Transcript 4-Transfusion

BLOOD TRANSFUSION
Blood transfusion is generally the process of receiving blood or blood
products into one's circulation intravenously. Transfusions are used for
various medical conditions to replace lost components of the blood.
Early transfusions used whole blood, but modern medical practice
commonly uses only components of the blood, such as red blood cells,
white blood cells, plasma, clotting factors, and platelets.
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
INDICATION OF BLOOD TRANSFUSION
• 1- To replace blood lost during surgery or loss of blood due to
bleeding in case of injury or any disease cause bleeding such as
bleeding DU.
• To restore oxygen carrying capacity of blood
• To provide plasma factor to prevent or treat bleeding
• If patient cannot make blood in blood disease
All donated blood should also be tested
for the ABO blood group system and Rh
blood group system to ensure that the
patient is receiving compatible blood.
Before a recipient receives a transfusion,
- The first step before a transfusion is given is to type and screen the
recipient's blood.
- compatibility testing between donor and recipient blood must be
done..
- The sample is then screened for any alloantibodies that may react with
donor blood.
It takes about 45 minutes to complete (depending on the method
used).
- the history of the patient to see if they have previously identified
antibodies and any other serological anomalies.
- The blood bank scientist also checks for special requirements of the
patient (e.g. need for washed, irradiated or CMV negative blood)
Donar must be free of the disease and especially HIV,
Hepatitis B, Hepatitis C, Treponema pallidum (syphilis)
and, where relevant, other infections that pose a risk to
the safety of the blood supply, such as Trypanosoma
cruzi (Chagas disease) and Plasmodium species (malaria
Component of blood
• Denoting blood is usually subjected to processing after it is collected to make it possible to use in
specific patient.
• Collected blood is separated in to blood components by centrifugation
1- RBC
2- Plasma ; FFP fresh frozen plasma, Cryoprecipitate
3-platlets
4-albumin protein
5-clotting factor concentrate
6-immunoglobins (antibody)
7- others Anti-D, Growth Factors, Colloid volume expanders
• Apheresis may also used to collect blood components
1-Whole Blood
• Storage
• 4° for up to 35 days
• Use filter as platelets and coagulation factors will not be active after 3-5 days
• Donor and recipient must be ABO identical
• Indications
• Massive Blood Loss/Trauma/Exchange Transfusion
2-RBC Concentrate
• Storage
• 4° for up to 42 days, can be frozen
• 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
• Indications
i e anemia, hypoxia, shock due to bleeding etc.
RBC Transfusions
Preparations
• 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
• 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
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May need Premedication (Tylenol and/or Benadryl) (to ovoid allergy)
Filter use—routinely leukodepleted
Monitoring, clinical status
Do NOT mix with medications
• Complications
– Rapid infusion may result in Pulmonary edema
– Transfusion Reaction
3-Platelets
• Storage
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Up to 5 days at 20-24°
Contain Leukocytes and cytokines
1 unit/10 kg of body weight increases Plt count by 50,000
Donor and Recipient must be ABO identical
• Indications
– Thrombocytopenia, Plt <15,000
– Bleeding and Plt <50,000
– Invasive procedure and Plt <50,000
Platelet Transfusions
Preparations
• 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
• 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
4 - Plasma and FFP (fresh frozen plasma)
• Contents—Coagulation Factors (1 unit/ml)
• Storage
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FFP--12 months at –18 degrees or colder
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%
• Indications
– Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange
transfusion, massive transfusion
5-Cryoprecipitate
• Description
– Precipitate formed/collected when FFP is thawed at 4°
• Storage
– After collection, refrozen and stored up to 1 year at -18°
– ABO compatible preferred (but not limiting)
- Usual dose is 1 unit/5-10 kg of recipient body weight
• Indication
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Fibrinogen deficiency or dysfibrinogenemia
vonWillebrands Disease
Factor VIII or XIII deficiency
DIC (not used alone)
6 - Granulocyte Transfusions
• Prepared at the time for immediate transfusion (no storage available)
• Indications – severe neutropenia associated with infection that has
failed antibiotic therapy, and recovery of BM is expected
• Donor is given G-CSF (granulocyte- colony stimulating factor)and
steroids or Hetastarch (volum expander)
• Complications
– Severe allergic reactions
– Can irradiate granulocytes for GVHD prevention
Transfusion Complications
• Acute Transfusion Reactions (ATR’s)
• Chronic Transfusion Reactions
• Transfusion related infections
Acute Transfusion Reactions
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Hemolytic Reactions (AHTR)
Febrile Reactions (FNHTR)
Allergic Reactions
TRALI
Coagulopathy with Massive transfusions
Bacteremia
1 - Acute Hemolytic Transfusion Reactions
(AHTR)
• Occurs when incompatible RBC’s are transfused into a recipient who has preformed 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
• 1 in 25,000
• Can be fatal
Symptoms of AHTR
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High fever/chills
Hypotension
Back/abdominal pain
Oliguria
Dyspnea
Dark urine
Pallor
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
Labs found with AHTR
• Hemoglobinemia
• Hemoglobinuria
• Positive (DAT) direct agglutination test
• Hyperbilirubinemia
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)
2- 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
• 1 in 200
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
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May prevent reaction with leukocyte filter
Use single donor platelets
Use fresh platelets
Washed RBC’s or platelets
3 - 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
• 1 in 1,000
• Prevention—Premedication (Antihistamines)
4-Transfusion Related Acute Lung Injury
TRALI
• 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
5- 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
6-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)
7-Chronic Transfusion Reactions
• Alloimmunization
• Transfusion Associated Graft Verses Host Disease
(GVHD)
• Iron Overload
• Transfusion Transmitted Infection
transfusion Associated Infections
• Hepatitis C
• Hepatitis B
• HIV
• CMV
• CMV can be diminished by leukoreduction, which is
indicated for immunocompromised patients