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Transfusion Therapy and Blood Components: Indications and Use

Transfusion Therapy and Blood Components: Indications and Use. C. J. Julius, M.D. Staff Pathologist St. Elizabeth Health Center Youngstown, Ohio Assistant Professor of Pathology Northeastern Ohio Universities College of Medicine Rootstown, Ohio. EXPERT.

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Transfusion Therapy and Blood Components: Indications and Use

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  1. Transfusion Therapy and Blood Components: Indications and Use C. J. Julius, M.D. Staff Pathologist St. Elizabeth Health Center Youngstown, Ohio Assistant Professor of Pathology Northeastern Ohio Universities College of Medicine Rootstown, Ohio

  2. EXPERT • One who travels more than 50 miles with slides er…computer disk • A former “pert” • Someone who travels (by phone) more than 50 miles for a talk • One who imparts knowledge/educates • ALL OF THE ABOVE

  3. INTRODUCTION • PATIENTS HAVE GREATLY BENEFITED FROM COMPONENT THERAPY SINCE ITS INTRODUCTION IN THE 1950’S-1960’S • THIS THERAPY INVOLVES ADMINISTERING ONLY THE COMPONENT NEEDED • THIS THERAPY INVOLVES THE “MINIMUM FOR THE MAXIMUM”

  4. INTRODUCTION • PHYSICIANS SHOULD HAVE A GENERAL KNOWLEDGE OF BLOOD GROUPS AND ANTIGENS, PRE-TRANSFUSION TESTING, BLOOD COMPONENTS, AND COMPLICATIONS OF BLOOD TRANSFUSION

  5. BLOOD COMPONENT THERAPY • Whole Blood • Red Blood Cells • Leukocyte-Reduced • Washed • Frozen, Deglycerolized • Platelets • Plateletpheresis • Platelet concentrates • Granulocytes

  6. BLOOD COMPONENT THERAPY • Fresh frozen plasma • Solvent Detergent • Liquid Plasma • Cryoprecipitate • Other Issues • Irradiation • Filtration • CMV • Donors and donor issues

  7. BLOOD COMPONENT THERAPY • What? (Definition) • How? (Prepared) • When? (Prepared) • When? (Stored) • When? (Guidelines, AABB Standards) • Why? (Response; Patient Response) • AABB (New) • Nuances

  8. BLOOD COMPONENT THERAPY • COMPONENTS • PREPARATION • CHARACTERISTICS • INDICATIONS • CONTRAINDICATIONS • SIDE EFFECTS • MONITORS • MANIPULATIONS • NEW (AABB)

  9. WHOLE BLOOD • Composition: RBC,plasma,WBC,platelets • 500 ml • ACD/CPD/CP2D: 21 Days • CPDA-1: 35 days • 1-6 C Storage • 1-10 C Transport • 1.4 ml solution to 10 ml blood

  10. WHOLE BLOOD • Donor-specific transfusions, trauma, increase both RBC Mass and plasma volume (WBC and platelets NOT functional; plasma deficient in labile clotting factors V, VIII) • 3-5% increase in HCT; 1-3 gm/dl increase in HGB • AABB NEW:Filtration:Irradiation • Nuances:Type for type; Type-specific

  11. RED BLOOD CELLS

  12. RED BLOOD CELLS (PREPARATION) • CENTRIFUGAL FORCE OR GRAVITATIONAL SEPARATION • CENTRIFUGATION (5 C) • GRAVITATIONAL

  13. RED BLOOD CELLS (CHARACTERISTICS) • AS-1 (300-350 ML)/HCT .60 (About) • CPDA-1 AND CPD (MANIPULATION DEPENDENT)/HCT <.80 • STORAGE 1-6 C • AS-1 = 42 DAYS • CPDA-1 = 35 DAYS • CPD = 21 DAYS

  14. RED BLOOD CELLS (CHARACTERISTICS) • RBC; reduced plasma;WBC • 250 ml - packed CPDA-1; 350 AS-1 • CPDA-1, AS-1 (less plasma) • ACD/CPD/CP2D: 21 days; CPDA-1:35 days; AS-1:42 days • 1-6 C Storage • 1-10 C Transport

  15. RED BLOOD CELLS (INDICATIONS) • SYMPTOMATIC DEFICIT OF OXYGEN-CARRYING CAPACITY • Chronic 6.0 or 7.0 gm/dl; Acute or ill (COPD) 9.0 gm/dl, cardiopulmonary complications, ICU patients 9.0 gm/dl • EXCHANGE TRANSFUSION • TO RESTORE RBC MASS IN SYMPTOMATIC ANEMIA (NOT TREATED BY HEMATINIC THERAPY)

  16. RED BLOOD CELLS (CONTRAINDICATIONS) • USE AS A VOLUME EXPANDER • AS AN ALTERNATIVE TO HEMATINIC THERAPY • WHEN NO SYMPTOMS ARE PRESENT • “LOOK GOOD ON PAPER” • “TWO UNIT MARTINI”

  17. RED BLOOD CELLS (SIDE EFFECTS) • DISEASE TRANSMISSION • BACTEREMIA (Beware the autologous unit) • TRANFUSION REACTIONS (Besides “bloody platelets” and granulocytes - the only crossmatched component)

  18. RED BLOOD CELLS (MONITORS) • HEMOGLOBIN AND HEMATOCRIT LEVELS • CAVEATS • 10 GM/L INCREASE AND .03 HCT INCREASE • EFFECTS OF VOLUME STATUS AND FLUID REPLACEMENT • “LAG PERIODS” = FLUID EQUILIBRATION; Not necessarily in the volume-replete! • CLINICAL ASSESSMENT ABOVE ALL! • One unit is O.K.!

  19. Red Blood Cells • Wiesen, AR et al. Equilibration of Hemoglobin Concentration after Transfusion in Medical Inpatients Not Actively Bleeding. ANN INTERN MED 121, No. 4, p. 278, 1994 • As early as 15 minutes post transfusion • Hemoglobin equilibration after 15 minutes is virtually identical to 24 hour level in non-bleeding patients • VOLUME REPLETE

  20. RED BLOOD CELLS (MANIPULATIONS) • LEUKOCYTES REDUCED • PRE OR POST STORAGE (85% RBC’s) • LEVELS < 5 X 106 PER UNIT • MOST FILTERS (3RD AND 4TH GENERATION) GUARANTEE LESS RED BLOOD CELLS (MANIPULATIONS) • DEGLYCEROLIZED (>80% RBC’s) • STORAGE 10 YEARS OR LONGER/Can RE-glycerolize - NOT a usual protocol • WASHED (Almost ALL plasma removed) • REJUVENATED RED CELL (<3days exp)

  21. RED BLOOD CELLS (MANIPULATIONS) • LEUKOCYTES • FEBRILE REACTIONS • HLA SENSITIZATION • CMV TRANSMISSION • DEGLYCEROLIZED • “POOR PERSON’S” LEUKOREDUCTION/ACTUALLY “RICH” PERSON’S • RARE BLOOD TYPES • IGA DEFICIENCY (NOT) • PNH (NOT)

  22. RED BLOOD CELLS (MANIPULATIONS) • WASHED • IGA DEFICIENCY • PNH (NOT) • REJUVENATED • INOSINE, PYRUVATE - PRIOR TO FREEZING OR TRANSFUSION • SALVAGE (AUTOLOGOUS)

  23. RED BLOOD CELLS (MANIPULATIONS) • Leukocyte-reduced: Pre-storage, post-storage, bedside; 4th generation leukodepletion filter <5 X 10’6 • CMV • HLA • Transfusion reactions to WBC antigens • Current debate (ALL OR SOME OF THE UNITS?) • Washed - IgA deficiency

  24. RED BLOOD CELLS (MANIPULATIONS) • Deglycerolized - IgA deficiency (Rich man’s version); • Rare donor registry (FROZEN BLOOD -without additive (<6 days from collection); with additive (prior to the expiration date of the Red blood cells; with rejuvenation (no later than 3 days after expiration)

  25. RED BLOOD CELLS (NEW) • AABB NEW: Apheresis Red blood cells - 180 ml packed RBC volume/unit, The donor of two-unit red cell apheresis collections shall meet specific HGB/HCT and weight requirements as outlined by FDA;

  26. RED BLOOD CELLS (NEW) • AABB NEW: Low volume units - 300-404 ml (450 +/-45 ml)-No other components prepared; Leukocyte-reduced - 85% original red blood cells;< 5 X 106; Irradiation - 2500 rads • Nuances:40% glycerol and 20% glycerol - 10 years

  27. PLATELETS

  28. PLATELETS (PREPARATION) • PLATELET CONCENTRATES • FROM WHOLE BLOOD DONATION • “LIGHT SPIN” / 20-24 C • “HEAVY SPIN”/ 20-24 C • RESUSPENSION TIMES (1 HOUR)

  29. PLATELETS (PREPARATION) • PLATELET PHERESIS UNIT • ONE DONOR • APHERESIS TECHNIQUES • ONE UNIT COLLECTED

  30. PLATELETS (CHARACTERISTICS) • PLATELET CONCENTRATES • VOLUME 50-60 ML (PLASMA/ACD) • PLATELETS >5.5 X 1010/UNIT • SHELF-LIFE 5 DAYS • pH - >6.2 • PLATELET PHERESIS UNIT • VOLUME 200-300 ML (PLASMA/ACD) • PLATELETS >3 X 1011/UNIT: Same for SPLITS • SHELF-LIFE 5 DAYS

  31. PLATELETS (INDICATIONS) • THROMBOCYTOPENIC BLEEDING • THROMBOCYTOPATHY AND BLEEDING • PROPHYLAXIS • 50,000/UL TRIGGER (OPERATIVE) • 20,000/UL TRIGGER (PROPHYLAXIS) • 5,000/UL TRIGGER

  32. PLATELETS (CONTRAINDICATIONS) • DO NOT USE IF BLEEDING UNRELATED TO PLATELET COUNT • TTP, ? ITP

  33. PLATELETS (SIDE EFFECTS) • DISEASE TRANSMISSION • BACTEREMIA (5 VS. 7 DAY STORAGE) • TRANSFUSION REACTIONS • RBC ANTIGEN SENSITIZATION

  34. PLATELETS (MONITORS) • 10 MINUTE, 15 MINUTE, OR 1 HOUR POST PLATELET COUNT • HLA SENSITIZATION • PLATELET ANTIBODY FORMATION • CLINICAL ASSESSMENT • Post platelet count-30-60,000/ul increase per single “dose” • Refractory patients-HLA-, cross-matched; yield better acute response/increment(s)

  35. PLATELETS (MANIPULATIONS) • FILTRATION (< 5 X 106 PER dose/pool/apheresis or <8.3 X 105 platelet concentrate) • BEDSIDE or MACHINE (HAEMONETICS) • LEUKOCYTE-Reduced PRODUCTION • COBE SPECTRA (PRODUCTION) • PLASMA “POORING” • INCOMPATIBLE PLASMA ISSUES • HLA-MATCHED • CROSS-MATCHED PLATELETS

  36. GRANULOCYTES

  37. GRANULOCTYES • They’re BACK!!!

  38. GRANULOCYTES (PREPARATION) • Leukapheresis

  39. GRANULOCYTES (CHARACTERISTICS) • > 1.0 X 1010 granulocytes in at least 75% of units tested • Also contain leukocytes, platelets and as many as 25 ml of red cells in 200-300 ml of plasma depending on the collection procedure

  40. GRANULOCYTES (INDICATIONS) • Severely neutropenic patients who have documented infection unresponsive to aggressive antibiotic therapy

  41. GRANULOCYTES (SIDE EFFECTS) • Transfusion reactions

  42. GRANULOCYTES (MONITORING) • Increased WBC count (GRANULOCYTES) • Clinical symptoms controlled

  43. GRANULOCYTES (AABB-NEW) • 20-24C storage and transport • Expiration - 24 hours • Irradiation - NO CHANGE in original expiration date

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