Apheresis Service Annual Haemoglobinopathy Course Sept, 2012 LUHANGA MUSUMADI Clinical Nurse Specialist Lead for Adolescent Transition Guy s & St Thomas NHS Foundation Trust Hospitals Luhanga.Musumadi@gstt.nhs.uk
Assess access Preparing patients for an EBT/RBCX program Informed consent: Provide literature / consider cognition issues in CVA and younger patients, may require family involvement Introduce patient to ward/unit/ Optia machine/ Meet other SCD patients on EBT program Address concerns regarding blood and virology risk (cultural and religious influences) Speak to employer or educational establishment regarding regular absences
Manual transfusion Manual Vs Automated Automated exchange Advantages Cheap Out of hours service Little training required Disadvantages Slow Estimates only High iron loading Poorly tolerated by patients Risk of Contamination &infection Advantages Quick, &Less labour Little iron loading Less volume shift Predictable end result Achievable low Hb S% Disadvantages Expensive equipment On call service costs Training
Access Peripheral requires large veins and fistula needle Portacath Requires strict asep<c techniques Femoral line inser<on with interven<onal radiology
Venous access - peripheral
Double lumen vortex port Access needle 16g non- coring needle Procedure Ames approx 2hrs The flow rates vary between 34-40
Femoral Line Vascular - X ray guided (NICE guidelines) Consent Cannulation NBM for sedation Considerations >DVT >Infection > Pain (local and oral analgesia)
How to do an automated exchange
Rou<ne bloods & Monitoring issues Pre Bloods FBC, HbS %, U&E, LFT, Bone profile, X- match, cloqng, FerriAn (day before) 6-8 units 6-10 weekly Consent EBT and femoral line Annual Virology (hepaaas B,C and HIV)
Prepara<on for procedure Height and weight Haematocrit IniAal Replacement (57%) End Hct (up to 2% above iniaal Hct) FracAon cells remaining (S %) Pre HbS% X 100 = FCR Target HbS% Volume to exchanged
Running the procedure In a stable patient at least 1.5 hour Need to slow rate if patient unwell up to 2 hours Children Small pts < 50kg Pregnant women Previous vaso-vagal Observations every 15-20 minutes Hypocalcaemia po or iv Ca Check Hb and S % 30min post tx Saline flush & Heplock Remove needles/ lines Observe for 1 hour
Targets & intervals Interval Can range between 4-10 weekly Target HbS Pre 8-10gdl Post Hb approx 1gm/dl above starting Hb
Managing a patient during an EBT/ RBCX Paediatric pts or adult emergency should be in HDU for monitoring reasons Local anaesthetic cream/spray prior to access or analgesia/sedation prior to vascath if appropriate Get patient to go to use toilet immediately prior EBT Ensure patient adequately distracted and comfortable) TV /Video/music etc
Managing a patient during an EBT/ RBCX Hypovolaemia and vaso-vagal episodes rare, but may happen. Give additional fluids via Optia if required or encourage oral fluids at home before precedure VOC pain may increase as opiates will be washed out during EBT
Vortex port-safety management & infection control Must have Protocols in place Strict controls on access Only trained and competent staff - Bands 6 and above to access ports
Challenges Non- flush blockages at ini<al access Difficul<es securing access needle Non flow/raised access pressures during procedure?? Flow rate,?? Posi<onal
Benefits of exchangesyoung Pt. A Ferritin 80 00 70 00 60 00 50 00 40 00 ug/l 30 00 20 00 10 00 0 H H L L Ferritin (ug/l) Jan 2010 Apr Jul Oct Jan 2011 Apr Jul Oct Jan 2012 Apr DA SI LVA RAMO S, G INGA
Benefits of exchanges Pt B. F e r r i t i n 3 0 0 0 F e r r it i n ( u g / l ) 2 5 0 0 u g / l 2 0 0 0 1 5 0 0 1 0 0 0 5 0 0 0 H L 2 0 1 0 2 0 1 1 2 0 1 2 J E F F R E Y - W H I T E, H A S S A N A Z I Z I H L
Improving Compliance with EBT/RBCX PosiAve encouragement and reminders about the need for EBT (team consistency) Issue le`ers with dates and Ame of next EBT and reminder telephone calls/ texts Ensure line inseraon is undertaken by competent person and if femoral under x- ray guidance or ultrasound with sedaaon Address needle, femoral line and blood phobias involve psychologist/play specialists if available
Improving Compliance with EBT/ RBCX ConsideraAons for other social issues (transport or childcare) Consider admiqng night before if issues with travelling, punctuality and reliability Flexibility and accommodaaons for work and school commi`ments (Exams for adolescents) and holiday Ames
Acknowledgements Dr Baba Inusa, Dr Jo Howard, Neil Westerdale, Magda Ferriera, Giselle Padmore- Penniston, Mylene Freires, Judith St Hillaire, Sharon Ndoro, Flo Bristow, Ernest Tsui, Helen Appleby,
The team
Thank you!
Manual or automated? Manual ozen emergency procedure, venesec<on followed by transfusion Labour intensive and <me consuming Imprecise Need more than one operator
INDICATIONS RBCx are generally reserved for the treatment or preven<on of life or organ threatening complica<ons of Sickle cell disease in suscep<ble individuals such as: Cerebrovascular disease Acute chest syndrome Priapism Pregnancy Pre- opera<ve
Exchange transfusion Procedure Manual exchange Automated exchange (Erythrocytapheresis)
How to do an automated exchange
How to do an automated exchange
How to do an automated exchange