Transcript Hemat8-Tranfusion Medicine

‫بسم هللا الرحمن الرحيم‬
‫(وقل اعملوا فسيري هللا عملكم ورسوله واملؤمنون)‬
‫صدق هللا العظيم‬
BLOOD COMPONENT THERAPY
Dr. Samy Marouf
BLOOD COMPONENT THERAPY
It is the transfusion of specific blood
components required by the patient.
Principles
Use blood products only when it is
essential.
Replace only the deficient component, if
possible.
Identify the cause and if possible, treat it.
Use alternative , IV fluids
Blood components
WB
PRBC
FFP
PLT
Platelets
rich
plasma
Whole
blood
2nd centrifugation
Platelets
concentrate
1stcentrifugation
FFP for
clinical use
Red
Cell
concentrate
Optimal additive
solution
Red cells in
OAS
Fresh plasma
FFP for
fractionation
Cryoprecipitate
Blood COMPONENTS AVAILABLE
FROM THE BLOOD BANK
Whole blood
Packed RBCs
Random donor Platelets
Single donor platelets (Apheresis)
Fresh Frozen Plasma (FFP)
Cryoprecipitate
Whole Blood
450 ml of whole blood with 63 ml of anticoagulant
need for oxygen carrying capacity and volume
replacement
no viable platelets or WBC
decreased labile coagulation factors (Factor V and VIII)
Not available since it is not efficient utilization of blood
Whole Blood
Expected gain 1 gm /dl
active bleeding >30%
Neonatal exchange transfusion
Packed Red Blood Cells (PRBCs)
200-250 ml of RBCs and 50 ml of plasma
Hematocrit 55-70% depending on anticoagulant
shelf life 35 to 42 days depending on the
anticoagulant
treatment of symptomatic anemia where oxygen
carrying capacity is needed
Packed Red Blood Cells (PRBCs)
Indications :
1- Acute blood loss (100% blood volume = 5 Liters of
blood)
a – Amount of Loss:
i - > 15% with severe cardiac or Respiratory
disease.
ii – 15 – 30% with preexisting Anemia , or
continuous blood loss.
iii- > 30% blood loss.
b- Hb:
i- < 7 gm/ dl.
ii - < 8 gm/dl in elderly with cardiovascular or
Resp. disease.
3- Preoperative Transfusion :
a- Treat cause of anemia.
b- Avoid cause of bleeding .
c- Follow Maximum Surgical blood usage list.
4- Chronic Anemia:
a- Treat cause of anemia.
b- Erythropoietion therapy.
c – B- Thalassemia: Hb. Maintained > 9.5 gm/
dl.
d – sickle cell disease :
i – if Hb < 7 gm/ dl.
ii – if Hb < 10 gm/ dl. In cases with:
- Cerebro vascular accid. or at high risk.
- Acute chest or abdominal syndrome.
- pre operative for major surgery.
- pregnancy .
- priapism.
Dose : 10 ml/kg
Indication for Platelet Transfusion
Decrease platelet production (Bone marrow failure)
– Therapeutic:for patient who are bleeding
associated with BMF caused by either disease,
therapy or irradiation.
– Prophylactic: >10x 109/L to decrease morbidity in
patients with thrombocytopenia due to B.M.F.
Indications for prophylactic Platelets
transfusion
major bleed, major surgery >100,000
minor bleed, minor procedure >50,000
prevent spontaneous bleed > 10,000
Pooled Platelets
are prepared from the platelet portion of 6 whole
blood units plus 300 ml of plasma (potential for 6
infectious disease exposures) expires after 5 days
6 X 5 X 10 E10 = 3.0 x 10 E 11 platelets
6 x 5000 rise /RD plt = 30,000
transfuse the patient with platelets from many
donors to see which platelets will raise the platelet
count
Plateletpheresis
donated by a single donor
3.0 x 10 E11 platelets plus 300 ml of plasma,
expires after 5 days
raises the platelet count 30,000
used for all platelet transfusions until less than
10,000 platelet increase
Low Post-transfusion Increment to
Platelets
Definition : it is failure to obtain satisfactory
response to platelet transfusion of unselected
platelet components.
Low Post-transfusion Increment to
Platelets
1 hour post (platelet recovery) poor
– platelet alloantibodies
– platelet autoantibodies
– hepatosplenomegaly
24 hour post (platelet survival) poor
– infection
– DIC
bleeding
fever
Administration of Platelet Concentrate:
ABO compatible platelet are preferred but not
necessary.
Platelet concentrate should be transfused as soon as
possible after reaching the ward with standard blood
transfusion sets with 170 mm filters.
The transfusion should normally be completed within
30 minutes.
Observation during platelet transfusion should include
pulse& temperature before& after transfusion.
Fresh Frozen Plasma (FFP)
200-250 ml of plasma frozen at -18C within 8
hours of collection
no platelets are present
contains all coagulation factors
an unconcentrated source of fibrinogen
– use Cryo to correct a low fibrinogen level
needs 20-30 min lead time to thaw prior to use
FFP Continued
Definite indication:
Replacement of single or multiple factor
deficiencies
Immediate reversal of warfarin effect
Vitamin K deficiency
Acute disseminated intravascular coagulation
Thrombotic thrombocytopenic purpura
not used if non bleeding or for volume
replacement
indicated when PT/PTT are >17/55 sec
Cryoprecipitate (Cryo)
a white precipitate that forms when FFP at -18C
is thawed to 4C
volume is 10 to 15 ml
adult dose is 10 to 20 pooled units
30 minutes is needed for thawing and pooling
Cryoprecipitate continued
Cryoprecipitate can be used for the replacement
of all of the following:
– vWF
– Factor VIII
– Factor XIII
– Fibrinogen
vWD
Hemoplilia A
Factor XIII def
dec. fibrinogen *
head injury, massive bleed, trauma,
GRANULOCYTE CONCENTRATES
Prepared by cytopheresis
Donor prepared by administering cortisol
(releases marginating pool) and hydroxyethyl
starch (facilitates RBC/WBC separation)
1 X 1010 WBCs in 200 to 600 mL plasma
Storage at RT for 24 hours
ABO/Rh compatible; HLA compatible
Criteria for use
< 500 WBC/mm3
-active infection (as evidenced by
fever) not responding to antibiotics
*myeloid hypoplasia with
reasonable chance for survival
*Limited usage; usually for neonates
with sepsis (immature WBCs)
Leukocyte Reduced blood component
Leukocyte Reduced RBCs
RBCs with 99.99% of WBCs removed by
leukocyte reduction filter
prevents repeated nonhemolytic febrile
transfusion reactions
reduces immunosuppression of recipient by
donor WBC
All cellular components are leukoreduced now
Leukocyte Reduced RBCs
continued
decreases post-operative surgical infections due
to reduced immunosuppression
prevents or delays HLA alloimmunization
identical to CMV seronegative blood
does not prevent graft versus host disease, only
gamma irradiation prevents graft versus host
disease
Indications for Leukocyte Reduced
RBC continued
after second nonhemolytic febrile transfusion
reaction
newly diagnosed leukemics
long term multiple transfused patients
– sickle cell disease
– aplastic anemia
– thalassemia
Irradiated blood component
(Gamma) Irradiated RBCs
RBCs and platelets are exposed to gamma
irradiation at 2500 rads for 4.5 minutes
this inactivates the T lymphocytes in the donor
unit and prevents graft versus host disease in an
immunocompromised recipient
Indications for Gamma Irradiated
bone marrow transplant recipients
congenital immunodeficiency syndromes
intrauterine transfusions
transfusions from all blood relatives
Hodgkin’s disease
WBC products (to neutropenic patient)
– (never Stem Cells)
Massive Transfusion
Massive Transfusion
Definition : transfusion of a volume of blood equal to
the patient total blood volume in less than 24 hours
Problem of massive transfusion : thrombocytopenia ,
coagulation factor depletion , O2 affinity changes ,
hypocalecaemia , hyperkalemia , acid base
disturbance , hypothermia
Managemant: (saline, Ringer,albumin HES)
Massive Transfusion
Give blood products as a ratio
1 dose : 1 dose : 1 dose
: 1 dose
5 RBC :
2 FFP : 6 RD PLT : 10 Cryo
________________ (1 PPH) _________
Hgb(10gm)
PT PTT(<1.5 N)
Plt Ct (50000/ul))
Fib(>100mg%)
AUTOLOGOUS TRANSFUSION
AUTOLOGOUS TRANSFUSION
Definition : It is the use of patient own blood.
Autologous transfusion is alternative to allogenic
transfusion in elective surgery (T& C) ,3 types
(predeposite transfusion ,acute normovolaemic
hemodilution , intraoperative blood salavage
Advantages: no risk of viral infection ,all immunological
reaction ,decrease post-operative infection ,tumor
recurrence
AUTOLOGOUS TRANSFUSION
Disadvantages: 50% discarded , not used for
other patients , volume overload, bacterial
contamination, clerical errors
Exclusion criteria : unconfirmed date ,poor
venous access, infection , anemia ,
hemodynaemic instability
AUTOLOGOUS TRANSFUSION
Blood donation schedule:
safety
Donor and pre-transfusion test
Storage
Blood warmers
Blood warmers
Hypothermia is defined as the core body
temperature below 35 C.
Possible side effects of hypothermia are cardiac
arrhythmia homeostasis abnormalities from
impaired platelet function and slowed enzymatic
reactions in the coagulation cascade
vasoconstriction , dehydration , lack of oxygen to
tissues increased red cell release of potassium and
(with blood component transfusion) citrate toxicity.
The metabolism of drugs is also impaired.
Advantages of blood warning devices:
The primary advantage of using blood warming devices
during massive transfusion is to prevent the
complications caused by hypothermia thus improving
survival rates and patient outcomes including
decreased length of hospitalization.
Hypothermia impairs immune function may promote
surgical-wound infection and delay wound healing.
Disadvantages and complication:
1-Risk of hemolysis.
2-Risk of sepsis.
3-Decreased infusion rate.
5-Expense.
Indication for use:
• Massive transfusions (1 unit /10 minutes).
• Trauma situations in which core-re-warming
measures are indicated.
• Administration rate >50 ml/minute for 30
minutes or more (adults).
• Administration rate >15 ml/kg/hour
(children).
• Exchange transfusion of a newborn.
Warning:
• • Do not warm blood components by placing
on or near a radiator heater patient-warming
blanket or in a conventional microwave oven
or plasma thawer.
• Do not allow the unit to sit at ambient room
temperature for prolonged periods to warm
up.
• Do not place blood components under
running hot tap water or in an unmonitored or
improvised warm water bath.
• Do not return blood components that have
been warmed to inventory
Non infectious COMPLICATION
OF BLOOD TRANSFUSION
Transfusion Reaction
Acute Hemolytic Transfusion
Reaction
a clerical error (wrong specimen, wrong patient)
1 in 6,000 to 25,000 transfusions
back pain, chest pain, fever, red urine, oliguria,
shock, DIC, death in 1 in 4
stop the transfusion
Administration
Identity check
Work up of An AHTR
start normal saline
treat patient symptomatically
send blood bag and tubing to culture
send red top and purple top tubes
urine specimen for hemoglobinuria
DAT is positive
Non Hemolytic Febrile Transfusion
Reaction
NHFTR
(1:100)
Recipient has WBC antibodies to Donor WBCs
contained within RBCs and Plateletpheresis
products
DAT is negative
rise in temperature by 2F or 1C
other causes for fever are eliminated
blood that is hanging can be restarted ??
Allergic (Urticarial) Transfusion
Reaction
Recipient has antibodies to the Donor’s plasma
proteins (1 in 1000)
offending protein is not identified
urticaria, itching, flushing, wheezing
this is the only transfusion reaction where the
blood that is hanging can be restarted after
treatment with Benadryl
if symptoms continue then STOP
Anaphlyactic Transfusion Reaction
anaphylactic reaction (1 in 150,000)
1 in 700-900 people never made IgA
occurs when exposed to normal blood products
which contain IgA
bronchospasm, vomiting and diarrhea and
vascular collapse
treat with Epinepherine, Solu-Medrol,
Circulatory Overload
marginal cardiovascular status
given blood components too rapidly
develops acute shortness of breath, heart
failure, edema (1: 10,000)
systolic BP increases 50 mm
infuse slowly, not to exceed 4 hours
split the unit of RBC and give half
Transfusion Related Acute
Leukocyte Lung Injury
TRALI reaction (1:10,000)
Donor plasma contains WBC antibodies that
when transfused to the recipient cause
agglutination of recipient’s WBC in the
pulmonary capillary beds
Chest X ray looks like ARDS
Donor removed from donating blood
Blood Used on Emergency Basis
Blood Used on Emergency Basis
Blood used on Emergency Basis
– for a patient that is bleeding out
– and the blood type is unknown
group O, Rh negative, uncrossmatched
recipient may have an unexpected antibody
after 5 min use ABO and Rh type specific blood
Sepsis from Bacterial
Comtamination
Platelets:
– skin contaminants most common cause
– plateletpheresis 1 in 5000
– pooled platelets 1 in 1000
RBC:
– Sepsis from RBC due to Yersinia,
Gram Positive 1 in 3,000,000
Enterics or
Knowing is not enough;
we must apply.
Willing is not enough;
we must do."