Guideline

Purpose

This guideline describes the processes for requesting, administering, and monitoring buffy coat granulocyte infusions at The Royal Children’s Hospital for relevant oncology, haematology and immunology patients. 

Responsibilities

• The Bone marrow transplant physician or other primary treating clinician is responsible for contacting the laboratory haematologist/transfusion medicine specialist to discuss the clinical indication and role of buffy coat granulocytes in the management of their patient.  
• It is the role of the laboratory haematologist/transfusion medicine team/head of laboratory to discuss the request for granulocytes with Australian Red Cross Lifeblood.
• The Lifeblood transfusion medicine specialist will provide a copy of the formal request form entitled “Patient Tailored Component Request Form and Disclaimer – Whole Blood derived Buffy Coat Granulocytes”
• This formal request form needs to be completed by the bone marrow transplant physician or laboratory haematologist and the disclaimer signed with acknowledgement that granulocytes are non-conforming blood component.
• The Bone Marrow Transplant physician or other primary treating clinician informs the AUM in the clinical area regarding the anticipated timing of the granulocyte infusion to ensure appropriately skilled nursing staff are available to allow timely administration.
• The RCH Blood Bank receives the product from Lifeblood, ensures it is irradiated and issues it to the clinical area. In the rare event that the product was received un-irradiated (i.e., Lifeblood irradiator down-time), the RCH Blood Bank will irradiate the units on-site, prior to issue. 

Description 

• Buffy coat granulocytes are an irradiated whole blood derived component that contains granulocytes.
• The product is a patient-tailored component issued on a case-by-case basis upon authorization from the Lifeblood Transfusion Medicine Specialist.
• The product contains high levels of red cells and must be ABO and Rh compatible with the recipient 

Clinical Indications 

• Despite evidence that donated granulocytes are functional, their clinical efficacy is uncertain.
• Serious adverse events are well recognised complications following granulocyte transfusions therefore the use of granulocytes should be limited to patients in whom benefits are thought to outweigh the risks. 

Minimum criteria

1. (a) Severe neutropenia, defined as a neutrophil count of <0.5 x 10^9/L, where neutrophil recovery/engraftment is anticipated, or  
   (b) chronic granulomatous disease or other congenital disorders of neutrophil function
2. Active therapy with high likelihood of achieving disease remission 
3. Evidence of bacterial or fungal infection (i.e., clinical symptoms of infection, positive symptoms of infection, positive cultures, pathological diagnosis of infection from biopsies or radiological evidence) 
4. Poor response to antimicrobial treatment (at least 48 hours except in extreme circumstances) 

• In patients meeting the above criteria, daily granulocyte support may be coordinated through Lifeblood. Note there may be challenges providing granulocytes on weekends and public holidays. 

Specifications 

• Irradiated whole blood derived buffy coat component containing granulocytes
• Volume (ml) > 40ml (Typical 46 – 66ml)
• Neutrophil count > 0.3 x 10^9/unit
• Platelets > 60 x 10^9/unit
  • The component contains 1-2 adult transfusion doses of platelets and additional platelet transfusions are therefore unlikely to be required.
• Buffy coats have a high haematocrit and may reduce the need for top up red cell transfusions, venesection may be needed if patients are not red cell transfusion dependent.
• In addition to mandatory testing, all granulocytes are tested for antibodies to human T-cell lymphotropic virus (HTLV)
• Available in groups O, A and B and Rh positive and negative groups
  • Note granulocytes contain red cells
  • Buffy coat components should be ABO and Rh (D) type compatible with the recipient’s plasma
  • In HSCT patients, buffy coat components should be compatible with both donor and recipient blood groups

• Available in CMV negative or CMV unscreened – consider CMV status of transplant recipient.  
• CMV negative granulocytes should be issued where possible for CMV negative recipients at risk of CMV disease.
• If a CMV negative component is unavailable, the clinician must balance the potential risk of subsequent CMV disease against the risk of morbidity/mortality from bacterial or fungal infection. 

Shelf/life and storage 

• Granulocytes should be used as soon as possible after their preparation.
• Store at 20 – 24 degrees for maximum of 24 hours (expiry is 24 hours after the first collection).
• Please discuss with on-call haematologist if expiry time has been met and infusion has not yet been completed
• Granulocytes must be irradiated
• Never store in a refrigerator
• Buffy coat granulocytes must not be agitated during storage – do not send via pneumatic tube

Order and dose 

• Adult dose is a minimum of 10 buffy coats (~500mls)
• Children <50kg – a dose of 10ml- 20ml/kg to a maximum of 10 buffy coats
• The dose requested from Lifeblood may differ from dose received, since it depends on the product meeting all specifications and mandatory testing requirements.
• Buffy coats can be ordered in EPIC and may be administered within EPIC. 
• A paper compatibility report will be issued by laboratory to ensure there is no delay in administration

Consent 

• Transfusion consent must be obtained for granulocyte transfusions. 

Administration 

• Granulocyte transfusions are associated with a high rate of mild and moderate transfusion reactions. Premedication prior to infusion may reduce this risk and are advised in most patients. 

Premedication 

• Hydrocortisone 25 - 100mg IV (1-2 hours prior to infusion)
  
• Antihistamine – Cetirizine 2.5 - 10mg Oral or IV Phenergan (1-2 hours prior to infusion)
  
• Paracetamol 15mg/kg up to 1g (½-1hour prior to infusion)
  
• Ensure the patient is well hydrated prior to administration - consider pre-hydration with 0.9% saline (e.g.,125ml/m²/hr for 4hours pre infusion.)

Preparation 

• Product must be checked and signed by two members of nursing or medical staff at the time of administration as per all fresh blood product administrations.
• Visually check the granulocyte product, confirm the appropriate labelling, integrity of the product and irradiation status.
• Perform baseline transfusion observations – Temperature, Heart Rate (HR), Blood pressure (BP), Respiratory Rate (RR), Oxygen saturations.
• Ensure adrenaline and oxygen are available and medical staff available for resuscitation if a severe reaction occurs.
• There is a risk of transfusion associated circulatory overload if a large infusion volume relative to patient weight is given, consider frusemide post infusion 

Staffing 

• Two nursing staff are required to check and administer the product
• The patient must be closely monitored for transfusion reactions and a nurse must remain at the bedside during the entire infusion.
• Medical staff should be present for the first 15 minutes of the infusion and available throughout for urgent medical review  

Observations 

• Standard transfusion observations – Temperature, HR, BP, RR and Oxygen saturations at the following time points:

Infusion 

• Infuse as soon as possible.
• Granulocyte transfusion must be prioritised for administration – may need to hold other non-urgent medications/infusions to allow delivery due to short expiry life.
• Transfuse through a standard blood administration set containing a filter with a pore size of 170-200 microns. Do NOT use bedside leucocyte reduction filters.
• Administer via a central venous catheter or wide bore IV cannula.
• Do not infuse other medications or infusions through the same IV line or VAD lumen as granulocytes
• Granulocytes must be infused by gravity, do NOT use an IV pump. 
• Review volume for infusion, patient weight and confirm IV line drip rate (drop factor)
• Note: IV line in use typically administer 20 drop/mL 
  

Volume of granulocytes X drop factor of line (e.g., 20 drops/mL) = n drops/minute

Time for infusion in minutes

To adjust the rate, use the roller clamp to regular to infuse at the desired rate, will need to count the drops/minute for a full minute.

Rates 

• If <5kg commence at 1-2 drops/minute (<10ml/hr) for 15 minutes
• If >5kg commence at 3 – 6 drops per minute (10 – 20ml/hr) for 15 minutes
• If observations remain stable and no transfusion reaction is observed, increase the infusion rate to a rate as fast as tolerated, taking into account patient weight, volume of product, routine IV maintenance volume and maximum red cell transfusion rate of 5ml/kg/hr
• Aim to infuse total product over approximately 2 - 4 hours.
• e.g., 10 buffy coats of approximately 500mls, administered over 2 – 4 hours, will need to be infused at between 125 to a maximum of 250mls/hr.  
• Record time of completion of units 

Note: the product can be viscous and difficult to infuse, regular flushing or use of a giving set with normal saline and gentle agitation of the product may help maintain the flow rate. 

Note: Administer separately to amphotericin B: there must be at least 2 hours between amphotericin B and granulocyte infusions as there may be an increased risk of pulmonary reactions in patients receiving granulocytes with amphotericin B. 

Reactions and adverse events 

• Acute reactions
  • There is a high rate of mild- moderate reactions (25 – 50%) – typically fevers > 38 degrees and chills – slowing the infusion and premedications can help reduce their incidence.
  • 1% chance of severe pulmonary reactions e.g., Transfusion-associated acute lung injury (TRALI – symptoms of cough, dyspnoea, hypoxia with CXR changes
  • Polycythaemia has been reported post transfusion due to the high HCT in buffy coat granulocytes and venesection is sometimes required.
• Delayed transfusion reactions
  • HLA alloimmunization
  • Red cell alloimmunization
  • Platelet refractoriness
  • Transfusion associated graft versus host disease (TA-GVHD)
  • Transfusion-transmitted infection. 

• If the patient develops signs and symptoms of transfusion reaction, the infusion should be stopped temporarily.
• Do not discard blood product
• Keep IV line open with normal saline.
• Patient should be evaluated urgently by medical staff.
• Notify the blood bank and oncall haematologist
• Notify the bone marrow transplant physician or primary treating clinician.
• Mild alterations in observations e.g., a drop in BP or tachycardia may be able to be managed by just slowing the infusion rate.
• If symptoms are easily treated and resolve granulocytes may be able to be recommenced.
• The decision to discard granulocytes should only be made in conjunction with senior medical staff and the haematology consultant.
• All transfusion reactions and adverse events must be reported as soon as possible after the events, so that a timely and thorough review can occur. Notify blood bank and on-call haematologist.   
• Transfusion reactions will be reported to VHIMS and the Blood Management committee. Severe reactions will be reported to STIR. 

Post infusion 

• Continue monitoring vital signs (Temperature, HR, RR, BP and Oxygen saturations) every 1 hour until 6 hours post completion of granulocytes, particularly delayed respiratory reactions.
• Document urine output for 12 hours- report oliguria (urine output <2ml/kg/hr) to the bone marrow transplant physician or treating physician.
• Check FBC 60 minutes after the infusion to assess for polycythaemia and neutrophil increment.
• Minimum daily FBC monitoring.  
• Consider the possibility of a delayed transfusion reactions or adverse events to granulocytes in patients who clinically deteriorate in the days to weeks following granulocyte transfusions.  
  

Determining the recipient response

• Monitor change in neutrophil count to determine response and need for ongoing granulocyte support.
• Granulocytes may be given maximally once a day.
• Monitor for changes in signs and symptoms of underlying infection.
• Criteria for cessation
  • Neutrophil recovery or bone marrow engraftment with a neutrophil count >0.5 x 10^9/L for 3 days.
  • Clinical infection has resolved based on clinical symptoms/signs and supportive investigations
  • The patient’s clinical condition worsens and patient care is redirected.
  • Severe reaction to granulocyte transfusions