Adverse effects of aRCE
| Risk . | Clinical comments and mitigation/treatment strategies . |
|---|---|
| Catheter-related complications | |
| Thrombosis | Catheters should be locked with heparin or citrate after the procedure. Many institutions (including ours) also perform a 30-60 minute dwell of thrombolytic medication prior to all procedures. Resistance to draw or flush with frequent procedure alarms may suggest thrombosis, and radiologic evaluation of line such as fluoroscopy should be performed. |
| Infection | Blood cultures should be obtained in any febrile SCD patient with a CVC. High suspicion of catheter related bacteremia if signs of sepsis occur after flushing CVC, and prompt antibiotics are warranted. |
| Migration of line | Tip of line should be near superior vena cava/right atrial junction. Poor flow rates, frequent alarms, or resistance to draw or flush can suggest migration of line from central location and should be evaluated with chest radiograph. |
| Communication between 2 catheters of implanted ports creating recirculation | We have experienced this 3 times over the past 10 years and only suspected recirculation based on no change in HbS and platelets in post-aRCE labs compared to pre-aRCE labs because no alarms or other indications of difficulties occurred during procedure. Communication was diagnosed by fluoroscopy exam and necessitated line replacement. |
| Transfusion reactions | Febrile nonhemolytic transfusion reactions and allergic reactions are the most commonly seen transfusion reactions, though hemolytic and other transfusion reactions are also possible. |
| Hypocalcemia due to citrate toxicity | Citrate-induced hypocalcemia can cause paresthesias or nausea/vomiting though is typically asymptomatic when detected. Ionized calcium can be monitored during the procedure, and we elect to give calcium gluconate infusions through the return line to maintain normal ionized calcium. |
| Hypotension | Changes in blood pressure can occur, though rare, and are typically responsive to normal saline boluses. |
| Symptoms related to fluid shifts | Vasovagal symptoms, abdominal pain, nausea, and vomiting despite normal blood pressure and ionized calcium can be seen, though rare, and are presumed to be due to fluid shifts during the procedure. Normal saline boluses and/or antiemetics can be administered in future procedures for patients who experience these symptoms. |
| Alloimmunization | Prophylactic phenotypically matching RBCs at a minimum for Ce, Ee, and K antigens (in addition to ABO/D) is recommended for SCD.34 Despite this, alloimmunization can occur and if multiple/rare RBC antibodies develop, and it can be difficult to maintain patients on chronic aRCE programs due to the need for rare blood. Note that lower alloimmunization rates with aRCE compared to chronic simple transfusion have been reported despite significantly increased exposure with aRCE.31 |
| Risk . | Clinical comments and mitigation/treatment strategies . |
|---|---|
| Catheter-related complications | |
| Thrombosis | Catheters should be locked with heparin or citrate after the procedure. Many institutions (including ours) also perform a 30-60 minute dwell of thrombolytic medication prior to all procedures. Resistance to draw or flush with frequent procedure alarms may suggest thrombosis, and radiologic evaluation of line such as fluoroscopy should be performed. |
| Infection | Blood cultures should be obtained in any febrile SCD patient with a CVC. High suspicion of catheter related bacteremia if signs of sepsis occur after flushing CVC, and prompt antibiotics are warranted. |
| Migration of line | Tip of line should be near superior vena cava/right atrial junction. Poor flow rates, frequent alarms, or resistance to draw or flush can suggest migration of line from central location and should be evaluated with chest radiograph. |
| Communication between 2 catheters of implanted ports creating recirculation | We have experienced this 3 times over the past 10 years and only suspected recirculation based on no change in HbS and platelets in post-aRCE labs compared to pre-aRCE labs because no alarms or other indications of difficulties occurred during procedure. Communication was diagnosed by fluoroscopy exam and necessitated line replacement. |
| Transfusion reactions | Febrile nonhemolytic transfusion reactions and allergic reactions are the most commonly seen transfusion reactions, though hemolytic and other transfusion reactions are also possible. |
| Hypocalcemia due to citrate toxicity | Citrate-induced hypocalcemia can cause paresthesias or nausea/vomiting though is typically asymptomatic when detected. Ionized calcium can be monitored during the procedure, and we elect to give calcium gluconate infusions through the return line to maintain normal ionized calcium. |
| Hypotension | Changes in blood pressure can occur, though rare, and are typically responsive to normal saline boluses. |
| Symptoms related to fluid shifts | Vasovagal symptoms, abdominal pain, nausea, and vomiting despite normal blood pressure and ionized calcium can be seen, though rare, and are presumed to be due to fluid shifts during the procedure. Normal saline boluses and/or antiemetics can be administered in future procedures for patients who experience these symptoms. |
| Alloimmunization | Prophylactic phenotypically matching RBCs at a minimum for Ce, Ee, and K antigens (in addition to ABO/D) is recommended for SCD.34 Despite this, alloimmunization can occur and if multiple/rare RBC antibodies develop, and it can be difficult to maintain patients on chronic aRCE programs due to the need for rare blood. Note that lower alloimmunization rates with aRCE compared to chronic simple transfusion have been reported despite significantly increased exposure with aRCE.31 |