GAP-113
Management of Implantable LVAD Insertion in a Patient with Known Anaphylaxis to Blood Plasma Proteins
Andrews J, Jooste E, Ames W, Homi H, Machovec K
Duke University Medical Center, Durham, NC, USA
Allergic reactions are common adverse events with blood transfusion (1). We present a 7 year old female with nephroblastoma and chemotherapy-induced cardiomyopathy who presented for left ventricular assist device (VAD) placement, but with a history of anaphylaxis to plasma proteins.
The child presented with bilateral nephroblastoma and underwent right and partial left nephrectomy followed by chemotherapy, including doxorubicin. Upon subsequent hospitalization for pancytopenia, she experienced a moderate allergic reaction to platelets. The following day, despite premedication, she again suffered a reaction while receiving platelets, with severe hypotension, chills and emesis. This was diagnosed as a major anaphylactic reaction to blood proteins.
Six months after starting chemotherapy, she presented with tachycardia, dyspnea and renal failure, and she was diagnosed with chemotherapy-induced cardiomyopathy. After 5 weeks of inotropic therapy, she experienced cardiac arrest requiring extracorporeal membrane oxygenation and was scheduled for VAD implantation.
Multidisciplinary cooperation was necessary for management of her transfusion needs during VAD implantation. Her platelet count decreased to 55,000/µL due to hemodilution during cardiopulmonary bypass, necessitating transfusion of washed and irradiated platelets, after premedication. She did not require coagulation factor or fibrinogen replacement.
While the child did not have an adverse transfusion reaction during LVAD implantation, her case illustrates the difficulty in managing a child requiring cardiac surgery who has a plasma protein allergy. Blood donor proteins are the source of anaphylactic reactions. Cellular transfusion products, like red blood cells and platelets, are washed to rid the product of proteins (2). However, the time needed for washing must be considered – one hour to wash RBC and two hours to wash platelets. Fresh frozen plasma (FFP) and cryoprecipitate are protein-rich products and should be avoided. Physicians have three options when needing to replace coagulation factors: 1) administer factor concentrates, including prothrombin complex concentrate (PCC) and fibrinogen concentrate; 2) administer Octaplas, a solvent-detergent treated pooled plasma product (3), or 3) administer FFP after appropriate premedication, with prophylactic inotropic and vasopressor support. Acute normovolemic hemodilution may also play a role (4).
Long term management of this child’s transfusion needs requires multidisciplinary action. Given her age, critical illness, and projected long wait for transplant, she will require coagulation factor replacement during her course. Factor concentrates are appropriate, but the thrombogenic risks of PCC and recombinant factor VII in a pediatric patient with a VAD are unknown. If FFP or cryoprecipitate units must be used, the need for increased cardiovascular support should be anticipated, in case of anaphylaxis recurrence. In a cardiac surgical setting, it may be appropriate to administer protein rich products during bypass when full cardiopulmonary support is assured.
1. Br J Haematol 2013;160:434-444
2. Transfusion 2011;51:1030-1036
3. Transfusion and Apheresis Science 2012;46: 129-136
4. Paediatr Anaest 2017;27:85-90
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