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Blood and Blood Components. Goals Of Blood Collection . Maintain viability and function Prevent physical changes Minimize bacterial contamination. Anticoagulants Preservative Solutions. Anticoagulants prevent blood clotting Preservatives provide nutrients for cells Heparin

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Goals of blood collection
Goals Of Blood Collection

Maintain viability and function

Prevent physical changes

Minimize bacterial contamination


Anticoagulants preservative solutions
Anticoagulants Preservative Solutions

Anticoagulants prevent blood clotting

Preservatives provide nutrients for cells

Heparin

Rarely if ever used anymore

Anticoagulant ONLY

Transfuse within 48 hours, preferably 8



Additive solution
Additive Solution

Primary bag with satellite bags attached.

One bag has additive solution (AS)

Unit drawn into CPD anticoagulant


Additive solution1
Additive Solution

Remove platelet rich plasma within 72 hours

Add additive solution to RBCs, ADSOL, which consists of:

Saline

Adenine

Glucose

Mannitol

Extends storage to 42 days

Final hematocrit approximately 66%


Changes occur during storage
Changes Occur During Storage

Shelf life = expiration date

At end of expiration must have 75% recovery

At least 75% of transfused cells remain in circulation 24 hours AFTER transfusion


Storage lesion
Storage Lesion

Biochemical changes which occur at 1-6C

Affects oxygen dissociation curve, increased affinity of hemoglobin for oxygen.

Low 2,3-DPG, increased O2 affinity, less O2 released.

pH drops causes 2,3-DPG levels to fall

Once transfused RBCs regenerate ATP and 2,3-DPG

Few functional platelets present

Viable (living) RBCs decrease


Plasma hemoglobin

Plasma K+

Na+

K+

Viable cells

pH

ATP

2,3-DPG

Plasma Na+

Helps release oxygen from hemoglobin (once transfused, ATP & 2,3-DPG return to normal)


Storage lesion1
Storage Lesion

Significant for infants and massive transfusion.

Other biochemical changes

ATP decreases

Potassium increases

Sodium decreases

Plasma hemoglobin increases


Preparation of components
Preparation of Components

Collect unit within 15 minutes to prevent activation of coagulation system

Draw into closed system – primary bag with satellite bags with hermetic seal between.

If hermetic seal broken transfuse within 24 hours if stored at 1-4C, 4 hours if stored at 20-24C


Preparation of components1
Preparation of Components

Centrifuge – light spin, platelets suspended

Remove platelet rich plasma (PRP)

Centrifuge PRP heavy spin

Remove platelet poor plasma

Freeze plasma solid within 8 hours

Thaw plasma at 1-4C – precipitate forms

Centrifuge, express plasma leaving cryoprecipitate. Store both at -18C

RBCs – CPD – 21 days, ADSOL – 42 days – 1-6C


Preparation of components2
Preparation of Components

Summary – One unit of whole blood can produce:

Packed RBCs

Fresh frozen plasma (FFP)

Cryoprecipitate (CRYO)

Single donor plasma (SDP) – cyro removed

Platelets – terms PC (platelet concentrate) OR RD PC (random donor platelet concentrate)


Components
Components

Fresh frozen plasma

Cryosupernatant

Cryoprecipitate

Albumin

Immunoglobulin

etc

Red cells

Platelets

Whole blood

Cellular components

Fresh plasma

Factor VIII

Fibrinogen


Preparation of components3
Preparation of Components

Sterile docking device joins tubing

Used to add satellite bags to maintain original expiration of component

May be used to pool components


Blood component general information
Blood Component General Information

Blood separated into components to specifically treat patients with product needed

Advantages of component separation

Allow optimum survival of each component

Transfuse only component needed


Blood component general information1
Blood Component General Information

Transfusion practice

Transfusion requires doctor’s prescription

All components MUST be administered through a filter

Infuse quickly, within 4 hours

D (Rh) neg require D neg cellular products

ABO identical preferred, ABO compatible OK

“Universal donor” – RBCs group O, plasma AB


Blood component general information2
Blood Component General Information

Fresh Whole Blood

Blood not usually available until 12-24 hours

Candidates

Newborns needing exchange transfusion

Patients requiring leukoreduced products


Blood component general information3
Blood Component General Information

Summary of storage temperatures:

Liquid RBCs 1-6C

Platelets, Cryo (thawed) and granulocytes 20-24C (room temperature)

ANY frozen plasma product ≤ -18C

ANY liquid plasma product EXCEPT Cryo 1-6C


Blood components
Blood Components

Cellular

Red blood cell products

Platelets

Granulocytes

Plasma

FFP

Cryoprecipitate



Whole blood
Whole Blood

Clinical indications for use of WB are extremely limited.

Used for massive transfusion to correct acute hypovolemia such as in trauma and shock, exchange transfusion.

RARELY used today, platelets non-functional, labile coagulation factors gone.

Must be ABO identical.



Packed red blood cells
Packed red blood cells

Indications

Symptomatic deficit of oxygen-carrying capacity

Exchange transfusion

Hemolytic disease of new born

Acute chest syndrome in sickle cell crisis

Contraindications

Anemias that can be corrected with specific medications such as iron, vitamin B12, folic acid, or erythropoietin

Coagulation deficiency

Volume expansion

To improve oncotic pressure, wound healing and sense of well being


Leukocyte reduced red cells lr rbc
Leukocyte Reduced Red Cells (LR-RBC)

Leukocytes can induce adverse affects during transfusion, primarily febrile, non-hemolytic reactions.

Reactions to cytokines produced by leukocytes in transfused units.

Other explanations to reactions include: immunization of recipient to transfused HLA or granulocyte antigens, micro aggregates and fragmentation of granulocytes.

Historically, indicated only for patients who had 2 or more febrile transfusion reactions, now a commonly ordered, popular component.

“CMV” safe blood, since CMV lives in WBCs.

Most blood centers now leukoreduce blood immediately after collection.

Bed side filters are available to leukoreduce products during transfusion.



Washed red blood cells w rbcs
Washed Red Blood Cells (W-RBCs)

Washing removes plasma proteins, platelets, WBCs and micro aggregates which may cause febrile or urticarial reactions.

Patient requiring this product is the IgA deficient patient with anti-IgA antibodies.

Prepared by using a machine which washes the cells 3 times with saline to remove and WBCs.

Two types of labels:

Washed RBCs - do not need to QC for WBCs.

Leukocyte Poor WRBCs, QC must be done to guarantee removal of 85% of WBCs. No longer considered effective method for leukoreduction.

e. Expires 24 hours after unit is entered.




Red blood cells frozen red blood cells deglycerolized d rbc
Red Blood Cells Frozen; Red Blood Cells Deglycerolized (D-RBC)

Blood is frozen to preserve: rare types, for autologous transfusion, stock piling blood for military mobilization and/or civilian natural disasters.

Blood is drawn into an anticoagulant preservative.

Plasma is removed and glycerol is added.

After equilibration unit is centrifuged to remove excess glycerol and frozen.

Expiration

If frozen, 10 years.

After deglycerolization, 24 hours.

Storage temperature

high glycerol -65 C.

low glycerol -120 C, liquid nitrogen.


Red blood cells frozen red blood cells deglycerolized d rbc1
Red Blood Cells Frozen; Red Blood Cells Deglycerolized (D-RBC)

Thaw unit at 37C, thawed RBCs will have high concentration of glycerol.

A solution of glycerol of lesser concentration of the original glycerol is added.

This causes glycerol to come out of the red blood cells slowly to prevent hemolysis of the RBCs.

After a period of equilibration the unit is spun, the solution is removed and a solution with a lower glycerol concentration is added.

This procedure is repeated until all glycerol is removed, more steps are required for the high glycerol stored units.

The unit is then washed.


Rejuvenated red blood cells
Rejuvenated Red Blood Cells (D-RBC)

A special solution is added to expired RBCs up to 3 days after expiration to restore 2,3-DPG and ATP levels to prestorage values.

Rejuvenated RBCs regain normal characteristics of oxygen transport and delivery and improved post transfusion survival.

Expiration is 24 hours or, if frozen, 10 years



Platelets
Platelets (D-RBC)

Single donor platelets >3.0 x 1011per bag(250ml) (derived by apheresis)

Random derived platelets >5.5 x 1010 per bag(50ml)

4-10 RDPs are pooled for one adult transfusion

Stored up to five days at 20-24°C (room temperature).

Continually agitated to prevent clumping. Storage is limited to five days due to the risk of bacterial contamination


Transfusion of platelets indications and contraindications
Transfusion of Platelets: (D-RBC)Indications and Contraindications

Indications

Bleeding due to critically decreased circulating platelet count or functionally abnormal platelets

Prevention of bleeding from marrow hypoplasia (platelet count <10,000/μL)

Selected cases of postoperative bleeding (platelet count <50,000/μL)

Contraindications

Plasma coagulation deficits

Some conditions with rapid platelet destruction (eg, ITP, TTP) unless life-threatening hemorrhage


Platelets plts platelet concentrate pc or random donor platelet concentrate rd pc
Platelets (PLTS), Platelet Concentrate (PC) or Random Donor Platelet Concentrate (RD-PC)

Used to prevent spontaneous bleeding or stop established bleeding in thrombocytopenic patients.

Prepared from a single unit of whole blood.

Due to storage at RT it is the most likely component to be contaminated with bacteria.

Therapeutic dose for adults is 6 to 10 units.

Some patients become "refractory" to platelet therapy.

Expiration is 5 days as a single unit, 4 hours if pooled.

Store at 20-24 C (RT) with constant agitation.

D negative patients should be transfused with D negative platelets due to the presence of a small number of RBCs.


Preparation of platelet concentrate
Preparation of platelet concentrate Platelet Concentrate (RD-PC)

Plasma

RBCs

PRP

Platelet concentrate


Platelets plts platelet concentrate pc or random donor platelet concentrate rd pc1
Platelets (PLTS), Platelet Concentrate (PC) or Random Donor Platelet Concentrate (RD-PC)

One bag from ONE donor

Need 6-10 for therapeutic dose


Pooling platelets
Pooling Platelets Platelet Concentrate (RD-PC)

6-10 units transferred into one bag

Expiration = 4 hours


Platelets pheresis apheresis platelet concentrate single donor platelet concentrate sd pc
Platelets Pheresis, Apheresis Platelet Concentrate, Single Donor Platelet Concentrate (SD-PC)

Used to decrease donor exposure, obtain HLA matched platelets for patients who are refractory to RD-PC or prevent platelet refractoriness from occurring.

Prepared by hemapheresis, stored in two connected bags to maintain viability.

One pheresed unit is equivalent to 6-8 RD-PC.

Store at 20-24 C (RT) with agitation for 5 days, after combining, 24 hours

D negative patients should be transfused with D negative platelets due to the presence of a small number of RBCs


Apheresis
Apheresis Donor Platelet Concentrate (SD-PC)


Apheresis1
Apheresis Donor Platelet Concentrate (SD-PC)


Platelets pheresis
Platelets Pheresis Donor Platelet Concentrate (SD-PC)

One bag (unit) from one donor

One unit is a therapeutic dose

Volume approximately 250 ccs


Granulocytes
Granulocytes Donor Platelet Concentrate (SD-PC)

Lymphocyte

Monocyte

Neutrophils

Eosinophils

Basophils


Granulocytes1
Granulocytes Donor Platelet Concentrate (SD-PC)

Primary use is for patients with neutropenia who have gram negative infections documented by culture, but are unresponsive to antibiotics.

Therapeutic efficacy and indications for granulocyte transfusions are not well defined.

Better antimicrobial agents and use of granulocyte and macrophage colony stimulating factors best for adults, best success with this component has been with babies

Daily transfusions are necessary.

Prepared by hemapheresis.

Expiration time is 24 hours but best to infuse ASAP.

Store at 20-24 C.


Plasma components
Plasma Components Donor Platelet Concentrate (SD-PC)


Fresh frozen plasma volume 200 250cc
Fresh Frozen Plasma – Donor Platelet Concentrate (SD-PC)Volume 200-250cc


Indications
Indications Donor Platelet Concentrate (SD-PC)

Active bleeding or risk of bleeding due to deficiency of multiple coagulation factors,

Severe bleeding due to warfarin therapy, or urgent reversal of warfarin effect

Massive transfusion with coagulopathic bleeding.

Bleeding or prophylaxis of bleeding for a known single coagulation factor deficiency for which no concentrate is available.

Thrombotic thrombocytopenic purpura.

Rare specific plasma protein deficiencies, such as C1- inhibitor.


Contra indications
Contra-indications Donor Platelet Concentrate (SD-PC)

Increasing blood volume or albumin concentration

Coagulopathy that can be corrected with administration of vitamin K.

Normalizing abnormal coagulation screen results, in the absence of bleeding.


Fresh frozen plasma ffp
Fresh Frozen Plasma (FFP) Donor Platelet Concentrate (SD-PC)

Used to replace labile and non-labile coagulation factors in massively bleeding patients OR treat bleeding associated with clotting factor deficiencies when factor concentrate is not available.

Must be frozen within 8 hours of collection.

Expiration

frozen - 1 year stored at <-18 C.

frozen - 7 years stored at <-65 C.thawed - 24 hours


Fresh frozen plasma ffp1
Fresh Frozen Plasma (FFP) Donor Platelet Concentrate (SD-PC)

Storage temperature

frozen -18 C, preferably -30 C or lower

thawed - 1-6 C

Thawed in 30-37C water bath or FDA approved microwave

Must have mechanism to detect units which have thawed and refrozen due to improper storage.

Must be ABO compatible


Plasma liquid plasma recovered plasma and source plasma
Plasma, Liquid Plasma, Recovered Plasma and Source Plasma Donor Platelet Concentrate (SD-PC)

Used to treat patients with stable clotting factor deficiencies for which no concentrate is available or for patients undergoing therapeutic plasmapheresis.

Prepared by separating the plasma from the RBCs on or before the 5th day after expiration of the whole blood.

Once separated can:

Freeze, store at -18 C for 5 years

If not frozen, called liquid plasma, store at 1-6 C for up to 5 days after expiration of WB.

Once FFP is one year old can redesignate as Plasma, expiration is 5 years.


Pooled plasma solvent detergent treated
Pooled Plasma/Solvent Detergent Treated Donor Platelet Concentrate (SD-PC)

Most recently licensed product.

Prepared from pools of no more than 2500 units of ABO specific plasma frozen to preserve labile coagulation factors.

Treated with chemicals to inactivate lipid-enveloped viruses.

Contains labile and non-labile coagulation factors but lacks largest Von Willebrand’s factor multimers.

Used same as FFP.Safety concerns

Decreases disease transmission for diseases tested for.

Doesn’t inactivate viruses with non-lipid envelopes: parvo virus B19, hepatitis A, and unrecognized pathogens


Cryoprecipitate cryo factor viii or anti hemophilic factor ahf
Cryoprecipitate (CRYO), Factor VIII or Anti-Hemophilic Factor (AHF)

Cold insoluble portion of plasma that precipitates when FFP is thawed at 1-6C.

Cryoprecipitate contains high levels of Factor VIII and Fibrinogen, used for treatment of hemophiliacs and Von Willebrands when concentrates are not available.

Used most commonly for patients with DIC or low fibrinogen levels.

A therapeutic dose for an adult is 6 to 10 units.

Can be prepared from WB which is then designated as "Whole Blood Cryoprecipitate Removed" or from FFP

Plasma is frozen.

Plasma is then thawed at 1-6 C, a precipitate forms.

Plasma is centrifuged, cryoprecipitate will go to bottom.

Remove plasma, freeze within 1 hour of preparation


Cryoprecipitate (VIII, vW) Factor (AHF)

Thaw at 30-37°C Store at RT 4 hrs

FFP

Plasma cryoprecipitate, reduced (TTP, FII, V, Vii, IX, X, XI)

Frozen within 8 hours

Thawed FFP

Refrozen with 24 hrs of separation Store at ≤18°C 1 yr

5 day expiration at 1-6°C


Cryoprecipitate cryo factor viii or anti hemophilic factor ahf1
Cryoprecipitate (CRYO), Factor VIII or Anti-Hemophilic Factor (AHF)

Storage Temperature

Frozen -18 C or lower

Thawed - room temperature

Expiration:

Frozen 1 year

Thawed 6 hours

Pooled 4 hours

Best to be ABO compatible but not important due to small volume


Indications and contra indications
Indications and Contra-indications Factor (AHF)

Indications

Bleeding associated with fibrinogen deficiencies (<100mg/dl) and Factor XIII deficiency esp if FFP cannot be given due to volume overload

Indicated in hemophilia A or von Willebrand’s disease (vWD) when appropriate Factor VIII concentrates or Factor VIII concentrates containing FVIII:vWF are not available.

Fibrin Sealant

Uremic bleeding

Contraindications

Do not transfuse cryoprecipitate unless laboratory studies confirm deficiency of a specific clotting protein for which this component is indicated (e.g. fibrinogen).




Irradiation of blood components1
Irradiation of Blood Components Factor (AHF)

Cellular blood components are irradiated to destroy viable T- lymphocytes which may cause Graft Versus Host Disease (GVHD).

GVHD is a disease that results when immunocompetent, viable lymphocytes in donor blood engraft in an immunocompromised host, recognize the patient tissues as foreign and produce antibodies against patient tissues, primarily skin, liver and GI tract. The resulting disease has serious consequences including death.

GVHD may be chronic or acute


Irradiation of blood components2
Irradiation of Blood Components Factor (AHF)

Patients at greatest risk are:

severely immunosuppressed,

immunocompromised,

receive blood donated by relatives, or

fetuses receiving intrauterine transfusions

Irradiation inactivates lymphocytes, leaving platelets, RBCs and granulocytes relatively undamaged.

Must be labeled "irradiated".

Expiration date of Red Blood Cell donor unit changes to 28 days.

May be transfused to "normal" patients if not used by intended recipient.



Donor blood inspection and disposition
Donor Blood Inspection and Disposition Factor (AHF)

It is required that donor units be inspected periodically during storage and prior to issuing to patient.

The following may indicate an unacceptable unit:

Red cell mass looks purple or clots are visible.

Zone of hemolysis observed just above RBC mass, look for hemolysis in sprigs, especially those closest to the unit.

Plasma or supernatant plasma appears murky, purple, brown or red.

A greenish hue need not cause a unit to be rejected.

Inspect platelets for aggregates.

Inspect FFP and CRYO for signs of thawing, evidence of cracks in bag, or unusual turbidity in CRYO or FFP (i.e., extreme lipemia).


Inspection of donor blood
Inspection of Donor Blood Factor (AHF)

Segment closest to unit is hemolyzed.

May indicate bacterial contamination


Donor blood inspection and disposition1
Donor Blood Inspection and Disposition Factor (AHF)

If a unit's appearance looks questionable do the following:

Quarantine unit until disposition is decided.

Gently mix, allow to settle and observe appearance.

If bacterial contamination is suspected the unit should be cultured and a gram stain performed.

Positive blood cultures usually indicative of:

Inadequate donor arm preparation

Improper pooling technique

Health of donor - bacteremia in donor

If one component is contaminated, other components prepared from the same donor unit may be contaminated.


Inspection of donor blood1
Inspection of Donor Blood Factor (AHF)

Reissuing blood cannot be done unless the following criteria is met:

Container closure must not have been penetrated or entered in any manner.

Most facilities set 30" time limit for accepting units back, warming above 6-10C even with subsequent cooling increases RBC metabolism producing hemolysis and permitting bacterial growth.

Blood must have been kept at the appropriate temperature.

One sealed segment must remain attached to container.

Records must indicate that blood has been reissued and inspected prior to reissue.


Transportation of blood and blood components
Transportation of Blood and Blood Components Factor (AHF)

WB and RBC

Sturdy well insulated cardboard and/or styrofoam container, wet ice in ziplock bag to cool, temperature must be monitored.

Mobile collection units should transport blood ASAP and leave at RT if platelets are to be made.

In-house transport place in cooler with wet ice and thermometer, monitor temperature every 30 minutes.



Transportation of blood and blood components1
Transportation of Blood and Blood Components Factor (AHF)

Frozen components

Temperature must be maintained at or below required storage temperature.

Use dry ice in well insulated container.

Platelets and granulocytes

Maintain at 20-24 C.

Transport in well insulated containers without ice.

Commercial coolers available to maintain at 20-24C.


Transportation of blood and blood components2
Transportation of Blood and Blood Components Factor (AHF)

Handling donor units

Should not remain at RT unnecessarily, when blood is issued it should be transfused as soon as possible.

When numerous units are removed from fridge, remove fluid filled container with a thermometer at same time as blood, when temperature reaches 6 C return to fridge.


Records
Records Factor (AHF)

Must be made concurrently with each step of component preparation, being as detailed as possible for clear understanding.

Must be legible and indelible.

Must include dates of various steps and person responsible.


Complications of transfusion
Complications of Transfusion Factor (AHF)

  • Transfusion reactions occur in 2% of units or within 24 hours of use.

  • Most common adverse side effects are usually mild and non-life-threatening

  • Two categories:

    • Infectious complications

      • i.e HIV and HCV  1 transmission/2 million transfusion

    • Non-infectious complications


Non infectious complications of transfusions
Non-infectious Complications of Transfusions Factor (AHF)

Technical Manual

  • Acute (< 24°)

    • Immunologic

    • Non-immunologic

  • Delayed (> 24°)

    • Immunologic

    • Non-immunologic


Acute 24 immunologic
Acute (< 24°) Immunologic Factor (AHF)

  • Hemolytic

  • Fever/chills, non-hemolytic

  • Urticarial/Allergic

  • Anaphylactic


Acute 24 non immunologic
Acute (< 24°) Non-Immunologic Factor (AHF)

  • Transfusion-related acute lung injury (TRALI)

  • Circulatory overload

  • Nonimmune hemolysis

  • Air embolus

  • Hypocalcemia

  • Hypothermia

  • Acid/Base Disturbances

  • Citrate Toxicity

  • Coagulopathy


Delayed 24 immunologic
Delayed (> 24°) Immunologic Factor (AHF)

  • Allo-immunization

    • RBC antigens

    • HLA

  • Hemolytic

  • Graft-versus-host disease (GVHD)

  • Post-transfusion purpura

  • Immuno-modulation


Delayed 24 non immunologic
Delayed (> 24°) Non-Immunologic Factor (AHF)

  • Iron overload


Infectious complications

Infectious complications Factor (AHF)

Viral ( hepatitis, HIV, CMV, HTLV)

Parasitic and bacteremia (especially platelets)


Acute 24 immunologic1

Acute (< 24°) Immunologic Factor (AHF)

Hemolytic

Fever/chills, non-hemolytic

Urticarial/Allergic

Anaphylactic


Hemolytic
Hemolytic Factor (AHF)

  • Most severe hemolytic reactions, occur when transfused RBCs interact with preformed Ab

  • Transfused Ab reactions, with recipient’s RBCs rarely cause sxs.

    • May cause accelerated RBC destruction

  • Can occur after infusion of as little as 10-15 mL ABO-incompatible blood

  • Etiology

    • 1:38,000 to 1:70,000

    • Clerical and other human error most common causes of ABO-incompatible transfusion

    • Mortality estimated to be 1:1,000,000 transfusion

  • Highly variable in acuity and severity

    Severity of the reaction depends in the amount of blood given

    • Severe

      • Fevers and/or chills, Hypotension, Dyspnea, Tachycardia

      • Pain, DIC, Shock, Rise in temperature, renal failure


Hemolytic1
Hemolytic Factor (AHF)

  • Pathophysiology

    • Intravascular hemolysis, opsonization, generation of anaphylotoxins

    • Complement activation  classical pathway

      • IgM and IgG

      • C1q binds to Ig

      • C3 activation  cleavage of C3 leads to C3a being released into plasma and C3b deposition onto RBC membrane

        • C3a  proinflammatory effects

        • C3b  erythrophagocytosis

      • C5 cleaved  C5a into plasma

        • C5a  proinflammatory (100-fold more potent than C3a)

      • Assembly of remaining components of the MAC then occurs on RBC surface

      • Lysis of RBC

    • Cytokines activation

      • TNF, IL-1, IL-6, IL-8

    • Coagulation activation

      • Bradykinin


Hemolytic2
Hemolytic Factor (AHF)

  • Laboratory findings

    • Hemoglobinemia

    • Hemoglobinuria

    •  LDH

    • Hyperbilirubinemia

    •  Haptoglobin

    •  BUN, creatinine in ARF (Aggressive Fluid Resuscitation)

    • DAT +


Hemolytic3
Hemolytic Factor (AHF)

  • Differential diagnosis

    • AIHA (Auto immune hemolytic anemia)

    • Nonimmune hemolysis

    • Microangiopathic hemolytic anemia

    • Drug-induced

    • Infections

    • Any causes of hemolysis


Hemolytic4
Hemolytic Factor (AHF)

  • Treatment/Prevention

    • Stop transfusion

    • Supportive care to maintain renal function

      • Goal of urine O/P 100 mL/hr. in adults for at least 18-24 hours

    • Low dose dopamine

    • Treatment of DIC

      • ? Heparin – direct anticomplement effect

    • Prevention of clerical/human errors

    • Double Check name, type and crossmatch

    • Temperature Monitor


Acute 24 immunologic2

Acute (< 24°) Immunologic Factor (AHF)

Hemolytic

Fever/chills, non-hemolytic

Urticarial/Allergic

Anaphylactic


Fevers chills non hemolytic fnhtr
Fevers/chills, non-hemolytic (FNHTR) Factor (AHF)

  • Defined as a rise in temperature of 1°C or greater.

  • Incidence

    • 43-75% of all transfusion reaction.

    • PRBCs 0.5-6%

    • Plts 1-38%

  • Signs/Symptoms

    • Chills/rigor

    • HA

    • Vomitting


Fevers chills non hemolytic fnhtr1
Fevers/chills, non-hemolytic (FNHTR) Factor (AHF)

  • Etiology

    • Reaction…

      • Between recipient antibodies against transfused WBC (HLA, WBC antigens) in product

      • Cytokines that accumulates in blood bag during storage

  • Differential Diagnosis:

    • Other causes of fever ruled out

      • Hemolytic

      • Bacterial/Septic

  • Treatment/Prevention

    • Discontinue transfusion

    • Acetaminophen/meperidine

    • Leukoreduced blood component


Acute 24 immunologic3

Acute (< 24°) Immunologic Factor (AHF)

Hemolytic

Fever/chills, non-hemolytic

Urticarial/Allergic

Anaphylactic


Uritcarial allergic
Uritcarial/Allergic Factor (AHF)

  • Continuum

    • Mild – urticarial

    • “Anaphylactoid”

    • Severe – anaphylactic

  • Incidence

    • 1-3% of all transfusion reaction.

  • Signs/Symptoms

    • Uriticarial/hives – upper trunk and neck

    • Fever

    • Pulmonary signs (10%) – hoarseness, stridor, “lump in throat”, bronchoconstriction

      • No cutaneous involvement

    • GI – pain, diarrhea

    • Circulatory – tachycardia, hypotension


Uritcarial allergic1
Uritcarial/Allergic Factor (AHF)

  • Etiology

    • Circulating Ab against soluble material in the blood

      • Proteins in donor plasma

    • Binds to preformed IgE Ab on mast cells

      • Release of histamine

    • Vasoactive substances

      • C3a, C5a, leukotrienes

  • Differential Diagnosis:

    • Hemolytic

    • Bacterial

    • TRALI

  • Treatment/Prevention

    • Discontinue transfusion

    • Antihistamine/steroids

    • Washing of blood products, pretreatment, leukoreduction?


Acute 24 immunologic4

Acute (< 24°) Immunologic Factor (AHF)

Hemolytic

Fever/chills, non-hemolytic

Urticarial/Allergic

Anaphylactic


Anaphylactic
Anaphylactic Factor (AHF)

  • Rare

  • Incidence

    • 1:18,000 to 170,000

    • Plt 1:1598-9630

    • FFP 1:28,831

    • RBCs 1:23,148-57,869

  • Signs/Symptoms

    • In addition to uritcarial/allergic…

      • Cardiovascular instability

        • Cardiac arrhythmia

        • Shock

        • Cardiac arrest

      • More pronounced respiratory involvement


Anaphylactic1
Anaphylactic Factor (AHF)

  • Etiology

    • IgA Ab (IgE, IgG, IgM) in IgA deficiency

      • Serum IgA < 5 mg/dL

      • Estimated 1 in 342 blood donors

    • C4 Ab

    • Ab against nonbiologic origin

    • Haptoglobin deficiency (IgG or IgE anti-haptoglobin)

  • Differential Diagnosis:

    • Hemolytic

    • Bacterial

    • TRALI

    • Circulatory overload


Anaphylactic2
Anaphylactic Factor (AHF)

  • Treatment/Prevention

    • Discontinue transfusion

    • Supportive care

    • Epinephrine

    • Antihistamine/steroids

    • In IgA deficient pts.  IgA-deficient product, wash blood product


Delayed 24 immunologic1

Delayed (> 24°) Immunologic Factor (AHF)

Allo-immunization

Hemolytic

Graft-versus-host disease (GVHD)

Post-transfusion purpura

Immuno-modulation


Allo immunization
Allo-immunization Factor (AHF)

  • Occurs weeks to months after transfusion

  • Incidence

    • 1-1.6% to RBC antigens

    • 10% to HLA

  • Signs/Symptoms

    • PRBCs  hemolysis

    • Plts.  refractoriness

  • Treatment/Prevention

    • Plts.

      • Leukoreduction

      • Cross-matched and/or HLA-matched plts.


Delayed 24 immunologic2

Delayed (> 24°) Immunologic Factor (AHF)

Allo-immunization

Hemolytic

Graft-versus-host disease (GVHD)

Post-transfusion purpura

Immuno-modulation


Hemolytic5
Hemolytic Factor (AHF)

  • Once allo-immunization has occurred, Abs may diminish to undetectable levels or Caused by antibodies to non-D antigens of the Rh system or foreign alleles

    • Especially Kidd system (anti-Jka and anti-Jkb)

    • Hemolysis typically extravascular

  • Anamnestic response

    • Within hours or days (up to 6 weeks), IgG Ab reacts with transfused red cells

    • Prospective study

      • 58 of 2082 (2.8%) RBC recipients were found to have alloAbs (previous undetected) w/in 7 days of transfusion

    • Not be preventable

    • High risk

      • Previous blood transfusions

      • Pregnancy

      • females who have a known disposition of alloimmunization

  • Incidence

    • Based on above study, only 1 recipient with new Ab w/in 7 days of transfusion was shown to have hemolysis

    • Estimated rate

      • 1 in 2082 recipients

      • 1 in 11,328 units

    • Other reports at 0.02 to 0.009%


Hemolytic6
Hemolytic Factor (AHF)

  • Signs/Symptoms

    • Fever

    • Declining Hb and hematocrit value

    • Mild jaundice

    • Hemoglobinuria

    • ARF – uncommon

  • Check for alloAb in both serum and RBC(Coombs test)

  • Treatment/Prevention

    • Rarely necessary

    • May need to monitor urine O/P, renal function, coagulation functions

    • IVIG

    • Appropriate units for transfusion


Delayed 24 immunologic3

Delayed (> 24°) Immunologic Factor (AHF)

Allo-immunization

Hemolytic

Graft-versus-host disease (GVHD)

Post-transfusion purpura

Immuno-modulation


Graft versus host disease gvhd
Graft-versus-host disease (GVHD) Factor (AHF)

  • Fatal complication cause by engraftment and clonal expansion of donor lymphocytes in susceptible host

    • Attack recipient tissues

    • Immunocompromised pts.

      • Hematologic malignancies or certain solid tumors receiving chemotherapy radiation

      • Stem cell transplant

      • Recipients of HLA matched products or familial blood donation

      • Lupus or CLL requiring fludarabine

      • Not reported in AIDS pts.

  • 2-30 days after transfusion

  • Incidence

    • Rare (0.002-0.005%)


GVHD Factor (AHF)

  • Signs/Symptoms

    • Appears w/in 10-12 days of transfusion

    • Skin – whole body erythroderma, desquamation

    • GI  N/A, diarrhea

    • Liver

    • BM  failure leading to pancytopenia

  • Treatment/Prevention

    • No effective treatment

    • Gamma irradiation

      • Render T-cells incapable of replication

      • FDA requirement

        • Minimum of 2500 cGy target to the midline of the container

        • Minimum of 1500 cGy target to all other part of component


Delayed 24 immunologic4

Delayed (> 24°) Immunologic Factor (AHF)

Allo-immunization

Hemolytic

Graft-versus-host disease (GVHD)

Post-transfusion purpura

Immuno-modulation


Post transfusion purpura ptp
Post-transfusion Purpura (PTP) Factor (AHF)

  • Characterized by abrupt onset of severe throbocytopenia (< 10 K)

    • Average of 9 days (range 1-24 days)

    • PRBCs or whole blood

    • Reported in plts., plasma, frozen deglycerolized PRBCs

  • Incidence

    • Rare

    • Over 200 cases published

    • Male:Female 1:5

    • Median age 51 years (range 16-83)

  • Clinical course

    • Usually self-limited, recovery w/in 21 days

    • 10-15% mortality

      • Intracranial hemorrhage


PTP Factor (AHF)

  • Signs/Symptoms

    • Profound thrombocytopenia

    • Purpura

    • Bleeding

    • Fever (reported)

  • Etiology

    • Plt. specific IgG Ab that are auto-Ab

      • All HPA implicated but HPA-1a most common

    • 3 mechanisms

      • Immune complex – pt. Ab and donor antigen

      • Concersion of antigen- autologous plts. to Ab targets to antigen in transfused components

      • Cross-reactivity of pts. autoAb with autologous plts.


PTP Factor (AHF)

  • Differential diagnosis

    • ITP

    • TTP

    • Alloimmunization

    • Sepsis

    • DIC

    • BM failure

    • Drug-induced

  • Treatment/Prevention

    • Steroids – controversial

    • Plasma exchange – achieves plts. counts to 20K in 1-2 days (up to 12 days)

    • IGIV – recovery of plts. Counts of 100K w/in 3-5 days

      • Block Ab-mediated clearance

    • Splenectomy – refractory pts., high risk of life-threatening hemorrhage

    • Plts. transfusion not effective

    • Antigen-negative blood product


Delayed 24 immunologic5

Delayed (> 24°) Immunologic Factor (AHF)

Allo-immunization

Hemolytic

Graft-versus-host disease (GVHD)

Post-transfusion purpura

Immuno-modulation


Immuno modulation
Immuno-modulation Factor (AHF)

  • ? Increases risk of recurrent cancer and bacterial infection

  • WBCs  cytokines during storage  interfere with immune function

  • Uncertain clinical significance

  • Leukoreduction of blood products


Summary

SUMMARY Factor (AHF)

“Because of the Risks Associated With Transfusion, Physicians Should Remain Familiar With Currently Recognized Alternatives to Transfusion. Autologous Transfusion Techniques (Such As Perioperative Collection and Preoperative Donation) Should Be Considered, When Indicated, to Reduce the Need for allogeneic Transfusion With Its Attendant Risks of Disease Transmission and Immune Reactions.”


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