No blood transfusion r/t high WBC??

[Aeterna, BSN, RN]

I meant to ask this of one of the more experienced onco nurses on the floor today but never got the chance/forgot...

I had a patient with leukemia. WBC was through the roof - steadily coming down over the last few days but still very high. His hemoglobin was low and he required a unit of PRBCs yesterday. I asked the MD if he would like to order another unit of blood for today but the MD said he didn't want to give too much blood until the WBC came down some more.

Does anyone know the rationale for this? I am very curious :confused:

[nursie_pants]

Sorry, I'm responding not with an answer but to also express my curiosity w/this.

Depending on just how low the h/h was, I think I've heard of doctors holding transfusions for pts w/leukocytosis... I'm not sure if the pt is at an increased risk for sepsis, or if an elevated WBC count generally presents a less-than-ideal conditions for a pt to receive/benefit from packed cells.

Hopefully someone else here has some answers! :)

[dardeedee]

Are they undergoing induction therapy? Are they eligible for a transplant? The more blood and blood products they receive, the more likely they are to develop antibodies. These patients have so much going on all at once it is hard to tell.

[EricJRN, MSN, RN]

I don't think there's a specific contraindication. It may just be an attempt to be conservative. When a patient produces a ton of leukemic cells, other blood cells can be "crowded out" - which contributes to the anemia and thrombocytopenia you often see even before treatment in leukemia.

The doc is likely thinking that the anemia will get better with "watchful waiting" as the white count continues to decrease.

[Aeterna, BSN, RN]

I don't think there's a specific contraindication. It may just be an attempt to be conservative. When a patient produces a ton of leukemic cells, other blood cells can be "crowded out" - which contributes to the anemia and thrombocytopenia you often see even before treatment in leukemia.

The doc is likely thinking that the anemia will get better with "watchful waiting" as the white count continues to decrease.

This actually makes a lot of sense to me. I'm still curious as to what exactly was going through the doc's mind at the time, but at least we have a guess. Thanks!

[globalRN]

when the WBC is high...the blood is very viscous...adding PRBC to this just thickens it more

..increases the existing high.risk of clotting

[caroladybelle, BSN, RN]

Intially, with an excessively high WBCs (blast crisis) the blood is quite thick. Pouring PRBCs which are quite thick, into vessels just worsens the blood flow. In addition, with huge amounts of WBCs, they tend to crowd out the RBCs from getting and transporting optimal amounts of oxygen. So they really don't help and may harm the pt.

Add in that giving something foreign (donor blood) will often provoke an immune response.......the body may kick up the WBC production when the pt least needs them.

[msjellybean]

when the WBC is high...the blood is very viscous...adding PRBC to this just thickens it more

..increases the existing high.risk of clotting

This was my thought as well.

[OCNRN63, RN]

This actually makes a lot of sense to me. I'm still curious as to what exactly was going through the doc's mind at the time, but at least we have a guess. Thanks!

Ask him. Seriously, it's how you learn.

[globalRN]

that is probably what was going thru his mind.

I don't order PRBC transfusions without considering the chance that the patient will end

up with an ischemic event/thrombus which would add to their problems. I have encountered this situation and opted not to transfuse. the nurses asked me why and I explained it to them

the tx is to address the high WBC and relieve the patient's distress, if that is not possible or treatable ....then palliative care and comfort