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Basics of Transfusion Therapy. Resident Education Lecture Series. Hemoglobin Level and Symptoms. HGB (GM%) SYMPTOMS 9-11 MINIMAL 7.5 EXERTIONAL DYSPNEA 6.0 WEAKNESS 3.0 DYSPNEA AT REST 2-2.5 HEART FAILURE. LINMAN NEJM 279:812, 1968. RBC Transfusion: Indications.

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basics of transfusion therapy

Basics of Transfusion Therapy

Resident Education Lecture Series

hemoglobin level and symptoms
Hemoglobin Level and Symptoms

HGB (GM%)SYMPTOMS

9-11 MINIMAL

7.5 EXERTIONAL DYSPNEA

6.0 WEAKNESS

3.0 DYSPNEA AT REST

2-2.5 HEART FAILURE

LINMAN

NEJM 279:812, 1968

rbc transfusion indications
RBC Transfusion: Indications
  • Acute Blood Loss
  • Symptomatic Anemia
  • Suboptimal O2 Capacity
  • Exchange (SS, Co)
slide4

RBC Transfusion: The Bathtub Principle

Kidney

Kidney

Kidney

100

30

0

100

30

0

100

40

0

Blood Volume

Blood Volume

Blood Volume

pre transfusion testing
Pre-Transfusion Testing
  • BLOOD TYPING:
    • ABO, D Antigens only

(Other antigens are weak immunogens)

  • ANTIBODY SCREEN:
    • Patient serum vs. cell panel
  • CROSSMATCH
    • Major: Patient Serum vs. Donor Cells
rbc products
RBC Products
  • PRBCMOST TRANSFUSIONS
  • WHOLE BLOOD ACUTE BLEEDING

EXCHANGE

PLASMA NEEDED

  • WASHED REMOVE PLASMA
  • FROZEN RARE RBC PHENOTYPE
  • IRRADIATED IMMUNODEFICIENT
  • CMV NEGATIVE IMMUNODEFICIENT

SERONEGATIVE, NEONATE

rbc transfusion volume
RBC Transfusion Volume
  • Usual: Up to 15cc/Kg in 3-4 hours
  • Unusual: Acute Hemorrhage:

replace ongoing losses

Chronic Anemia, Heart Failure, îBP

2cc/Kg/Gm HGB

Diuretic

Exchange

transfusion volume
Transfusion Volume
  • 10cc/Kg PRBC 2.4 GM% in HGB

10cc/kg = X cc/kg

2.4 GM% Desired HGB rise

  • PRBC cc = Blood Volume x (HGBF- HGBI)

HGBT

BV=70cc/KG, 80-90cc/KG newborn

hemolytic transfusion reactions
Hemolytic Transfusion Reactions
  • Acute HTR 1/25,000
    • Fatal Acute HTR 1-4/1,000,000
  • Delayed HTR 1/5-10,000
symptoms and signs of acute hemolytic reactions
Symptoms and Signs of Acute Hemolytic Reactions
  • Severe Back Pain
  • Substernal Tightness, Dyspnea
  • Hypotension / Circulatory collapse
  • Vomiting, diarrhea
  • Icterus
  • Hemoglobinuria
  • Renal shutdown
  • Diffuse Oozing from wounds/punctures
response to suspected hemolytic reaction
Response to Suspected Hemolytic Reaction
  • Stop Transfusion
  • Hydrate
  • Specimens to Blood Bank
    • Unit/Bag
    • Serum
    • Red cells
    • Urine
acute hemolysis diagnosis
Acute Hemolysis: Diagnosis
  • Do a direct antiglobulin test on post-transfusion sample
  • Obtain post-transfusion blood and urine and inspect visually
  • Recheck paperwork
  • Recheck ABO type of unit and pre-and post-transfusion specimens
  • Run urinalysis - to check for hemoglobinuria
cause of acute htr
Cause of Acute HTR
  • ABO incompatibility:source of error
    • 10% at phlebotomy/labeling
    • 23% in Transfusion Lab
    • 67% transfusion administration (at the bedside)
nonhemolytic transfusion reactions
Leukocyte Associated

FNHTR

Transfusion GVHD

Neonatal Neutropenia

Immunoglobulin Associated

Urticaria/Fever

Ig E

TRALI

Platelet Associated

Post transfusion Purpura

Neonatal Thrombocytopenia

Metabolic/ Physical

Citrate Toxicity

Hypothermia

Circulatory Overload

Massive Transfusions

Haemostatic Abnormalities

Metabolic complications

Hgb-O2 Curve Shift

Nonhemolytic Transfusion Reactions
risk of transfusion transmitted infection
Risk of Transfusion-Transmitted Infection

HIV 1 in 2,000,000

Hepatitis C 1 in 2,000,000

Hepatitis B 1 in 175,000

Hepatitis A Rare

HTLV I/II 1 in 3,000,000

Bacteria 1/3,000 (for platelets)

Malaria, T Cruzi, Babesia, Yersinia, Syphilis, Lyme, CJD, West Nile Virus…??

post transfusion hcv
Post Transfusion HCV

PercentNumber

Incidence 5-10 150-300,000

Chronic 50 75-150,000

Cirrhosis 20 15-30,000

neonatal post transfusion cmv
Neonatal Post Transfusion CMV
  • Incidence: 25% of seronegative infants

receiving >50ml CMV

seropositive blood

  • Severity 50% severe or lethal manifestations
neonatal transfusion cmv prevention by filtering blood
Neonatal Transfusion CMV Prevention by Filtering Blood

Seroconvert/Total

Filtered PRBC: 0/30

Unfiltered PRBC: 9/42

Gilbert, L1:98:228, 1989

prevention of post transfusion infection
Prevention of Post Transfusion Infection
  • Don’t Transfuse
  • Minimize Transfusion
  • Limited Donors (dedicated units)
  • Autologous Transfusions
  • Erythropoetin
  • Donor Screening: HIV Ab, HIV NAT, HCV Ab, HCV NAT, HBV Ag, Ab, HBc Ab, VDRL, West Nile NAT, HTLVI/II Ab, CMV Ab, Bacterial Culture (Platelets)
strategies to decrease operative rbc transfusion
Strategies to Decrease Operative RBC Transfusion

Hemostasis

Hemodilution

Cell salvage

DDAVP

Autologous Transfusion

Erythropoetin

neutropenia infection risk

Relapse

Remission

100

100-500

500-1000

1000

Neutropenia: infection risk

Bodey. Ann Int Med 64:328, 1966.

wbc indications 2004
WBC Indications 2004
  • PMN: Newborn Sepsis

Congenital/Acquired Neutropenia

PMN Dysfunction

Refractory Gram Negative Sepsis

  • Ly: Disseminated Varicella-Zoster
wbc transfusion logistics
WBC transfusion:Logistics
  • Donors Receive G-CSF +/- Decadron
  • 2-3 Hour Cytapheresis
  • 1010 Cells by Standards
  • Donors pretested for ID markers
  • Cells decay rapidly: limited value at > 6 hours post-collection
  • Quantitative impact limited
fresh frozen plasma
Fresh Frozen Plasma
  • 200-250 ml of plasma containing all clotting factors, AT III, Protein C & S.
  • Compatibility Important
  • Can Give: A plasma to A or O patient

B plasma to B or O patient

O plasma to O patient

AB plasma to anyone

indications ffp
Indications: FFP
  • Replacement of Coagulation Factors
    • Abnormal Bleeding with coagulopathy
      • Multiple factor deficiency:
        • Liver disease
        • DIC
        • Reversal of Warfarin
        • Dilutional
      • Isolated factor deficiency-no concentrate
        • Factor XI, XIII
  • Replacement of regulatory proteins
    • TTP, Hereditary angioedema
  • Not indicated for: volume expansion, reversal of Heparin, correction of INR < 1.5
guidelines ffp use
Guidelines: FFP Use
  • Usual dosing: Adult 10ml/Kg

Peds 10-15ml/Kg

  • 15-20% rise in factor levels
  • Usually does not correct laboratory coagulation status to “normal”
cryoprecipitate
Cryoprecipitate
  • 10-15 ml per unit (bag)
  • Fibrinogen 250 mg
  • Factor VIII 80-120 units
  • Von Willebrand Factor 40-70% of FFP
  • Factor XIII 20-30% of FFP
  • Fibronectin 20-40 mg
cryoprecipitate dosing
Cryoprecipitate: Dosing
  • 1-2 Units / 10 Kg
  • Expect 60-100 mg/dl rise in fibrinogen
  • Goal: Fibrinogen 70-100 mg/dl
platelets risk of spontaneous hemorrhage
Platelets: Risk of Spontaneous Hemorrhage

CountSite

> 40,000 Minimal

20-40,000 GI Mucosa

5-20 Skin, Mucus Membranes

< 5 CNS, Lung

slide35

Uremia

vWD

40

WAS

30

AA

ASA

Bleeding time (min)

20

ITP

10

0

0

50

100

150

200

250

300

Platelets (/microL)

Harker. NEJM 287:155, 1972.

prophylactic platelet tx guidelines
Prophylactic Platelet TX Guidelines

Platelet Count/μlRecommendation

0-5,000 Always

5-10,000 If Febrile of Minor Bleeding

11-20,000 If coagulopathy or minor procedure

>20,000 If Major Bleed or invasive procedure

transfused platelets survival
Transfused Platelets/Survival
  • 6 units = 1 single donor unit (SDP); available as ¼, ½ and full SDP
  • Dose: child 1 unit/5-6 kg

adult 1 unit/8-10 kg

  • Lifespan: 7-10 Days Native

2-3 Days Transfused

  • Factors shortening Lifespan:
    • Fever, Sepsis
    • HLA, Platelet Specific Abs
    • DIC
    • Product Age?
from abp certifying exam content outline
From ABP Certifying Exam Content Outline
  • 2. Transfusion and collection of blood
  • Understand the risk of transmitting infectious diseases during blood transfusion(s)
  • Recognize that erythrocyte transfusions may be associated with hemolytic, febrile, and urticarial reactions
  • Understand the role of erythrocyte transfusions in the management of anemia
credits
Credits
  • Bruce Camitta MDM W Lankiewicz MD
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