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Transfusion Medicine: Types, Indications and Complications David Harford Hematology/Oncology History of Transfusions Blood transfused in humans since mid-1600’s 1828 – First successful transfusion 1900 – Landsteiner described ABO groups 1916 – First use of blood storage

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history of transfusions
History of Transfusions
  • Blood transfused in humans since mid-1600’s
  • 1828 – First successful transfusion
  • 1900 – Landsteiner described ABO groups
  • 1916 – First use of blood storage
  • 1939 – Levine described the Rh factor
transfusion overview
Transfusion Overview
  • Integral part of medical treatment
  • Most often used in Hematology/Oncology, but other specialties as well (surgery, ICU, etc)
  • Objectives
    • Blood components
    • Indications for transfusion
    • Safe delivery
    • Complications
blood components
Blood Components
  • Prepared from Whole blood collection or apheresis
  • Whole blood is separated by differential centrifugation
    • Red Blood Cells (RBC’s)
    • Platelets
    • Plasma
      • Cryoprecipitate
      • Others
  • Others include Plasma proteins—IVIg, Coagulation Factors, albumin, Anti-D, Growth Factors, Colloid volume expanders
  • Apheresis may also used to collect blood components
differential centrifugation first centrifugation
Differential CentrifugationFirst Centrifugation

Closed System

Whole Blood

Main Bag

Satellite Bag

1

Satellite Bag

2

First

Platelet-rich

Plasma

RBC’s

differential centrifugation second centrifugation
Differential CentrifugationSecond Centrifugation

Platelet-rich

Plasma

RBC’s

Second

Platelet

Concentrate

Plasma

RBC’s

whole blood
Whole Blood
  • Storage
    • 4° for up to 35 days
  • Indications
    • Massive Blood Loss/Trauma/Exchange Transfusion
  • Considerations
    • Use filter as platelets and coagulation factors will not be active after 3-5 days
    • Donor and recipient must be ABO identical
rbc concentrate
RBC Concentrate
  • Storage
    • 4° for up to 42 days, can be frozen
  • Indications
    • Many indications—ie anemia, hypoxia, etc.
  • Considerations
    • Recipient must not have antibodies to donor RBC’s (note: patients can develop antibodies over time)
    • Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)
    • Usually transfuse over 2-4 hours (slower for chronic anemia
platelets
Platelets
  • Storage
    • Up to 5 days at 20-24°
  • Indications
    • Thrombocytopenia, Plt <15,000
    • Bleeding and Plt <50,000
    • Invasive procedure and Plt <50,000
  • Considerations
    • Contain Leukocytes and cytokines
    • 1 unit/10 kg of body weight increases Plt count by 50,000
    • Donor and Recipient must be ABO identical
plasma and ffp
Plasma and FFP
  • Contents—Coagulation Factors (1 unit/ml)
  • Storage
    • FFP--12 months at –18 degrees or colder
  • Indications
    • Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange transfusion, massive transfusion
  • Considerations
    • Plasma should be recipient RBC ABO compatible
    • In children, should also be Rh compatible
    • Account for time to thaw
    • Usual dose is 20 cc/kg to raise coagulation factors approx 20%
cryoprecipitate
Cryoprecipitate
  • Description
    • Precipitate formed/collected when FFP is thawed at 4°
  • Storage
    • After collection, refrozen and stored up to 1 year at -18°
  • Indication
    • Fibrinogen deficiency or dysfibrinogenemia
    • vonWillebrands Disease
    • Factor VIII or XIII deficiency
    • DIC (not used alone)
  • Considerations
    • ABO compatible preferred (but not limiting)
    • Usual dose is 1 unit/5-10 kg of recipient body weight
granulocyte transfusions
Granulocyte Transfusions
  • Prepared at the time for immediate transfusion (no storage available)
  • Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, and recovery of BM is expected
  • Donor is given G-CSF and steroids or Hetastarch
  • Complications
    • Severe allergic reactions
    • Can irradiate granulocytes for GVHD prevention
leukocyte reduction filters
Leukocyte Reduction Filters
  • Used for prevention of transfusion reactions
  • Filter used with RBC’s, Platelets, FFP, Cryoprecipitate
  • Other plasma proteins (albumin, colloid expanders, factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusions
  • May reduce RBC’s by 5-10%
  • Does not prevent Graft Verses Host Disease (GVHD)
rbc transfusions preparations
RBC TransfusionsPreparations
  • Type
    • Typing of RBC’s for ABO and Rh are determined for both donor and recipient
  • Screen
    • Screen RBC’s for atypical antibodies
    • Approx 1-2% of patients have antibodies
  • Crossmatch
    • Donor cells and recipient serum are mixed and evaluated for agglutination
rbc transfusions administration
RBC TransfusionsAdministration
  • Dose
    • Usual dose of 10 cc/kg infused over 2-4 hours
    • Maximum dose 15-20 cc/kg can be given to hemodynamically stable patient
  • Procedure
    • May need Premedication (Tylenol and/or Benadryl)
    • Filter use—routinely leukodepleted
    • Monitoring—VS q 15 minutes, clinical status
    • Do NOT mix with medications
  • Complications
    • Rapid infusion may result in Pulmonary edema
    • Transfusion Reaction
platelet transfusions preparations
Platelet TransfusionsPreparations
  • ABO antigens are present on platelets
    • ABO compatible platelets are ideal
    • This is not limiting if Platelets indicated and type specific not available
  • Rh antigens are not present on platelets
    • Note: a few RBC’s in Platelet unit may sensitize the Rh- patient
platelet transfusions administration
Platelet TransfusionsAdministration
  • Dose
    • May be given as single units or as apheresis units
    • Usual dose is approx 4 units/m2—in children using 1-2 apheresis units is ideal
    • 1 apheresis unit contains 6-8 Plt units (packs) from a single donor
  • Procedure
    • Should be administered over 20-40 minutes
    • Filter use
    • Premedicate if hx of Transfusion Reaction
  • Complications—Transfusion Reaction
transfusion complications
Transfusion Complications
  • Acute Transfusion Reactions (ATR’s)
  • Chronic Transfusion Reactions
  • Transfusion related infections
acute transfusion reactions
Acute Transfusion Reactions
  • Hemolytic Reactions (AHTR)
  • Febrile Reactions (FNHTR)
  • Allergic Reactions
  • TRALI
  • Coagulopathy with Massive transfusions
  • Bacteremia
acute hemolytic transfusion reactions ahtr
Acute Hemolytic Transfusion Reactions (AHTR)
  • Occurs when incompatible RBC’s are transfused into a recipient who has pre-formed antibodies (usually ABO or Rh)
  • Antibodies activate the complement system, causing intravascular hemolysis
  • Symptoms occur within minutes of starting the transfusion
  • This hemolytic reaction can occur with as little as 1-2 cc of RBC’s
  • Labeling error is most common problem
  • Can be fatal
symptoms of ahtr
Symptoms of AHTR
  • High fever/chills
  • Hypotension
  • Back/abdominal pain
  • Oliguria
  • Dyspnea
  • Dark urine
  • Pallor
what to do if an ahtr occurs
What to do?If an AHTR occurs
  • STOP TRANSFUSION
  • ABC’s
  • Maintain IV access and run IVF (NS or LR)
  • Monitor and maintain BP/pulse
  • Give diuretic
  • Obtain blood and urine for transfusion reaction workup
  • Send remaining blood back to Blood Bank
blood bank work up of ahtr
Blood Bank Work-up of AHTR
  • Check paperwork to assure no errors
  • Check plasma for hemoglobin
  • DAT
  • Repeat crossmatch
  • Repeat Blood group typing
  • Blood culture
labs found with ahtr
Labs found with AHTR
  • Hemoglobinemia
  • Hemoglobinuria
  • Positive DAT
  • Hyperbilirubinemia
  • Abnormal DIC panel
monitoring in ahtr
Monitoring in AHTR
  • Monitor patient clinical status and vital signs
  • Monitor renal status (BUN, creatinine)
  • Monitor coagulation status (DIC panel– PT/PTT, fibrinogen, D-dimer/FDP, Plt, Antithrombin-III)
  • Monitor for signs of hemolysis (LDH, bili, haptoglobin)
febrile nonhemolytic transfusion reactions fnhtr
Febrile Nonhemolytic Transfusion Reactions (FNHTR)
  • Definition--Rise in patient temperature >1°C (associated with transfusion without other fever precipitating factors)
  • Occurs with approx 1% of PRBC transfusions and approx 20% of Plt transfusions
  • FNHTR caused by alloantibodies directed against HLA antigens
  • Need to evaluate for AHTR and infection
what to do if an fnhtr occurs
What to do?If an FNHTR occurs
  • STOP TRANSFUSION
  • Use of Antipyretics—responds to Tylenol
  • Use of Corticosteroids for severe reactions
  • Use of Narcotics for shaking chills
  • Future considerations
    • May prevent reaction with leukocyte filter
    • Use single donor platelets
    • Use fresh platelets
    • Washed RBC’s or platelets
washed blood products
Washed Blood Products
  • PRBC’s or platelets washed with saline
  • Removes all but traces of plasma (>98%)
  • Indicated to prevent recurrent or severe reactions
  • Washed RBC’s must be used within 24 hours
  • RBC dose may be decreased by 10-20% by washing
  • Does not prevent GVHD
allergic nonhemolytic transfusion reactions
Allergic Nonhemolytic Transfusion Reactions
  • Etiology
    • May be due to plasma proteins or blood preservative/anticoagulant
    • Best characterized with IgA given to an IgA deficient patients with anti-IgA antibodies
  • Presents with urticaria and wheezing
  • Treatment
    • Mild reactions—Can be continued after Benadryl
    • Severe reactions—Must STOP transfusion and may require steroids or epinephrine
  • Prevention—Premedication (Antihistamines)
trali transfusion related acute lung injury
TRALITransfusion Related Acute Lung Injury
  • Clinical syndrome similar to ARDS
  • Occurs 1-6 hours after receiving plasma-containing blood products
  • Caused by WBC antibodies present in donor blood that result in pulmonary leukostasis
  • Treatment is supportive
  • High mortality
massive transfusions
Massive Transfusions
  • Coagulopathy may occur after transfusion of massive amounts of blood (trauma/surgery)
  • Coagulopathy is caused by failure to replace plasma
  • See electrolyte abnormalities
    • Due to citrate binding of Calcium
    • Also due to breakdown of stored RBC’s
bacterial contamination
Bacterial Contamination
  • More common and more severe with platelet transfusion (platelets are stored at room temperature)
  • Organisms
    • Platelets—Gram (+) organisms, ie Staph/Strep
    • RBC’s—Yersinia, enterobacter
  • Risk increases as blood products age (use fresh products for immunocompromised)
chronic transfusion reactions
Chronic Transfusion Reactions
  • Alloimmunization
  • Transfusion Associated Graft Verses Host Disease (GVHD)
  • Iron Overload
  • Transfusion Transmitted Infection
alloimmunization
Alloimmunization
  • Can occur with erythrocytes or platelets
  • Erythrocytes
    • Antigen disparity of minor antigens (Kell, Duffy, Kidd)
    • Minor antigens D, K, E seen in Sickle patients
  • Platelets
    • Usually due to HLA antigens
    • May reduce alloimmunization by leukoreduction (since WBC’s present the HLA antigens)
transfusion associated gvhd
Transfusion Associated GVHD
  • Mainly seen in infants, BMT patients, SCID
  • Etiology—Results from engraftment of donor lymphocytes of an immunocompetent donor into an immunocompromised host
  • Symptoms—Diarrhea, skin rash, pancytopenia
  • Usually fatal—no treatment
  • Prevention—Irradiation of donor cells
transfusion associated infections
Transfusion Associated Infections
  • Hepatitis C
  • Hepatitis B
  • HIV
  • CMV
    • CMV can be diminished by leukoreduction, which is indicated for immunocompromised patients
prevention
Prevention

1 In PRBC transfusion

2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood

summary
Summary
  • Blood Components
    • Indications
    • Considerations
  • Preparation and Administration of blood products
  • Acute and chronic transfusion reactions
transfusion reaction summary
Transfusion Reaction Summary
  • AHTR can be fatal
  • Stop the Transfusion
  • Monitor for symptoms and complete evaluation
  • FNHTR is a diagnosis of exclusion
  • TRALI (ARDS-like reaction)
  • Chronic Transfusion reactions
  • Prevention methods – using filters, irradiation and premedication