Transcript Lecture_090414

Principles of Transfusion
Hospitalists
Brian Platz, MD AP/CP, BB/TM
September 4, 2014
Itinerary
• Ordering Blood in HealthConnect
• For the Newbies…
• ‘Dosing’ of Blood Products
• Transfusion Reactions
• ID risks from Blood Transfusion
• Special Needs (CMV neg, LR, Irradiated)
• (Compatibility Testing)
Ordering Blood in HealthConnect
Crossmatch of rbc units now automated
Orders for Type & Screen are ‘implied’ if needed.
(You do not need to order them separately)
For the Newbies
Kaiser ‘Fresh Frozen Plasma’
In case no one has told you,
Kaiser blood banks may give out
‘Plasma, thawed’
in lieu of
‘Fresh Frozen Plasma.’
FFP
Separated and frozen within 6 hours of
donation. Prevents degradation of the “labile”
factors (V, VIII). Must be used within 24 hours after
being thawed.
After 24 hours, must be destroyed or relabeled as
Plasma, thawed
up to 5 days.
Can be stored and used for
Degradation of Coagulation Factors in FFP
For the Newbies
‘DoubleCheck’
• 40% of ABO mismatched transfusions occur
because of patient misidentification or
specimen mislabeling at phlebotomy.
• Regulations require the BB to compare every
blood type test to historical records for that
patient, to confirm ABO type.
• If it is the patient’s first time here, we have no
history, so we won’t recognize a drawing error.
For the Newbies
‘DoubleCheck’
• We require a second (distinct) draw on
patients without a prior typing on record.
• Should be behind the scene for inpatients
(may be more problematic for outpatients).
• We catch about 2-3 of these ‘misdraws’ per
year.
For the Newbies from the East Coast
Platelet Pheresis
• Obtained by pheresis from a single donor
• 1 unit from a whole blood donation contains
>5.5 × 1010 platelets and will raise platelet
count of a 70-kg adult by 5000 to 10,000/µL
• 1 pheresis unit contains ≥3.0 × 1011 platelets
(~6 single units) and should increase platelet
count about 40,000/µL
For the Newbies
JW Liaison
• ??
• (but the operator has this number, too)
• Don’t assume you know what the patient will
and won’t accept. JW are a diverse group.
FYI
• WLA is now using an ‘electronic crossmatch’
• Computer compares the donor unit ABO type
to the patient’s ABO type, and will not allow
the tech to issue an incompatible unit.
• Faster (and more reliable) than the 3-5 minute
‘immediate spin’ crossmatch.
Products
and
Dosing
Red Blood Cells
• 400 ml donation, Hct at least 38%
• plasma (+/- platelets) removed: 250 ml, Hct 65-80%
• preservative added, Hct ~55-65%
• Dosage relies on patient blood volume, target Hct, volume and Hct of
donor unit(s).
• Reality Check: 1 unit rbcs will raise Hb 1g or Hct 3%
Platelets
• whole blood unit contains >5.5 × 1010 platelets in 40 to 70 mL of plasma.
• apheresis platelets usually contains ≥3.0 × 1011 platelets and is the
equivalent of 4 to 6 units of platelets.
• Use for low platelets (consumption, hemorrhage), dysfunctional platelets
• Thrombocytopenia is unlikely cause of bleeding with counts > 50,000/µL.
• prophylactic transfusions may be appropriate at <5000 to 10,000/µL
• not indicated in HIT or ITP, unless actively bleeding.
• contraindicated in TTP (beware of HELPP syndrome)
• Dosage: patient blood volume, target count, unit count.
•CCI = (postcount – precount) × BSA / platelets transfused
• Reality Check: 1 pheresis unit gives 20-60,000 increase in platelet count (I
use 40,000)
• in chronic platelet transfusion, can make antibodies to the platelets
(usually PLA1 or HLA-related).
Fresh Frozen Plasma
• Prepared from whole blood or apheresis, frozen at -18 C or colder
• 200-250 ml (whole blood), 400-600 (apheresis)
• Clotting factors, vWF, fibrinogen, fibronectin, albumin, ADAMTS13
• Must be used within 24 hours of thawing (can then be relabeled as “Plasma,
Thawed” which implies less of the labile clotting factors, V, VIII and Protein S)
• Uses: Pre-op for patients with multi-factor deficiencies (liver disease, DIC),
patients undergoing massive transfusion, bleeding while on Warfarin (Vit K - II,
VII, IX, X), Thrombotic Thrombocytopenic Purpura, (second line choice for
specific factor deficiencies).
• Dosing: based on patient’s known factor level(s), desired levels, patient’s
blood volume, volume of plasma units. Still variable, as different people have
different levels of the clotting factors.
• Reality Check: give 2 units, re-evaluate
Cryoprecipitate
• aka Cryoprecipitated Antihemophilic factor (AHF), cryo
• Prepared from FFP (FFP produces cryo and CPP)
• fibrinogen*, Factor VIII, Factor XIII, vWF, and fibronectin.
•assume 80 IU of Factor VIII and 150 mg of fibrinogen for each unit
• Fibrinogen: one bag per 7 to 10 kg body weight to raise plasma
fibrinogen by approximately 50 to 75 mg/dL (fibrinogen <100 mg/dL)
• VIII = (Desired increase in Factor VIII level in % × 40 × body weight
in kg) / average units of Factor VIII per bag.
• von Willibrand Dz: vWF content of Cryoprecipitated AHF is not usually
known; an empiric dose of 1 bag per 10 kg of body weight
• Reality Check: 8-12 bags. Usually ordered by surgeons to correct
fibrinogen. They have their own ‘learning’ on AHF. I don’t argue.
Transfusion
Reactions
Transfusion Reactions
TYPE
CAUSE
FREQ
NOTES
Febrile
Transfused WBCs/cytokines
1:100
Cellular products
F>M
Give Tylenol
Allergic
Patient allergic to something
transfused plasma (nuts,
PCN).
1:333
Give
antihistamines
Anaphylactic/
Anaphylactoid
Severe allergic reaction or
IgA deficient patients making
anti-IgA. Circulatory collapse,
laryngeal edema.
Hypotension without fever.
1:20,000 to
1:47,000
~1 death per year
Self-limited, but
may require
intubation/ICU
Septic
Platelets: Staph
RBCs: Yersinia enterocolitica.
Hypotension with high fever.
1:5000 Plt
1:250,000 RBCs
Fatal in 1:50,000
platelet tx
Transfusion Reactions (Cont)
TYPE
CAUSE
FREQ
TransfusionAssociated
Circulatory
Overload
(TACO)
Too much volume given.
Cardiogenic edema.
NL to high BP
Varies with the
underlying dz.
Up to 10% in
elderly and
ICU.
TransfusionRelated
Acute
Lung Injury
(TRALI)
Anti-HLA antibodies + patient’s 1:12,000
PMNs. Get caught up in
pulmonary bed and cause noncardiogenic edema.
NL to low BP, +/- fever. Usually
within 6 hours of transfusion.
Acute
Hemolytic
Error in patient identification.
Incompatible red cells given.
NOTES
(less frequent
since advent of
pRBCs)
BNP elevated
5-15% mortality
ARC uses only
MALE donors for
plasma.
BNP < 250
5-10% mortality
1:250,000 to
Est 1:6,000 to
1:600,000 fatal 1:33,000 non-fatal
Transfusion Reactions (Cont)
TYPE
CAUSE
FREQ
NOTES
Iron
Overload
Chronic transfusion (in our
hospital, sickle cell and
thalassemia patients)
50% of patients
transfused with 75
or more units have
increased Fe in
myocardium
Chelation with e.g.
deferoxamine (IM,
IV). Trials on oral
medications.
Graft-vsHost
disease
Host is ‘blind’ to transfused
lymphocytes, but
transfused lymphocytes can
recognize ‘host’ as foreign.
E.g.
Donor: HLA A3- B27Recip: HLA A3A24 B7B27
Disease is rare (0.11% in susceptible
patients) due to
irradiation. Transfusion-
Prevented by
irradiation (2500
cGy of gamma
radiation). Fatal in
87-100% Brubaker D.
Alloimmuni
zation
associated graft-versus-host disease.
Dwyre DM, Holland PV
Vox Sang. 2008 Aug; 95(2):85-93.
Due to immunization by red 0.5-3% Gen Pop
cell antigens in the donor
37% Thalassemia
Transfus Med 2006;16:200
unit.
18-47% SSD
Transfusion 2002;42:37
Transfusion-associated graftversus-host disease. Hum Pathol.
1986;17:1085–1088
“Antibody Formers”
TRALI v TACO
TRALI
TACO
DYSPNEA
YES
YES
ABG
Hypoxemia
Hypoxemia
BP
Low to Normal
Normal to High
TEMP
Normal to Elevated
Normal
CXR
White out. Normal
heart size. No vascular
congestion.
White out. Normal to increased
heart size. Vascular congestion.
Pleural effusions.
BNP
Low (<250 pg/mL)
High
Pulmonary artery
occlusion pressure
Low to Normal
High
Echocardiogram
Normal heart function
Abnormal heart function
Response to Diuretics
Worsens
Improves
Response to Fluids
Improves
Worsens
Shealynn Harris, MD, Asst Med Dir., ARC, SoCal Div.
ID Risks
How Safe is the Blood Supply?
Donor Testing
•
•
•
•
•
•
•
•
HBsAg, anti-HBcAb
anti-HCV
anti-HTLV I/II
anti-HIV 1/2
NAT testing for HCV, HBC, HIV, WNV
anti-Trypanosoma cruzi Ab (Chagas Disease)
Serologic test for syphilis
(in addition, all platelet donations are tested for
bacteria)
• (perhaps anti-CMV, if not known to be positive)
Current ID Risks / Transfusion
(12.9 million units transfused each year in US)
ID
RISK / UNIT
HIV
1 : 2,300,000
HCV
1 : 2,000,000
HBV
1 : 350,000
HTLV I/II
1 : 2,000,000
WNV
1 : 350,000
BACTERIAL SEPSIS
1 : 1,000,000
GETTING STRUCK BY LIGHTNING IN
A GIVEN YEAR
1 : 500,000
GETTING STRUCK BY LIGHTNING IN
A LIFETIME
1 : 6250
WINNING MEGAMILLIONS JACKPOT
1 : 175,711,536
COMMENTS
LONG WINDOW PERIOD
11 CONFIRMED CASES BY A
TRANSFUSION.
USUALLY MILD DISEASE
1 : 150-200 SEVERE/FATAL
In Florida
Special Needs
Special Needs
CMV Negative—Historically, based on Serology of donor, but
Prestorage Leukocyte reduction is equivalent, for most situations. Used
for pregnant women, intrauterine transfusion, low birth weight or
premature infants, BM/solid organ transplant patients, and severely
immunocompromised patients (including HIV infection). Not indicated
if patient is CMV positive, (50-80% of population is positive).
Leukocyte-Reduction (LR)—Prestorage LR reduces the
number of white cells to <5 x 10^6/unit (>3-log reduction). Helps
prevent febrile reactions and HLA alloimmunization.
Irradiation—Treating a unit with 2500 cGy of gamma radiation
destroys the lymphocytes ability to divide. The ONLY purpose is to
prevent GVHD. Used for Directed donations to family members, HLAmatched platelet tx, intrauterine tx, organ transplant patients
CMV Negative
Serologic test not 100% reliable—
A “negative” unit can actually be positive either
because of the window period, or because the
antibody titer becomes undetectable.
Leukoreduction— Appears to be as effective.
Some Suppliers (ARC)— No longer supply them.
THUS
When “CMV-negative” is requested, we will supply
Leukocyte-reduced. If you really, really want CMVseronegative units, you must call the blood bank.
Leukocyte Reduction
“Pre-storage”
Performed under controlled conditions, over a
specified period of time, at a cooled temperature. Greater than 3-log
reduction in lymphocytes.
“Before-issue”
Run through a LR filter in the lab, before being picked
up. (We don’t do this here. I’ve never worked anywhere that did this)
“At the Bedside”
Run through a LR filter while being transfused to
the patient. NOTE: this is NOT equivalent to “CMV-Negative”.
NOTE: a Leukocyte-reduction filter is different from the
“microaggregate” filter that is used for all cellular products.
Special Needs (cont)
IgG-deficient donors– Used only for IgA-deficient
recipients who are making igG anti-IgA antibodies (1 in 333
people, but many don’t make the anti-IgA)
Washed RBCs—Rarely necessary. Use special donors if IgAdeficient units are needed. Used for, eg, washing the mothers red
cells when she is a directed donor for a newborn child with HDN
Frozen—We use mostly with Sickle Cell Disease patients
(multiply-transfused, multiple antibodies) or if an unlucky patient
is making antibodies to a high-frequency antigen.
Compatibility
Testing
TYPE AND SCREEN
TYPE—ABO and Rh (5 minutes).
SCREEN—For “unexpected” antibodies, (30 minutes).
ANTIBODY SCREEN NEGATIVE
ANTIBODY SCREEN POSITIVE
Can Use “Immediate-spin
crossmatch” (5 minutes) or
“electronic crossmatch”
(1 second)
First, must perform a “Panel”
to identify which antibody is
being made (45 minutes)
Must use units that lack the
identified antibody (takes 5-30
minutes to type the unit)
Must use “Coombs Phase
Crossmatch” 30 minutes)
Total time: 35 minutes.
Total time: 2 hours +
As long as the sample is valid
(72 hours), additional units
will take about 5 minutes.
Additional units will take 45
minutes to an hour to get
ready.
Please!!!!
Do not hesitate to call me!!
Any time, day or night.
I would MUCH rather be awoken at 3am to help
coordinate the best care for a patient than to get
to work the next day to find the little red light on
my phone blinking and a bunch of messages
from irate clinicians about poor quality of care.
MSM Donors
•Still not in the US (Lifetime deferral)
•Canada has reduced deferral to 5 years
•UK has 1 year deferral
•South Africa has 6 month deferral
•Chile and China are among countries
that now allows gay men to donate
The American Red Cross and the AABB both advocate changing the U.S.
policy on donations by gay men to a one-year ban -- on par with donation
policies for other high-risk groups.
Synthetic Blood
• Hemoglobin-based
• Perfluorocarbon-based
Many have been tested, but they tend to show an increase in death and
often increase in heart attacks in trials on trauma patients
• Produced by stem cells (Pharming)
Arteriocyte contracted by DARPA (Defense and Research Projects Agency).
Produce rbcs from umbilical stem cells. Studies going on. The major
advantage is the natural rbc shape and near-normal life span. Cost has been
reduced to $1000/unit. Each cord can produce 20 units.
Young Blood
Fountain of Youth?
the
Studies joining the vascular systems of young mice and old
mice show REVERSED signs of aging in the older mice: agerelated decline in cognitive function, muscle atrophy, and the
sense of smell.
• This might explain vampires
• I anticipate a resurgence in Goth culture
• In light of the above, for the first time in my life I’m glad
I’m over 50 and no longer have young blood.
Katsimpardi et al. Vascular and neurogenic rejuvenation of the aging mouse brain by young systemic factors. Science 2014; 344(6184): 630-4.
Sinha, et al. Restoring systemic GDF11 levels reverses age-related dysfunction in mouse skeletal muscle. Science 2014; 344(6184): 649-52.
Villeda, et al. Young blood reverses age-related impairments in cognitive function and synaptic plasticity in mice. Nature Medicine 2014.
?
brianplatz.com
blood bank stuff
x4350
310-594-2269