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Transfusion Medicine: Types, Indications and Complications

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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Transfusion Medicine: Types, Indications and Complications

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  1. Transfusion Medicine:Types, Indications and Complications David Harford Hematology/Oncology

  2. 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

  3. 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

  4. 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

  5. Differential CentrifugationFirst Centrifugation Closed System Whole Blood Main Bag Satellite Bag 1 Satellite Bag 2 First Platelet-rich Plasma RBC’s

  6. Differential CentrifugationSecond Centrifugation Platelet-rich Plasma RBC’s Second Platelet Concentrate Plasma RBC’s

  7. 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

  8. 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

  9. 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

  10. 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%

  11. 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

  12. 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

  13. 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)

  14. 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

  15. 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

  16. 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

  17. 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

  18. Transfusion Complications • Acute Transfusion Reactions (ATR’s) • Chronic Transfusion Reactions • Transfusion related infections

  19. Acute Transfusion Reactions • Hemolytic Reactions (AHTR) • Febrile Reactions (FNHTR) • Allergic Reactions • TRALI • Coagulopathy with Massive transfusions • Bacteremia

  20. Frequency of Transfusion Reactions

  21. 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

  22. Symptoms of AHTR • High fever/chills • Hypotension • Back/abdominal pain • Oliguria • Dyspnea • Dark urine • Pallor

  23. 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

  24. 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

  25. Labs found with AHTR • Hemoglobinemia • Hemoglobinuria • Positive DAT • Hyperbilirubinemia • Abnormal DIC panel

  26. 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)

  27. 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

  28. 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

  29. 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

  30. 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)

  31. 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

  32. 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

  33. 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)

  34. Chronic Transfusion Reactions • Alloimmunization • Transfusion Associated Graft Verses Host Disease (GVHD) • Iron Overload • Transfusion Transmitted Infection

  35. 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)

  36. 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

  37. Transfusion Associated Infections • Hepatitis C • Hepatitis B • HIV • CMV • CMV can be diminished by leukoreduction, which is indicated for immunocompromised patients

  38. Prevention 1 In PRBC transfusion 2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood

  39. Summary • Blood Components • Indications • Considerations • Preparation and Administration of blood products • Acute and chronic transfusion reactions

  40. 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

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