Search

Background Entrustable professional activities (EPAs) are well-defined, executable, observable, and measurable activities that are performed by a trainee and can be performed independently as training progresses. The purpose of this study is to develop EPAs specific for the practice of apheresis medicine (AM). Methods Members of the American Society for Apheresis Graduate Medical Education subcommittee developed a list of 28 apheresis medical activities linked to Accreditation Council for Graduate Medical Education milestones and competencies in five areas: (a) consultation, (b) clinical care for therapeutic apheresis, (c) clinical care for donor collections, (d) test optimization, and (e) vascular access. Ten AM experts using a validated tool to measure the quality of the EPAs (QUEPA) evaluated these activities with use of a Likert scale. Per group consensus, an activity was considered acceptable for each domain if it had received an average score greater than 3.7, and it was rated 4 or 5 (agree or strongly agree) by at least 70% of experts. Results Of the 28 activities, 11 did not have acceptable QUEPA scores: 7 activities were rated as unobservable, 4 were rated unfocused, 2 were rated unrealistic and not generalizable, and 2 were rated as not addressing multiple competencies. Four activities had unacceptable scores in more than one domain. Subcommittee members edited these 11 activities over two review cycles to produce a final list of 26 activities. Conclusion A set of practical, focused, and observable EPAs in AM were systematically developed. These EPAs can be used to assess and support trainee performance in AM.

Current management of heparin-induced thrombocytopenia (HIT) involves prompt discontinuation of all heparin products and concomitant initiation of a direct thrombin or anti-Xa inhibitor for anticoagulation. In the setting of HIT complicated by an urgent need for cardiopulmonary bypass (CPB), the safety and the efficacy of short-term heparin-based anticoagulation after therapeutic plasma exchange (TPE) have been previously demonstrated. Patients with HIT requiring TPE are frequently on extracorporeal circuits (either CPB, extracorporeal membrane oxygenation [ECMO] or external ventricular assist devices [VADs]). Performing TPE in parallel with these circuits involves additional consideration for circuit size, anticoagulant/citrate management, as well as flow rates, and risk of air embolus. We report a case of a patient with HIT on external biventricular assist device (BiVAD) requiring urgent CPB who experienced thrombotic and hemolytic complications related to anticoagulation management around apheresis line placement for TPE. We also present results from a national survey of academic apheresis services regarding specific practices in managing patients with HIT on extracorporeal circuits who require TPE. In addition, we demonstrate the utility of TPE in patients with HIT on extracorporeal circuits and the risks of this procedure and the need to develop practice guidelines.

Background A prior practice survey revealed variations in the management of patients with sickle cell disease (SCD) and stressed the need for comprehensive guidelines. Here we discuss: 1) common indications for red blood cell exchange (RCE), 2) options for access, 3) how to prepare the red blood cells (RBCs) to be used for RCE, 4) target hemoglobin (Hb) and/or hematocrit (Hct) and HbS level, 5) RBC depletion/RCE, and 6) some complications that may ensue. Study design and methods Fifteen physicians actively practicing apheresis from 14 institutions representing different areas within the United States discussed how they manage RCE for patients with SCD. Results Simple transfusion is recommended to treat symptomatic anemia with Hb level of less than 9 g/dL. RCE is indicated to prevent or treat complications arising from the presence of HbS. The most important goals are reduction of HbS while also preventing hyperviscosity. The usual goals are a target HbS level of not more than 30% and Hct level of less than 30%. Conclusion Although a consensus as to protocol details may not be possible, there are areas of agreement in the management of these patients, for example, that it is optimal to avoid hyperviscosity and iron overload, that a target Hb S level in the range of 30% is generally desirable, and that RCE as an acute treatment for pain crisis in the absence of other acute or chronic conditions is ordinarily discouraged.

We surveyed multiple apheresis centers represented by the authors for their clinical approach to the management of anticoagulation issues during therapeutic plasma exchange (TPE). We present the results of their practices and a review of the pertinent literature. As plasma is removed during TPE, replacement with all or partial non-plasma-containing fluids (eg, 5% albumin) may lead to significant changes in hemostasis. These changes are amplified in patients who are receiving anticoagulation. We discuss various anticoagulants as well as the monitoring and adjustment of anticoagulation before, during, and after TPE. No single guideline can be applied, but rather, patients must be monitored individually, taking into account their often complex clinical conditions and medication profiles.

Congenital factor XI (FXI) deficiency is associated with a variable bleeding phenotype. Recent reports have documented the use of therapeutic plasma exchange to rapidly and isovolumetrically increase FXI levels before invasive procedures in patients with congenital FXI deficiency. We report a case of acquired FXI deficiency in a pregnant woman with lupus. We proved that the inhibitor was an IgG, therefore potentially capable of crossing the placenta. While immune suppression eliminated detectable circulating inhibitor, the woman's FXI remained quite low. A multi-disciplinary team was formed and therapeutic plasma exchange with 100% plasma replacement was performed when the patient went into labor, to acutely raise her FXI level and remove any potential non-neutralizing inhibitor. The mother had a controllable level of bleeding during post-TPE cesarean section; the baby had no bleeding and the baby's FXI levels were not overtly abnormal. Therapeutic plasma exchange in acquired FXI deficiency (or other acquired hemophilias) can both acutely isovolumetrically raise factor levels and remove any circulating inhibitor.

BACKGROUND Autoantibodies against Factor VIII (FVIII) define the rare but life-threatening bleeding disorder acquired hemophilia A (AHA). Correction of FVIII deficiency and eradication of the factor inhibitor are the ultimate therapeutic goals in this disorder. Bypassing agents such as recombinant factor VIIa (rFVIIa) or FVIII inhibitor bypassing agent are often used to control coagulopathy before the inhibitor is eradicated. Bypassing agents carry a risk of thrombosis, however. CASE REPORT We report a patient with newly diagnosed AHA and thalamic bleed who additionally had active atrial fibrillation and developed a segmental pulmonary embolism, limiting tolerable rFVIIa dosage. This patient with very-high-risk brain bleed and concurrent thrombosis on bypass agent represented a significant management dilemma for which we successfully utilized therapeutic plasma exchange (TPE) to reduce the inhibitor titer. RESULTS FVIII inhibitor was undetectable and FVIII level was above the lower limit of normal within 12.5 days from starting TPE. While the patient ultimately died 24 days from admission for reasons unrelated to bleeding, his intracerebral hemorrhage was unchanged in size and no other bleeding morbidity was observed. CONCLUSION This patient achieved eradication of FVIII inhibitor and did not have bleed expansion while receiving multimodal therapy including corticosteroids, rituximab, and TPE. We discuss the periprocedural risks of TPE in an acquired hemophilia patient and our multiteam management of that risk.

BackgroundAcute haemolytic transfusion reactions due to ABO incompatible blood transfusion remain a leading cause of transfusion-associated morbidity and mortality in the USA. Erroneous patient identification and specimen labelling account for many errors that lead to ABO mistransfusions; these errors are largely preventable.MethodsOur hospital requires a two-sample process of ABO/Rh typing prior to transfusion. Both samples must be drawn independently. To prevent simultaneous sample draw, our second sample tube has a unique pink top that is only available from the blood bank and can only be sent to the patient’s floor once the first sample arrives in the lab. We performed an audit of this process from 19 March to 30 July 2014 and 19 March to 30 July 2015.ResultsWe reviewed type and crossmatch orders for 2702 new patients during the audit period and 824 patients (30.5%) required transfusion. All patients evaluated received compatible blood, and no mistransfusions were recorded using this method. Three per cent of testing was performed incorrectly, which safely defaulted to giving type O blood.ConclusionsThe two-sample protocol used by our institution can decrease the risk of mistransfusion. Our protocol was relatively inexpensive, safe, efficient and practical for adaptation by other hospitals.

Autoantibodies against Factor VIII (FVIII) define the rare but life-threatening bleeding disorder acquired hemophilia A (AHA). Correction of FVIII deficiency and eradication of the factor inhibitor are the ultimate therapeutic goals in this disorder. Bypassing agents such as recombinant factor VIIa (rFVIIa) or FVIII inhibitor bypassing agent are often used to control coagulopathy before the inhibitor is eradicated. Bypassing agents carry a risk of thrombosis, however.We report a patient with newly diagnosed AHA and thalamic bleed who additionally had active atrial fibrillation and developed a segmental pulmonary embolism, limiting tolerable rFVIIa dosage. This patient with very-high-risk brain bleed and concurrent thrombosis on bypass agent represented a significant management dilemma for which we successfully utilized therapeutic plasma exchange (TPE) to reduce the inhibitor titer.FVIII inhibitor was undetectable and FVIII level was above the lower limit of normal within 12.5 days from starting TPE. While the patient ultimately died 24 days from admission for reasons unrelated to bleeding, his intracerebral hemorrhage was unchanged in size and no other bleeding morbidity was observed.This patient achieved eradication of FVIII inhibitor and did not have bleed expansion while receiving multimodal therapy including corticosteroids, rituximab, and TPE. We discuss the periprocedural risks of TPE in an acquired hemophilia patient and our multiteam management of that risk.

Introduction: Patients with hematologic malignancies frequently require lumbar punctures (LPs) for administration of intrathecal chemotherapy. With myelosuppressive chemotherapy, thrombocytopenia is common and patients often require platelet transfusions in order to reduce the risk of bleeding during invasive procedures. However, there is a dearth of evidence supporting a platelet threshold required for LPs. Guidelines from the American Association of Blood Banks recommend a minimum platelet count of 50 x 103/µL, but this is based largely on expert opinion. Platelet transfusion is associated with risk of transfusion reaction and alloimmunization, cost, and procedural delays. Given these risks, we instituted a reduction in platelet threshold to 40 x 103/µL for lumbar puncture. We retrospectively reviewed patient outcomes to assess the safety and efficacy of this approach. Methods: In November 2017, a platelet count threshold for LPs was introduced for adult oncology patients in both the inpatient and outpatient settings at Froedtert and the Medical College of Wisconsin. Previous guidelines recommended a platelet count of 50 x 103/µL in order to undergo a lumbar puncture. This threshold was decreased to 40 x 103/µL for oncology patients. Guidelines were agreed upon and implemented in all procedure settings: the inpatient procedure team, the outpatient procedure suite, and the radiology department (for fluoroscopy-guided lumbar puncture). Data regarding the pre-procedure platelet count, number of platelet transfusions given per procedure, CSF RBCs, and occurrence of post-procedure spinal hematomas were collected through the electronic medical record. Results: From November 1, 2016 to May 1, 2018 267 oncology patients underwent a lumbar puncture. Oncologic diagnosis was NHL, ALL, AML, solid malignancy, or other hematologic malignancy/disorder in 26%, 23%, 18%, 16%, and 17%, respectively. 42% of were female. A total of 845 LPs were performed under fluoroscopy, with ultrasound guidance, and by an experienced provider in 26%, 58%, and 16% of cases respectively. 534 LPs (63%) were performed with a platelet transfusion threshold of 50 x 103/µL (Plt≥50) and 311 LPs (37%) were performed with a platelet transfusion threshold of 40 x 103/µL (Plt≥40). The average pre-LP platelet count was 152.8 x 103/µL in the Plt≥50 group and 138.4 x 103/µL in the Plt≥40 group. 79 patients in the Plt≥50 group and 42 patients in the Plt≥40 group had a recorded platelet count between 40-49 x 103/µL within 24 hours prior to the procedure. After institution of the new guidelines, 40 LPs were performed with a platelet count < 50 x 103/µL. The average number of units of platelets transfused per procedure significantly decreased from 0.58 to 0.39 after lowering the transfusion threshold (p < 0.05). One lumbar epidural hematoma occurred post-intervention and one lumbar subarachnoid hematoma occurred pre-intervention, both in patients whose pre-procedure platelet counts were > 100 x 103/µL. No traumatic hematomas were observed in patients whose pre-procedure platelet count was < 50 x 103/µL. The incidence of traumatic taps (identified as CSF red blood cells > 10/µL) was significantly higher in patients whose pre-procedure platelet count was < 50 x 103/µL (64% vs. 46%, p Conclusion: Decreasing the LP platelet transfusion threshold from 50 x 103/µL to 40 x 103/µL significantly reduced platelet transfusions. This was not associated with an increased risk of complications. However, the incidence of traumatic taps was significantly higher in patients with a platelet count < 50 x 103/µL. Given that the average cost of one unit of platelets is approximately $500 and 40 procedures were performed with a platelet count < 50 x 103/µL, decreasing the platelet transfusion threshold resulted in a cost savings of approximately $20,000 over the course of 6 months, not including administrative costs. Overall, this data suggests that lowering the platelet transfusion threshold for lumbar punctures to 40 x 103/µL is both safe and cost effective for oncology patients. Disclosures Atallah: Abbvie: Consultancy; Jazz: Consultancy; Novartis: Consultancy; BMS: Consultancy; Pfizer: Consultancy.

Background Radioactive iodine (RAI) is a treatment for patients with thyroid carcinoma after thyroidectomy. The Na+/I- symporter (NIS) plays a role in this ability to concentrate iodide within tumor cells. Recent studies have shown a correlation between immunohistochemical staining of NIS and the ability to concentrate iodide mainly in tumors > 1.0 cm. Here only papillary thyroid microcarcinomas (PTMC) with or without LN metastasis (LNM) are evaluated to observe NIS expression. Design A retrospective study involved 47 cases of PTMC (24 with and 23 without LNM). Immunostains were performed using two different monoclonal anti-NIS antibodies: clone SPM186 from Abeam and clone FP5A from Millipore. Results The findings were very similar using two different monoclonal antibodies. One out of 24 cases with LNM displayed focal expression of NIS while two cases showed several NIS-positive cells. None of 23 cases without LNM and none of metastatic tumors showed NIS expression. Ten benign nodules with Hiirthle cell features exhibited moderate membranous stain. Conclusion PTMC with or without LNM show minimal to no expression of NIS. NIS expression and function may not be the same in PTMC vs a non-PTMC and RAI therapy may not be effective in treating PTMC due to lack of NIS.