Transcript B - Infusion Nurses of Oregon

Blood 101
Hank Hanna, MD
Medical Director
American Red Cross
Pacific Northwest
Objectives
Become familiar with the Donation Process
Understand the components of whole blood and how they
are processed and modified.
Understand testing on donor units.
Know the indications for RBC, Plasma, Cryoprecipitate and
Platelet Transfusion.
Recognize various types of transfusion reactions.
Become aware of alternatives to transfusions.
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Background
Every two seconds, someone in the US needs a blood
transfusion.
Across the nation, the Red Cross collects approximately 5.3
million pints of blood from 3.1 million volunteer donors annually.
These blood donations are then processed into >7.7 million blood
products.
Regionally we collect 250,000 pints of blood each year.
We serve 60 hospitals in OR and WA
Regulated by: FDA, AABB, CMS(CLIA), FACT
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Donation Process
Health History Questionnaire
Physical
Ways to Donate
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Donation Process
Screening – required by FDA in order to maintain a safe blood
supply.
• Behavioral
• Physical
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Health History Questionnaire
Addresses behavioral part of screening
• Most blood facilities use a Health History Questionnaire
• All allogenenic donors must answer these questions.
• Sexual Behavior
• IV Drug Use
• Travel History
• Living Conditions
• Medications – Rx and OTC
• Current Health State
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Physical
Vital Signs
•
Heart Rate – 50-100 bpm
•
Temp - ≤37.5ºC per FDA
•
Blood Pressure – 180/100
•
Hemoglobin - ≥12.5 g/dL per FDA
•
12.0 g/dL for women is under consideration
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Ways to Donate
•
•
Whole Blood
• RBC, plasma, cryo
• Time: approx. 5 min.
• Donation Interval: every 8 weeks
Apheresis
• Double RBC, plasma, platelets, cryo
• Time: approx. 45-90 min. depending on product
• Donation Interval
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•
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Double RBC 16 weeks
Plasma every 4 weeks
Platelets every 2 days but no more than 2x/7 days and 24x/year
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Component Processing
Whole Blood
Apheresis
Component Modification
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Whole Blood Processing
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•
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Processed after donation
RBC, plasma and cryoprecipitate
Usually occurs within 8 hours of collection
•
Centrifuged to separate red cells from
plasma/cryoprecipitate
Plasma moved into separate bag and then frozen to -18ºC
Plasma thawed to precipitate cryoglobulins, centrifuged and
pushed into satellite bag
Plasma and Cryo stored at -18ºC for 1 year
•
RBC’s leukoreduced and then stored at 1-6ºC for 42 days
•
•
•
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Apheresis Processing
•
Components separated time of collection
•
Whole blood removed from vein into spinning pheresis bag
•
Spin creates gradients of RBC, platelets and plasma
•
Exit tubes at various levels for each component
•
Open the exit tube for desired component, drains to
collection bag
•
Rest is returned to donor
•
Double arm and single arm
•
Platelets stored at RT for 5 days
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Component Modification Leukoreduction
•
RBC are allowed to pass through WBC reducing filter
(<5.0x106 WBC)
•
Performed to reduce CMV transmission
•
•
Febrile transfusion reactions and HLA
alloimmunization.
Seronegative CMV vs Leukoreduction
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Component Modification Irradiation
•
•
•
•
Inactivates lymphocytes to prevent TA-GVHD
RBCs are exposed to gamma or x-irradiation
Changes expiration of RBC to 28 days.
Indications
• IUT, infants who have received IUT
• Cellular immunodeficiency
• Neonatal exchange transfusions
• Granulocyte transfusion
• Components from blood relatives
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Donor Unit Testing
Disease
Serologic
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Disease Testing
•
Prevents disease transmission
• Hepatitis B
• Hepatitis C
• HIV-1,-2
• HTLV I/II
• Syphilis
• WNV
• Chagas
• Bacteria (platelets only)
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Serologic Testing
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•
•
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ABO
D Antigen(Rh)
Weak D Antigen
Antibody Screen
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Transfusion
Recipient Testing
RBC
Plasma
Cryoprecipitate
Platelets
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Recipient Testing
•
Type and Screen
ABO
D Antigen
Weak D Antigen
Antibody Screen
Must have a sensitizing event (previous transfusion or
pregnancy) and be negative for those specific antigens
Rh, Kell most common
•
Donor compatibility (Crossmatch)
•
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•
•
•
•
•
Donor RBCs
Platelets
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Blood Group Compatibility
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Blood Group Compatibility
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Blood Types and the Population
Caucasians
African
American
Hispanic
Asian
O+
37%
47%
53%
39%
O-
8%
4%
4%
1%
A+
33%
24%
29%
27%
A-
7%
2%
2%
0.5%
B+
9%
18%
9%
25%
B-
2%
1%
1%
0.4%
AB +
3%
4%
2%
7%
AB -
1%
0.3%
0.2%
0.1%
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RBC
•
Indications
•
•
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Symptomatic Anemia
Red Cell Exchange
Exchange Transfusion
•
No "Magic Number"
•
Contraindications
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Anemia that can be corrected with a non-transfusion therapy.
Increasing blood volume
To improve wound healing
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Plasma
•
Indications
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•
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Active bleeding or risk of bleeding due to deficiency of multiple
coagulation factors or a single factor for which no concentrate is
available.
Severe bleeding due to warfarin or urgent reversal of warfarin effect.
Massive transfusion
TTP
Contraindications
•
•
•
Increasing blood volume or albumin concentration.
Coagulopathy that can be corrected with Vitamin K.
Normalizing abnormal coagulation results in the absence of bleeding.
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Cryoprecipitate
•
Indications
•
•
•
•
Source of fibrinogen
Massive transfusion
Plasmapheresis
Contraindications
•
Do not use for specific factor deficiencies for which a concentrate is
available.
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Platelets
•
Indications
•
•
Prophylactic:
•
•
•
•
Bleeding due to decreased or functionally abnormal platelets.
>10,000/mL in stable, non-bleeding patients
>20,000/mL in unstable, non-bleeding patients
>50,000 in actively bleeding patients or patients undergoing invasive
procedures/surgery
Contraindications
•
ITP, TTP, HIT, Thrombosis
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Transfusion Reactions
Hemolytic – Acute and Delayed
Non-Hemolytic
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Transfusion Reactions
•
•
•
•
STOP the transfusion
THINK, could it be an AHTR?
TREAT patient
INITIATE transfusion reaction workup
• Types
•
•
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Hemolytic: Acute, Delayed
Non-Hemolytic: Febrile, Allergic, Volume Overload (TACO), TRALI,
Bacterial, TA-GVHD
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Acute Hemolytic Reactions
• Symptoms: flank or back pain, hematuria, fever, chills,
nausea, vomiting, dyspnea, hypotension, renal failure, DIC,
IV site pain
• Cause: most commonly ABO incompatibility
• Pathophysiology: complement-mediated intravascular
hemolysis
• Potentially Fatal
• Treatment: discontinuation of transfusion, hydration,
intensive patient monitoring
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Delayed Hemolytic Reactions
• Symptoms: Less severe than AHTRs, fever and chills hours
to days after transfusion
• Cause: immunologic incompatibility not identifiable at time
of recipient testing
• Pathophysiology: RBCs tagged for removal by splenic
macrophages
• Treatment: supportive
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Non-Hemolytic
Febrile
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•
•
•
Symptoms: fever (↑1ºC), chills, malaise
Occurrence: 1% of all transfusions
Pathophysiology: cytokine release
Treatment: stop transfusion, evaluate for hemolysis
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Non-Hemolytic
Allergic
• Symptoms: urticaria
• Occurrence: About 3% of all transfusions
• Pathophysiology: recipient antibodies against donor plasma
proteins
• Treatment: antihistamines, may continue transfusion after
resolution of symptoms
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Non-Hemolytic
Volume Overload (TACO)
• Symptoms: dyspnea, cough, hypertension, tachycardia
• Occurrence: <1% of transfusions. More common in elderly,
pre-existing cardiovascular disease
• Pathophysiology: inability of circulation to handle
transfused fluid volume
• Treatment: oxygen, diuretics, supportive care
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Transfusion Associated Lung Injury
(TRALI)
• Symptoms: hypoxemia, respiratory failure, hypotension,
fever, noncardiogenic pulmonary edema,
•
Symptoms arise within 6 hours of transfusion
• Occurrence: 1 in 5,000 transfusions
• Pathophysiology: likely caused by donor antibodies to
recipient WBC, WBC’s activated by other donor substances
• Treatment: supportive care(O2, ventilation), hemodynamic
stabilization
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Non-Hemolytic
Bacterial/Sepsis
• Symptoms: severe chills, fever, hypotension, nausea,
vomiting
• Occurrence: rare due to bacterial testing prior to distribution
• Pathophysiology: endotoxin release
• Treatment: stop transfusion, culture patient
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Graft-Versus-Host Disease
(TA-GVHD)
• Symptoms: fever, rash, enterocolitis, elevated liver function
tests, pancytopenia
• Occurrence: rare but almost uniformly fatal
• Pathophysiology: donor lymphocytes mount attack against
recipient
• Prevention: irradiation
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Transfusion Alternatives
Hemoglobin Substitutes
Perfluorocarbon Emulsions
Intravenous Iron (“Bloodless Surgery”)
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Hemoglobin Substitute
• Mainly consist of free hemoglobin that is unstable and toxic
with short half lives due to phagocytosis and RES uptake.
• Ideal Substitutes:
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Free of toxicity and side effects
Able to uptake O2 in the lungs and deliver O2 to tissues
Sufficient half life
Rapid and harmless excretion
Stable at room temperature, easy to store
Easy to sterilize
Cheap to manufacture
No need for compatibility testing
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Perfluorocarbon Emulsions
• Hydrocarbons with Hs mostly replaced by Fs
• Dissolve O2 instead of binding like hemoglobin
• Have some utility and show more promise than hemoglobin
substitutes but can cause progressive hypertension at
higher doses, patients may be more predisposed to stroke.
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Intravenous Iron
• “Bloodless Surgery”
• Administer Iron and Erythropoietin for several days prior to
surgery to stimulate hematopoiesis
Day
Dose
1
1-2 g IV Iron
2
Erythropoietin, Vit B12
3
4
Erythropoietin, Vit B12
5
6
Erythropoietin, Vit B12
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8
Erythropoietin, Vit B12
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Erythropoietin, Vit B12
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Erythropoietin, Vit B12
Surgery
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Discussion / Questions?
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