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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


Satellite Bag






differential centrifugation second centrifugation
Differential CentrifugationSecond Centrifugation









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
  • 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%
  • 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
  • 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
  • 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
  • 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
  • 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

1 In PRBC transfusion

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

  • 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