Transfusion Medicine

1. May 2, 2013 Transfusion Medicine

2. Transfusion Medicine • Donors • Blood Components • Pre-Transfusion Testing

3. Required testing • ABO • Rh • Antibody screening • ID

4. Infectious Disease Testing • HIV • HCV • HBV • HTLV-I/II (Human T-cell lymphotropic virus) • Syphilis • West Nile virus • Chagas disease

7. Transfusion Medicine • Donors • Blood Components • Pre-Transfusion Testing

8. Blood Components • How are they made • Overview of blood products and indications for use • Specialized products

9. Collection Bag

10. Blood Collection Bag • Collection Bag (450 or 500 ml; 10.5 ml/kg): • sterile, disposable, not reused • closed system: open only at needle • Bag not “violated” • integral satellite bags ensure closed system Whole blood

11. Making Components

12. From Whole Blood to components, highly regulated,…. • Processing components • Centrifuge • Express Plasma • Results in up to 4 products • PRBC • Plasma • Platelets • Buffy Coat (research)

13. Making Components • To make PLATELETS: WB unit “soft spin” • Get Platelet rich plasma; RBC’s still pack at bottom • Separate Plasma • Hard Spin to get: plasma with platelets at bottom

14. Blood Component Therapy • Express Plasma into satellite bag • Additive solution (100 ml) added to most PRBC’s • Extends shelf-life to 42 days (otherwise 21 to 35 days)

15. Apheresis • Automated blood separators • Use continuous or rapid intermittent flow • Withdraw blood, centrifuge, separate components by density • Collect desired component • Return rest to the donor

16. Applications of Apheresis • DRBC or combo products • Multiple units of plasma or platelets • Primary source of platelets in the U.S. • Apheresis Plasma: major source for commercial protein concentrates • IVIG • WinRho • Factor concentrates

17. Blood Component Therapy • Concurrent Infectious disease testing • Takes about 48 hours • Tell your Autologous and Directed Donors

18. Component Storage • RBC: refrigerated (1-6°C); 21-42 days • Platelets: agitated (20-24°C); 5 days • Plasma: • Frozen (-18°C or colder) • Thawed (1-6°C)

19. Blood Components • How are they made • Overview of blood products and indications for use • Specialized products

20. Red blood cells • Purpose • Increase oxygen-carrying capacity • Indications • symptomatic anemia • exchange transfusions • 1 unit raises (approximately) • Hgb 1 g/dL • Hct 3%

21. Plasma products • Frozen plasma: separated from RBC’s, frozen • Thawed and cryo-reduced plasma • Cryoprecipitate AHF (antihemophilic factor) • Platelets • Recovered and source plasma

22. Plasma • Indications (source of plasma proteins) • Replace multiple factors (e.g. liver dz, DIC) • Massive transfusion • Warfarin reversal (emergent !!) in bleeding patient or pre-invasive procedure • Plasma exchange (e.g. TTP) • Consider Albumin • Factor deficiencies when no specific coagulation concentrates are available

23. Guidelines (OUMS) • Plasma • Indications • Bleeding patient with coagulopathy due to multiple factor deficiencies • Hepatic failure, massive transfusion, DIC • Bleeding patient requiring urgent reversal of vitamin K deficiency from warfarin effect • INR ≥ 1.6 or PT > 1.5 times greater than the midpoint of the reference range

24. PLASMA NOT INDICATED: • Single factor deficiencies • Coagulation factor inhibitors • Heparin • Volume expansion • Nutritional/protein supplement • Prophylaxes following cardiopulmonary bypass • Wound healing • Hypogammaglobulinemia

25. Cryoprecipitate • Contents: • Fibrinogen • vWF • FXIII • FVIII

26. Cryoprecipitate • Indications • Actively bleeding with probable DIC • Fibrinogen < 100 mg/dl • Can be used for Hemophilia A or vWD patients if concentrates or recombinant preps are NOT available

27. Cryoreduced Plasma • Cryoprecipitate-reduced (or cryo-poor) Plasma • Plasma remaining after removal of cryo • Similar to FFP but should not be used to treat coagulation factor deficiencies of Factor VIII, XIII, and fibrinogen

28. Platelets • 5 day shelf-life • Bacterial detection may happen after infusion • WB-Derived Platelets (six pack) vs. apheresis platelets • Apheresis at OU

29. Platelets Indications: • Bleeding 2nd to low platelets or functionally abnormal platelets • Prophylactic • <10 K prophylactic • < 20 K mucositis, infection, anatomic lesion • < 50 K • Active bleeding and isolated thrombocytopenia • Perioperative period • Invasive procedure • < 100 K • Intracranial, other organ hemorrhage (CNS, eye, etc), plastics • Plts are dysfunctional (congenital, drug, inhibitor, ET?) • Infants/Children: Term infant with shock or sepsis; ECMO; DIC, active bleed or invasive procedure

30. Granulocytes • Purpose • Treat life-threatening bacterial or fungal infection • Neutropenic patients with bacterial or fungal infection • Unresponsive to antimicrobial therapy • Bone marrow hematopoietic capacity expected to recover • Efficacy • Controversial • Logistics • Requires approval by a Blood Bank physician • Outdates 24 hours after collection • ID testing usually not complete (Emergency release) • ABO compatible and known donors • Dexamethasoneor GCSF given to donor prior to donation

31. Commercial protein products • Plasma-derived: • Plasma pools from thousands of donors • Individual proteins isolated by affinity, precipitation. • Pathogen inactivated (e.g. heat, solvents, detergents) non-enveloped viruses are resistant • Example: IVIG, WinRho • Recombinant: • Several proteins now produced by recombinant techniques, including Factor VIII and Factor IX.

32. Blood Components • How are they made • Overview of blood products and indications for use • Specialized products

33. Specialized Blood Components • Irradiated blood products • Leukoreducedblood products • CMV • Washing • Frozen and Deglycerolized RBCs

34. Irradiated blood products • Purpose (only ONE) • Prevent TAGVHD by inhibiting lymphocyte proliferation • Does NOT • Prevent transmission of diseases • Reduce white cell count

35. Transfusion Associated Graft vs Host Disease • Donor Lymphocyte infiltrate skin, liver, and GI tract. • Rare except in immunocompromised patients • Nearly 100% fatal

36. Irradiated blood products • Blood Products • pRBCs • Platelets • Liquid Plasma • Granulocytes • Disadvantage • Shelf life shortened to 28 days or original date, whichever is first • K+ leak approximately doubled

37. Irradiated blood products • Indication: prevent TAGVHD • Intrauterine, Infants ≤ 4 months of age • Patients with cellular immunodeficiency syndromes (SCID, DiGeorge’ssyndrome) • Bone marrow transplant • Hematologic diagnoses (e.g. leukemia, lymphoma) • Directed donations

38. Leukoreduced blood products • Reduces WBC content to <5 x106 per transfused product • Purpose • reduce febrile transfusion reactions • reduce alloimmunization • reduce transmission of CMV • Blood donation products • Whole blood: special WBC filters • Apheresis: leukoreduced by collection technology

39. CMV • Purpose • To prevent TT-CMV disease in patients at risk for developing severe clinical CMV disease • Infants ≤ 4 months • Immunocompromisedpatients • Likely to become immunocompromised (allo BMT candidates) • Seronegativevs Leukocyte reduced • Controversy

40. Washed • Purpose is to remove plasma • Reduce reactions (anaphylactic and severe allergic) • Special patients (e.g. IgA deficiency with IgA antibodies) • Reduces incompatible plasma • Cellular Blood products • Disadvantages • Lose product, functionality • 24 hour outdate • Takes time

41. Frozen/Deglycerolized RBCs • Freezing is done to prolong storage • Autologous RBCs (postponed surgery) • Rare RBC phenotypes • Process: Adding glycerol to donor RBCs, then freeze to -65°C or colder • Frozen RBC shelf-life 10 years (ID testing issues!!!) • Deglycerolizing a frozen RBC: • Place in a 37°C water bath • Wash glycerol off before issuing • Resulting product: a RBC “donut” • Shelf life of 24 hours

42. Transfusion Medicine • Donors • Blood Components • Pre-Transfusion Testing

43. Steps in Pretransfusion Testing required by the AABB • Request for transfusion • Identification of transfusion recipient • Identification of blood specimen collected • Testing of transfusion recipient’s blood specimen: • Blood specimen acceptability • ABO group and Rh type • Antibody detection testing • Antibody identification • Comparison of current and previous test results

44. REQUESTS FOR TRANSFUSION • Requests for blood and blood components • oral, electronic, or written format • have accurate recipient identification • Two independent patient identifiers; ideally first and last names and a unique ID number • Patient’s gender, age and ordering physician • History: Diagnosis, pregnancy and transfusion history • Component type, amount, special needs

45. PATIENT IDENTIFICATION AND SPECIMEN LABELING • Properly labeled pretransfusion specimen is critical to safe blood transfusion • Majority of hemolytic transfusion reactions arise from misidentification of patients or labeling errors • Phlebotomist identifies (wristband) patient and labels sample AT THE BEDSIDE • Date and phlebotomist’s initials

46. In The Laboratory • Tubes and Requisition must match • Risky to correct information on an incorrectly labeled specimen • Have strict policy canceling incorrectly labeled specimens • Wrong blood in tube 40 times more likely with specimens that fail to meet acceptability criteria

47. SPECIMEN • 3 days, expires 72 hours from time drawn can no longer be used for testing • Retention: 7 days post transfusion for work up of transfusion reactions

48. Compatibility Testing • TYPE: ABO and Rh grouping of the recipient and donor • SCREEN: Antibody screen of the patient’s serum • Antibody ID: if Antibody screen is positive • RBC Crossmatch

49. WHAT IS IMMUNOHEMATOLOGY? • For a Blood Banker,…Immunohematology is the study of antigens and antibodies associated with blood transfusion • Safe blood transfusion depends on immunohematology

50. Blood groups on the RBC ABO Ii Lutheran Gerbich Knops Diego Yt Duffy MNS Cromer Indian LW Kell Rh Nydegger, U.E. and Flegel, W.A