Natalie White
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The importance of blood products during treatment

Natalie White
Posted by
18 Jul 2017

I am Natalie White. I'm a Senior Biomedical Scientist and I work in Blood Transfusion and Haematology.

During my treatment for acute myeloid leukaemia I saw a different side to the work that I do.

During my treatment for acute myeloid leukaemia I required multiple blood transfusions and received 43 units of blood products (the name given to the different components that make up the blood). Within just six months, I received 19 units of red blood cells, 14 units of platelets and 10 units of granulocytes (a type of white blood cell), costing the NHS around £15,500!

As a Senior Biomedical Scientist (BMS) in a transfusion laboratory, I have ‘cross matched’ blood products on numerous occasions for patients on chemotherapy, those undergoing operations and for emergency haemorrhage situations.

Prior to my own diagnosis, I was always aware of the importance of blood products issued by the laboratory and the way this precious resource should be safeguarded to allow patients access to the products they require. And to also prevent inappropriate or excessive use of these selflessly donated products. I have personally received emails directly from the NHS Blood and Transplant service (NHSBT) advising our laboratory of the limited stock levels available and have made countless orders for blood products of a certain blood group, only to be offered a suitable alternative as the first choice was simply not available.

Since my diagnosis and blood transfusions, I am no longer able to donate blood. However I encourage my friends and family members to donate on my behalf and I am keeping a record of their donations in order for me to understand when my debt to the national blood service has been repaid.

The transfusion of red blood cells

My first transfusion was in October 2016 and was essentially to help make me feel well enough to get married, prior to my treatment commencing. I received two units of red blood cells four days before my wedding day in order to boost my haemoglobin levels and help with the tiredness and breathlessness I’d been experiencing.

A few weeks before, I had been cycling with friends and couldn’t quite understand why I wasn’t able to keep up! None of us are fitness freaks by any stretch of the imagination, but as I’d been horse riding regularly prior to this outing, I expected to at least be able to keep up on a bike ride along the canal! I hadn’t been given my diagnosis at this point but everything made sense when I later received my full blood count results.

My haemoglobin level was 80 g/L (Hb), when it normally runs at the higher end of normal – 150 g/L (Hb). Because it was a gradual process, it wasn’t until I was aware of my results that I realised how breathless and worn out I'd become. On top of this, at the time of my diagnosis I was working full time, plus on call at weekends, riding a horse multiple times a week and doing an MSc in Biomedical Science by distance learning. I figured feeling tired and drained was normal... 

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My next red cell transfusion was given as a result of blood loss during the process of harvesting my eggs. I’d been offered this procedure because I was 28 years old with no children and knew it was highly unlikely that I’d retain fertility after chemotherapy. Egg harvesting is normally a simple procedure where patients inject hormones into their stomach for around one week to help stimulate egg overproduction and then attend hospital for the eggs to be removed and frozen for future use. I had to attend the hospital for an appointment to see how the egg simulation was progressing on my wedding day!! The hospital gave me the earliest possible appointment and I booked the church a little later than I originally planned, telling my future husband not to be worried if I left him standing at the alter for a while.

The day of the procedure seemed to go well and I was sent home just hours after I'd woken from the anaesthetic. Although I felt sore, I thought this was expected. It wasn’t until later that evening that the pain began to worsen and became unbearable I had to ask my husband to take me back to the hospital. I expected to be prescribed some strong painkillers and then sent home but instead I had an ultrasound scan which showed excessive bleeding. I remained in hospital for almost two weeks until the blood was reabsorbed and the pain subsided, as surgery was considered too risky with my underlining condition. My haemoglobin level fell substantially due to both the blood loss and my leukaemia, and as a consequence I required two units of red blood cells.

The remaining 16 units of red blood cells were transfused after my chemotherapy treatment had commenced. Chemotherapy drugs affect fast-dividing normal cells as well as the cancerous cells. As a side effect of chemotherapy treatment, the fast dividing blood cells may be killed and the patient may require a blood transfusion. White cells, red cells and platelets are all affected, leaving the patient susceptible to infections and bleeding. Red cells are given to treat anaemia; platelets to prevent bleeding; and white cell donations (which are rarely used) can be effective in immunocompromised patients, where the immune system struggles to fight infection following chemotherapy. I had three cycles of chemotherapy and was transfused the 16 units of red blood cells over the three cycles. At one point my haemoglobin level fell to 60 g/L. It’s important to keep Hb levels above threshold levels in order to keep the body supplied with enough oxygen and to prevent cardiac arrest.

The transfusion of platelets

I practice in a different hospital from the one I was treated in. The protocols and procedures surrounding blood products are very similar as they both follow the British Committee for standards in Haematology (BCSH) guidelines, but they’re not the same. I don’t remember my first platelet transfusion because I was so unwell. It would have been given during my first chemotherapy cycle as my platelet count had fallen due to the treatment prescribed. I do remember the platelet transfusion ordered during my first cycle of chemotherapy, which was challenged by the blood transfusion laboratory. Over the last six years, I have challenged doctors who have ordered excessive amounts of blood products compared to our laboratories maximum blood order schedule. It is simply part of the job of a Biomedical Scientist working in blood transfusions. We safeguard the products we hold and protect them from inappropriate use without refusing products at a doctor’s request. However as a patient, I experienced the flip side of this...

I had an infected Hickman line which needed to be removed, but I also had a low platelet count and was susceptible to bleeding. The doctor who reviewed my morning blood counts had ordered a unit of platelets to be transfused prior to the removal of the line. My platelet count was just below the threshold for removal and the laboratory challenged the decision to transfuse. The doctor agreed with the laboratory and the request for platelets was cancelled – I was very distressed as a result of this decision. As a BMS I know the BCSH guidelines are ‘guidelines’ but I also know that had my full blood count been run again, the analyser would produce a report very similar to the first but not identical. My count was so close to the threshold that the difference was not considered significant. But to me it was. As the patient lying in the hospital bed about to have a line removed from one of the veins close to my heart, I was concerned and anxious about bleeding.

At first I refused to have my line removed. I blamed the laboratory for cost cutting and being heartless. I was very unwell with a very nasty infection in my liver at the time. I had no white blood cells of my own to help me fight the infection and was receiving regular red cell transfusions to help maintain my haemoglobin levels. I came to my senses a few hours later and agreed for the line to be removed without the platelets, as it was thought to be an additional source of infection. I requested for a cannula to be inserted prior to removal of my line so I had a line ready for use in case I did bleed. The Hickman line was removed with no issues. The platelets had not been necessary, the laboratory had prevented me from being exposed to a blood product I didn’t need and saved around £200. Had I bled during the removal of the line, the platelets would have been released without question.

My next ‘platelet problem’ came during my second chemotherapy cycle in which I developed petechea – bleeding in the skin – and required platelet support. My full blood count showed that my platelet count had fallen to 8 x109/L (the normal range is 150 x10 9/L – 450 x10 9/L) leaving me at risk of spontaneous bleeding. I had received several units of platelets but my platelet count was not incrementing and I required platelets on a daily basis.

I’m group A Rh D Positive so ideally I required A Rh D positive donor platelets for transfusion. I am aware that other blood groups are suitable and have an order of preference, but I have been trained to always endeavour to order group matched platelets if time permits. So when my nurse came to my bedside one afternoon with a bag of Group O platelets to transfuse into me, I questioned why.

 My nursing team were very professional and listened to my concerns. They called the blood bank for me, expressed my views and returned the platelets. The blood transfusion laboratory issued Group A and I was more at ease with the transfusion. This situation occurred again a few days later, as Group A platelets were again not available. After further talks with the blood transfusion laboratory and my own colleagues, I discovered the differences in the policies between the trust in which I work and the trust in which I was treated. Although I worried at first, I now respect the policy of my treatment hospital as it always strives to reduce waste – an undesirable outcome for donated blood products. The remaining twelve units of platelets were given in after my chemotherapy to prevent bleeding during my Hickman line reinsertion, spontaneous bleeding and bleeding from minor trauma once I was sent home.

The transfusion of granulocytes

I will never forget the morning when I was told I was due to receive a granulocyte (white blood cell) infusion. I was shocked and scared. In the six years I’d worked as a BMS in a transfusion laboratory, neither I nor any of my colleagues had ever issued granulocytes to a patient. I discovered that the issue of granulocytes was an extremely rare occurrence in this trust too. I was given 10 units of granulocytes in total, all during my first chemotherapy cycle, with each unit costing around £1000!

Transfusion was given despite my raised temperature and rash as I was just so unwell. Every time I saw the unit of white cells, I would panic because I worried about reacting to them and becoming more ill. In hindsight, I think the white cells (or rather their donors) should take most of the credit for saving my life during my first chemotherapy cycle. Essentially, I had a liver infection which occurred following the egg harvesting procedure. My doctors and I were unaware of the liver abscess and I was subjected to chemotoxic drugs due to my leukaemia, which attacked my normal functioning blood cells too and left me with no immune fighting white blood cells. The liver infection was then able to ‘take hold’ of me and I became extremely unwell. But by borrowing the immune system of blood donors via the granulocyte transfusion, my doctors were able to bridge the gap until my own immune system and blood counts recovered from the chemotherapy and the liver infection could be cleared.

I owe a lot to blood donors; not only my job, but more importantly my life

Comments

18.07.2017

Funny this popped up today, this morning I was trying to think about how many transfusions and platelets I had when I was ill. I was thinking I should write a blog as today is my 5th anniversary of my bone marrow transplant. I'm am now very well but had spent about an hour this morning remembering everything I went through. I reckon I had over 20 blood transfusions of 2 or 3 units of blood and about 5 lots of platelets. Words fail me as to how important it is for people to donate, I never did as I was 'scared' and now I can't as funnily enough, no one wants blood from someone who's had blood cancer. So for everyone who does, thank you so much. X

24.07.2017

Natalie,

Thank you so, so much for this blog which is absolutely brilliant and provides a brilliant oversight of just how important blood and platelets are to patients. Like Hannah I can't remember exactly how many I received during my treatment but they made an enormous difference.

So, so proud of how you're doing after your transplant and am frankly in awe of how much get up and go you've got already. Don't rush too much as you've still got your whole life ahead of you.

24.07.2017

Massive congratulations on being 5 years post transplant. That's absolutely wonderful news and a significant milestone.

I hope you did something nice to celebrate and couldn't agree more about how important blood and platelet transfusions are. My transplant was 13 years ago now and I can't remember for the life of me how many transfusions I had but I know they were multiple and I'm so glad that Natalie has written such a great blog on this.

Speaking of blogs, I'd love to read a blog about your experiences and how far you've come since your transplant and think this would be so valuable to patients like Natalie who are still some way further back in their 'journeys'.

05.08.2017

Natalie, your blog was so interesting and really raises the need for blood product resources and stocks.  Thanks for blogging and take lots of special care of yourself.

07.08.2017

Thanks Hannah and Andy. Tbh i only could only recall about half the transfusions i actually had and its wasnt untill i asked a collegue to confirm i realised i had had far more than i remembered. Really hoping this blog will continue to inspire people to donate.

07.08.2017

Thanks Erica!