diphenhydramine IV

50-100 mg hydrocortisone IV

Meperidine for rigors prn

• Give 2 hours apart from Amphotericin B preparations

• Monitor patient for possible reactions



Possible Reactions/ Nursing Interventions

• Fever, chills r/o granulocyte reaction• Intervention: Hold transfusion Repeat premedications

Give meperidine If better can restart after 30

minutes.


Possible Reactions/ Nursing Interventions

• Dyspnea r/o fluid overload vs. WBC migration range from overload/pulmonary

edema/ARDS• Intervention: Furosemide IV, breathing treatment Slow infusion rate Possible intubation


Possible Reactions/Nursing

Interventions• Pain at infection site

i.e. chest pain, lesions

• Intervention:

analgesics


Evaluating Response

• Disappearance of fever

• Clearance of positive cultures

• Improvement in physical findings

• Improvement in imaging (CT, CXR)

• Improvement in performance status


Case Study

• 10/12/10 26 yr old married female with relapsed ALL s/p allogeneic transplant. Admit for fever and increasing counts. Start Methotrexate and Peg L- asparaginase.

• 10/16/10 c/o facial pain with sinus pressure. CT c/w acute sinusitis. Seen by ENT, frozen section—fungal hyphae.

• 10/20/10 Ambisone, caspofungin started then posaconazole

• 10/22/10 Granulocytes started. Debridement #1.


Case Study

• 10/31/10 Debridement # 2, biopsy still positive.

• 11/15/10 Debridement # 3, no evidence of fungus per ENT

• 11/21/10 SCT evaluation, two goals met: Decrease blast < 10% and control of fungal infection


Case Study

• Received total of 35 WBC transfusions over eight week period.

• Tolerated well

• Able to do some transfusions outpatient

• 12/10/10 Begin cord transplant regimen

• 12/19/10 Date of infusion of stem cells


Future

• Comparative study to determine if standard of care prophylactic antibiotics plus prophylactic white blood cell transfusions decrease the rate of infection compared to prophylactic antibiotics alone


THANK YOU!


QUESTIONS ?

Documents

Dallas, TX November 2–4, 2012 GRANUOCYTE TRANSFUSIONS