Transcript From Transfusion

Blood Components and
Indications for Their Use
Christopher J. Gresens, M.D.
VP & Medical Director, Clinical Services
BloodSource
1665 — 1st Documented
Animal-to-Animal Transfusion
Dog-to-dog
transfusion
by Richard
Lower.
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
1667—1st Documented
Animal-to-Human Transfusion
Jean
Baptiste
Denis
infuses 15year-old boy
with lamb’s
blood.
From Zmijewski’s Immunohematology.
1818—1st Documented
Human-to-Human Transfusion
Following a 150-year
transfusion hiatus,
James Blundell
transfuses patient
with blood from a
human donor.
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
1800’s—All Manner of Blood
Collection Devices Utilized
(You think
present-day
donor centers
sometimes face
challenges in
recruiting repeat
blood donors?)
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
1900—
ABH Blood Group System ID’d
From Transfusion, Vol. 1, p. 2 (1961)
Karl Landsteiner
discovers ABH system
when he types
individuals as (what we
now call) group A,
group B, and group O.
In 1902, his proteges
identify a group AB
individual for the first
time.
The Discovery of Many Other
Red Cell Antigens Followed
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•
•
•
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•
Rh (C, c, D, E, e, …)
Kell (K, k, …)
Kidd (Jka, Jkb, …)
Duffy (Fya, Fyb, …)
MNSs, …
Lewis (Lea, Leb)
… … …
Early 1900’s—Getting Blood
from Point A to Point B
From Petz and Swisher’s Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.
Direct, donor-topatient
anastamosis
performed by
American
surgeon, George
Crile.
1914—
Modern Anticoagulation is Born
Citrate first
used for blood
anticoagulatio
n purposes.
From Petz and Swisher’s Clinical
Practice of Transfusion Medicine, 2nd
ed., 1989.
1939/40—Rh and Cause of
HDFN Discovered
Levine, Wiener, and
colleagues
combined their
efforts in making
these seminal
discoveries
From Netter Monograph Series
But, the importance of ABO
supersedes all …
From Petz and Swisher’s Clinical
Practice of Transfusion Medicine, 2nd
ed., 1989.
Outline
Blood Collection and
Component Preparation
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•
•
•
•
Blood Collection
Whole Blood Separation into Components
Apheresis
Blood Bag Solutions
Donor Testing
Outline
Major Types of Blood Components/Derivatives
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•
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•
Whole Blood
Red Blood Cells (RBCs)
Platelets
Fresh Frozen Plasma (FFP)
·Cryoprecipitate
Granulocytes
· Derivatives
·
Outline
Specialized Types of
Blood Components & Transfusions
• Irradiated Blood
• CMV-seronegative Blood
• Leukoreduced Blood
Blood Collection &
Component Preparation
Blood Collection
1.
Via Whole Blood Donation: Whole
blood is collected from healthy blood
donors into sterile blood bags that
contain anticoagulant/preservative.
2.
Via Hemapheresis: Machines with
internal centrifuges separate a donor’s
blood into individual components. The
desired components are retained, while
the remainder is returned to the donor.
Four-Bag
Collection System for Whole Blood
+ “Light” Spin = …
+ “Heavy” Spin = …
FFP vs. … ?
… Cryoprecipitate
Apheresis-Assisted
Donor Collection
Trima/Trima Accel
• Used for donor
procedures, only (singleor double-RBC units;
single-triple
plateletpheresis, and/or
plasma)
From Gambro BCT website
The Principles of Hemapheresis
Blood Bag Solutions
• Purpose of Anticoagulant-Preservatives
– To prevent clotting
– To provide nutrients for continued metabolism
and stabilization of cells
• Basic Needs of Stored Blood Cells
– Adequate glucose (dextrose)
– Adequate ATP levels
– Appropriate pH
Blood Bag Solutions
• The Storage Lesion: These are the metabolic changes
that occur to stored blood over time. Following is an
example for CPDA-1 RBCs.
Parameter
0 Days
35 Days
% Viable Cells
100
71
pH
7.55
6.71
[K+] (mmol/L)
5.1
78.5
[Plasma Hgb] (mg/L)
78
658
[2,3-DPG] (% of initial)
100
< 10
AABB Technical Manual, 14th ed.
Testing
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ABO
Rh
Antibody Screen
Infectious Diseases
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–
–
Syphilis
HBsAg
Anti-HIV-1/2
Anti-HBc
Testing
• Infectious Disease Testing (cont.)
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–
–
–
–
–
–
–
Anti-HTLV-I/II
Anti-HCV
HIV Nucleic acid testing (NAT)
HCV NAT
HBV NAT
WNV NAT
Anti-T. cruzi
(On some units) Anti-CMV
Currently Accepted Risks
of Transfusion
• Acute immune-mediated hemolytic transfusion
reactions: 1 in 19,000 risk for ABO mismatched
transfusion;
1 in 33,000 for major ABO mismatch; 1 in 600,000 for
death (Linden et al. Transfusion 1992; 32: 601-606)
• TRALI: 1: 300 to 1:5,000 (Kao S, et al. Transfusion 2003; 43: 185191)
• Septic transfusion reactions: < 1: 777
plateletpheresis units; 1: 38,565 RBC units (Infectious
Risks of Blood Transfusion. Blood Bulletin (America’s Blood
Centers), December, 2001)
• Anaphylactic transfusion reactions: 1: 20,000 to
1:47,000 (Salama A, et al. Transfusion 2004; 44: 509-511)
Transfusion Risks
(Continued)
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Circulatory overload
Allergic transfusion reactions
Febrile nonhemolytic transfusion reactions
Delayed hemolytic transfusion reactions
Transfusion-related graft-versus-host
disease
• Post-transfusion purpura
Transfusion Risks
(Continued)
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•
HIV: 1 in 2,135,000 units
HBV: 1 in 205,000-to-488,000 units
HCV: 1 in 1,935,000 units
HTLV-I/II: 1 in 514,000-2,993,000 units
CMV: << 1: 100 (when leukoreduced or CMVnegative blood used)
• WNV: ? (region-specific; very low)
• vCJD: ? (risk very, very low—even in U.K.)
“Infectious Risks of Blood Transfusion.” Blood Bulletin (America’s
Blood Centers). December 2001.
Top-10 Reasons for Giving Blood
10.
9.
8.
7.
6.
It makes me feel good about myself.
How else can I instantly lose one pound?
To put up my feet and relax without guilt.
All my friends & family do it, so I do, too.
It’s a nice way to meet people with similar
philosophies.
Top-10 Reasons for Giving Blood
5.
4.
3.
2.
The good-looking nurses (and doctors).
Because, even though I have few material
possessions to give, I always (God willing)
will have enough blood to share.
Because I know that, whatever they take
from me, I can replace.
How else can I experience so much
satisfaction with my clothes on?
…and the Number 1 Reason for
Giving Blood
1.
To help save the lives of others.
Whole Blood
• Clinical Indications: Provides both O2
delivery and volume in patients with
hypovolemic shock.
• Contraindications
– Thrombocytopenia (unless unit is VERY
fresh)
– Factor VIII or V deficiencies
– Normovolemic chronic anemia
Whole Blood
• Transfusion Criteria
– Must be ABO-identical
– Should be crossmatch compatible
• Dosage: One unit should raise a 70 kg
patient’s Hct by approximately 3% (in
the absence of ongoing bleeding or
hemolysis).
“Shotgun” Approach vs. . . .
Component Therapy
Recommended Target Hematocrits
for RBC Transfusions (To be Revisited)
• Clinical Indications: To restore O2-carrying capacity
in clinically significant (acute or chronic) anemias.
– Asymptomatic anemia: Typically, in stable patients,
Hgb thresholds of 7-to-8 g/dL should be crossed
before transfusion would be considered.
– Bleeding/acute blood loss: Transfuse at the
discretion of physician.
– Occasional exceptions, such as the need to transfuse
pre-renal transplant patients, regardless of their Hcts
(i.e., to induce immune tolerance), exist.
Recommended Target Hematocrits for
RBC Transfusions (Revisited)
• Lower limit (or “transfusion trigger”) for general
medical and surgical patients remains at Hgb (Hct)
levels of 7.0 g/dL (21%).
• Some patient groups (e.g., elderly with acute MI’s)
seem to have better outcomes when Hct is in 30-33%
range.
“Current data suggest restraining transfusions favors
positive patient outcomes—except when significant
underlying cardiac disease is present.”
“The Transfusion Trigger Updated: Current Indications for Red Cell
Therapy.” Blood Bulletin, Vol. 6; July, 2003.
RBC Transfusions
• Contraindications
– Pharmacologically treatable anemias
– Most coagulation deficiencies
• Transfusion Criteria
– Must be ABO-compatible (group O is “universal”);
– Should be crossmatch-compatible;
• Dosage: One unit generally will raise the Hct (Hgb)
of a 70-kg, non-bleeding/hemolyzing patient by 3%
(1 g/dL).
Clinical Indications for Platelets
• Overview: Platelet transfusions are used for
the treatment and/or prevention of bleeding in
patients with thrombocytopenia or (less often)
platelet function defects
Clinical Indications for Platelets
1910: Duke demonstrated that platelets from
transfused whole blood decrease bleeding time
and control bleeding.1
1962: Gaydos, et al. first documented relationship
between platelet count and spontaneous bleeding
in leukemia patients (hemorrhage not seen until
platelet count fell to < 50,000/uL).2
1. Duke WW. JAMA 1910; 55: 1185-92.
2. Gaydos, et al. NEJM 1962; 266: 905-9.
Clinical Indications for Platelets
1978: Slichter & Harker showed that blood loss in stable
aplastic patients accelerated only when platelet count
< 10,000/uL (moreover, bleeding increased substantially
with platelet count of < 5,000/uL).1
1986: NIH-Sponsored Consensus Conference …2
Plt ct > 50,000: Bleeding probably not due to low plt ct
Plt ct < 5,000: Severe bleeding risk
Plt ct 5-10K:   risk of spontaneous bleeding
Plt ct 10-50K:  risk of bleeding during hemostatic
challenge
1. Slichter & Harker. Clin Hemat 1978; 7: 523-39.
2. Consensus Conference on Platelet Transfusion Therapy. JAMA 1987; 257: 1777-80.
Clinical Indications for Platelets
A. Guidelines for Prophylactic Platelet Transfusions
1. No Clinical Factors—Maintain platelet count
> 10,000/uL
2. Significant Clinical Factors (e.g., sepsis, DIC,
VOD, GVHD)—Maintain platelet count
> 20,000/uL
B. If Patient is Bleeding or Pre-Surgery, maintain
platelet count > 50,000/uL
C. Exceptions … (To be discussed)
Dosing Platelets
A. For Infants/Children: 5-10 mL platelets/kg
B. For Adults (> 40 kg): 1 plateletpheresis unit (rarely 2)
C. Formula for Calculating Dose:
Platelet Dose = Desired Increment x BV
0.67
D. Expectations: Ideally, an appropriate dose of platelets
should raise the platelet count by 30,000-60,000/uL
(more discussion to come …)
F. Important: Obtain a platelet count within 24 hours of
transfusion (ideally, within 1 hours—especially if
refractoriness suspected)
Special Platelet Topics
A. Platelet Selection Criteria
1. ABO Matching
a. 1st Choice: ABO identical (e.g., A to A)
b. 2nd Choice: Plasma compatible (AB to A)
c. 3rd Choice: Plasma incompatible (A to AB)
2. Rh Matching: It sometimes is necessary to give
Rh- positive platelets to an Rh-negative patient. If
the patient is a female of child-bearing potential,
consider the use of RhIg.
Special Platelet Topics
B. Contraindications to Platelet Transfusions
1. TTP/HUS (unless bleeding)
2. ITP and HIT (unless bleeding)
3. DIC (unless bleeding)
4. (Controversial) Chronic aplastic anemia or
MDS (unless bleeding)1
5. Plasma coagulation defects unrelated to
platelets
1. Consensus Conf, Platelet Transfusion Therapy. JAMA 1987; 257: 1777-80.
Special Platelet Topics
C. Platelet-Associated Transfusion Reactions
1. List includes most of the usual reactions (e.g.,
TRALI, anaphylactic, circulatory overload, etc.),
but most notably …
2. Septic transfusion reactions
3. Acute hemolytic transfusion reactions (from
incompatible donor plasma)
4. Alloimmunization to class I HLA and other
antigens
FFP Transfusions
• Clinical Indications
– Coagulopathy (with active bleeding) documented
by (at least one of): INR > 1.5, PTT > 1.5 x upper
limit; coag factor assay of < 25% activity;
– Emergent reversal of warfarin effect;
– Documented acquired or congenital coagulation
factor deficiency (when specific factor concentrate
is unavailable);
– Plasma exchange for TTP/HUS.
FFP Transfusions
• Contraindications: Should not be used as a:
– volume expander in absence of factor deficiency;
– nutritional source;
– substitute for a readily available factor concentrate;
• Transfusion Criteria: Must be ABO-compatible with
patient (with only the rarest of exceptions);
• Dosage: Determined by clinical situation and body
size; generally, 15 mL/kg for loading dose and 10
mL/kg to maintain hemostasis.
Cryoprecipitate Transfusions
• Clinical Indications
– Correction of factor VIII deficiency or von
Willebrand’s disease when a specific factor
concentrate isn’t available;
– Factor XIII deficiency
– Hypofibrinogenemia (e.g., in DIC)
– Source of fibrin glue
Cryoprecipitate Transfusions
• Contraindications: Always first consider safer,
more effective therapies, e.g.,
– DDAVP for vWD;
– Factor VIII concentrate (if available) for
hemoph. A;
– Tisseel™ for fibrin sealant;
• Transfusion Criteria: ABO generally is not very
important, unless a lot is transfused quickly (e.g.,
on the order of > 30 units over 72 hours).
Cryoprecipitate Transfusions
• Dosage
Total Bags Needed = [Total Factor Required]
[Units of Factor per Bag]
Total Factor Required
= [Pt’s Plasma Volume] x [Desired - Initial Level]
Plasma Volume Of Ave. Adult
= [kg body wt.] x [70 mL/kg] x [1 - Hct]
Granulocyte Transfusions
• Clinical Indications
– Generally Accepted Indication
• Documented severe bacterial infections
unresponsive to 24-48 hours of appropriate
antibiotics in a patient with severe
neutropenia/neutrophil dysfunction
– Less Clear “Indication”
• Documented severe fungal infection
unresponsive to appropriate antifungal
therapy in a patient with severe neutropenia
Granulocyte Transfusions
• Contraindications
– Fever in absence of documented infection
– Prophylactic transfusions
• Transfusion Criteria: Must be ABOcompatible (red cell crossmatch is performed
with each concentrate).
• Dosage: Generally transfused daily (1-2
units/day) until infection clears or neutrophil
count exceeds 500/uL.
Plasma Derivatives
•
•
•
•
•
•
Albumin (5% or 25%)
Plasma Protein Fraction
Factor VIII
Factor IX
Immune Globulins (e.g., IVIG, RhIG, HBIG, . . . )
Etc.
Intravenous Immune Globulin
• Clinical Indications
– Replacement Therapy--e.g.,
• Primary hypogammaglobulinemia
• S/p progenitor cell transplant
• Pediatric HIV sepsis
– Immunomodulant Therapy--e.g.,
• ITP
• Acute Guillain-Barre syndrome
• Chronic inflammatory demyelinating
polyneuropathy
• Dosage: Varies.
Specialized Blood Components
• CMV-seronegative
• Irradiated
• Leukoreduced
Indications for CMV-Seronegative Blood
• Pre-/post-hematopoietic stem cell transplant
(if pt. is CMV-neg)
• Low birth weight (< 1,200 g) neonate
(if mom is CMV-neg)
• Intrauterine fetal transfusion
(regardless of mom’s CMV serology)
• Pregnancy (if mom is CMV-neg)
• Congenital immunodeficiency (if pt. is CMV-neg)
• Pre-/post-solid organ transplant (if pt. is CMV-neg)
• HIV infection/AIDS(if pt. is CMV-neg)
• Other possible indications: hematologic/solid
malignancy; neonatal exchange (if pt. is CMV-neg)
Indications for Irradiated Blood
•
•
•
•
•
•
•
Pre-/post-hematopoietic stem cell transplant
Hodgkin’s disease
Low birth weight neonate (< 1,200 g)
Neonatal exchange transfusion
Intrauterine fetal transfusion
Related donor
HLA-matched donor or crossmatch-compatible
platelet donor
• Treatment with either fludarabine or 2-CDA
Summary
• Blood Collection and Component
Preparation
• Major Types of Blood Components and
Plasma Derivatives
• Specialized Blood Components
– CMV-seronegative
– Irradiated, etc.
Top 10 Bogus Reasons for
Transfusing a Patient
10.
My patient could use some extra calories.
9.
For wound healing purposes.
8.
My patient is specifically requesting it, and
who am I to say no?
7.
(For autologous blood) It’s the patient’s blood
anyway, so what harm could come of it?
6.
Since it’s been out of storage for > 30
minutes, and the blood bank won’t take it back.
Top 10 Bogus Reasons for
Transfusing a Patient
5.
Because I’m “only” a resident, and my
attending ordered it.
4.
(For FFP) The patient requires volume
support.
3.
(For platelets) My non-bleeding patient has
ITP with a platelet count of < 5,000/uL.
2.
Because the Tour de France is coming up.
And the Number 1
Bogus Reason for Transfusing a
Patient…
1.
Hey! It’s only blood. What’s the big deal?
Please
donate
blood ...
… You
never know
whose life
you might
save.
Action Comics # 403 (1970)