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CANINE-Canine Transfusion Reactions.part 2.Prevention and Treatment

CANINE-Canine Transfusion Reactions.part 2.Prevention and Treatment

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Vol. 19, No. 2February 1997Continuing Education Article
FOCAL POINTKEY FACTS
5
Many transfusion reactions canbe prevented.
Canine TransfusionReactions. Part II.Prevention andTreatment
North Carolina State UniversityUniversity of Minnesota
Karyn Harrell, DVMJanice Parrow, CVT, LATg
Novo Nordisk Gentofte, Denmark 
 Annemarie Kristensen, DVM, PhD
ecent advances in transfusion medicine and the increased availability of canine blood components have made transfusion an important part of veterinary medicine. Transfusion is potentially life-saving, but it carriessome risk. Part I discussed the immunologic and nonimmunologic causes of transfusion reactions. This part discusses the prevention and treatment of transfusion reactions.
PLANNING TRANSFUSION THERAPY
The most important decision a clinician must make is whether transfusiontherapy is truly needed. An accurate assessment of the animal’s overall condi-tion and prior history must be made; the decision to use blood componentsshould not be based on numbers alone.
1–3
 As with all forms of medical therapy,avoiding unnecessary drug administration is the first step in preventing unde-sirable complications. After deciding to initiate transfusion therapy, the veterinarian must carefully choose the component to be given. The use of whole blood has been dramati-cally reduced recently in human and veterinary medicine.
2,4–6
More precise andefficient replacement for distinct deficiencies can be accomplished through theuse of specific component therapy.Use of component therapy will also decrease the risk of transfusionreactions.
4–7
If only coagulation factors are needed, plasma or cryoprecipitate isthe most appropriate therapy; hemolytic reactions can thus be avoided. A dogthat is anemic and has significant heart disease will be less likely to develop cir-culatory overload if packed red cells are given instead of whole blood. Reviews
s
The most important decisionis whether transfusion is trulyneeded.
s
Blood component therapy canbe less risky than transfusionof whole blood.
s
Unless the blood type of therecipient is known, universalblood should always be used.
s
A crossmatch should beperformed for all dogs receivingred cells, even if universal bloodis used.
s
The severity of most transfusionreactions is dose dependent, andearly recognition of a reactioncan avert disaster.
 
of the indications for administering specific blood com-ponents have been published.
5,8
SELECTING DONORSBlood Type
Many transfusion reactions can be prevented simply by following appropriate transfusion medicine guide-lines (see Preventing Transfusion Reactions in Dogs) when choosing donors, collecting and preparing bloodproducts, and administering these products to patients.Several of these points warrant further discussion.
Nonuniversal Blood 
Use of nonuniversal blood increases the risk of acutehemolytic transfusion reactions in a sensitized patientand might induce antibody formation in the recipi-ent.
4,5,7,9,10
These antibodies will decrease survival of donor red cells and sensitize the patient to additionaltransfusions. Transfusion of nonuniversal blood to abitch might lead to neonatal isoerythrolysis in puppiesthat are subsequently born.
8,11,12
Unless the blood type of the recipient is known, uni-versal blood should always be used.
5,9,13
 A quick and ac-curate card test for dog erythrocyte antigen (DEA) 1.1 isnow available. This test allows for the immediate identi-fication of the DEA 1.1 status of donor and recipient.Donor dogs can then be typed for other important anti-gens by established laboratories.
13,14
 Although mostdonors should have the universal blood type, donors of other blood types may be used when the recipient
sblood type is known to be compatible (DEA 1.1
posi-tive blood may be given to a DEA 1.1
positive patient).
Crossmatching 
Not all DEA groups have been well characterized, soa crossmatch should be performed for all dogs receivingred blood cells
even when universal blood is used.
15
 A full crossmatch includes a major part (which tests forantibodies in the recipient
s blood to the donor
s redcells) and a minor part (which detects antibodies in thedonor
s blood to the recipient
s red blood cells).
3,7,15,16
Controls testing reaction of the recipient
s cells with itsown serum and the donor
s cells with its own serum arealso run. Unless large quantities of plasma are trans-fused, a minor crossmatch is unnecessary.
7,15
 A major crossmatch is a superb screening test for in-compatibilities that could causeserious hemolytic transfusion re-actions.
3,7,16
This test is especially useful for patients that have beenpreviously transfused (antibodiescan form in as few as 4 days), inpatients with natural antibodies,and in multiparous females.
3,15,16
The major crossmatch (see theMajor Crossmatch protocol) issimple and can be performed inany clinic with a centrifuge, aheat block, and a microscope. Antigen
antibody reactionscan be temperature dependent.Consequently, the crossmatch isrun at 37
˚
C, 25
˚
C, and 4
˚
C.
3
Red blood cells that show a reac-tion at 37
˚
C or 25
˚
C should notbe given. It may also be necessary to compare the results with theself-controls (especially in cases of immune-mediated hemolyticanemia) and determine a
bestfit
transfusion.The incidence of hemolytictransfusion reactions will be re-duced by performing crossmatch-es when red cells are given. Even when blood showing a compati-
Small Animal
The Compendium 
February 1997
DEA 1.1
s
NATURAL ANTIBODY
s
MULTIPAROUS FEMALES
Donor*
s
Type all donors—at least forDEA 1.1.
s
Screen for metabolic andinfectious diseases.
s
Use sterile technique whencollecting blood.
s
Use appropriate separationmethods, and store bloodproducts at suggestedtemperatures.
Recipient
s
Perform a major crossmatch.
s
Use universal blood (unless thepatient
s blood type is known).
s
Consider the patient
s underlyingdiseases when choosingcomponents and administrationrate.
s
Administer diphenhydramine(0.5 mg/kg subcutaneously orintramuscularly).
Administration
s
Never 
use outdated or hemolyzedproducts.
s
Use only isotonic saline to dilutepacked red cells.
s
Warm blood products toappropriate temperatures.
s
Avoid mechanical damage tocellular components by usingappropriate pumps, filters, needlesizes, and administration rates.
s
Use warmed or open units within24 hours.
s
Complete each transfusion within4 hours.
s
Monitor transfusions carefully.
Preventing Transfusion Reactions in Dogs
*Screened and typed canine blood products can also be obtained from an establishedblood bank.
 
ble crossmatch is given, however, certain reac-tions may still occur.
7,15,16
 As a crossmatch testsonly for preexisting antibodies, posttransfusionsensitization may occur
even when appropri-ately matched blood is given (which emphasizesthe need to use universal red cells).
7,16
 A mildhemolytic reaction may also occur when anti-bodies are present at levels too low for the cross-match to detect. In addition, a crossmatch does
not 
test for antibodies to white blood cells orplatelets; these antibodies may be responsiblefor mild to severe nonhemolytic reactions.
17
20
Prophylactic Treatment 
The benefit of prophylactic treatment for theprevention of type I hypersensitivity reactionshas been debated.
5,21
In one experiment, an an-tihistamine given before plasma transfusion pre-vented acute hypersensitivity reactions.
21
Nocontrolled clinical or prospective studies havebeen published to date. Although we are cur-rently unable to document a definitive decreasein type I reactions when an antihistamine is giv-en in clinical cases, diphenhydramine (0.5mg/kg intramuscularly or subcutaneously) may reduce the risk of these reactions.Glucocorti-coids do not acutely suppress the production of IgG or IgM antibodies. For this reason, admin-istration of glucocorticoids before red celltransfusions will
not 
prevent a hemolytic trans-fusion reaction from occurring when incompat-ible blood is given to a sensitized patient.
7,22
Inaddition, steroids do not prevent the binding of IgE to mast cells or the subsequent release of vasoac-tive cellular products. Thus, there is no reason to ad-minister steroids in an attempt to prevent a type I hy-persensitivity reaction. Steroids should be given only if necessary to treat the primary disease or to treat shock if a severe transfusion reaction does occur.
Monitoring
The severity of most transfusion reactions is dose de-pendent; early recognition of a problem can avert disas-ter. Careful patient observation is critical, especially during the first 30 minutes of the transfusion.
5,18,21,23,24
 Accurate monitoring is facilitated by the use of a stan-dardized form to record significant data. When any blood component is to be given, baselinemeasurements of temperature, pulse, and respiratory rate should be recorded. Mucous membrane color,packed cell volume, total protein, a coagulation factortest, and platelet count should also be noted. The tem-perature, pulse, and respiratory rate should also bechecked at 15, 30, and 60 minutes into the transfusionand at 1, 12, and 24 hours after transfusion.
5
 When redcells are given, packed cell volume is recorded andserum examined for hemolysis at 15 minutes and at 1,12, and 24 hours after transfusion. More specific infor-mation (e.g., blood pressure, coagulation testing, renalfunction) may be collected as needed.It is also useful to record the primary disease, a sum-mary of prior transfusions or reactions, the componentand specific donor used, crossmatch information, andpremedications or other therapy. If a reaction does oc-cur, particular details should be summarized. Conscien-tious monitoring and documentation will enhance ear-ly recognition of reactions and aid in the identificationof the overall incidence of problems in the transfusionpractices in your clinic.
TREATMENT
If a reaction is suspected, the transfusion
must be stopped immediately 
.
2,7,11,16,25,26
 While the transfusion is
The Compendium 
February 1997Small Animal
DIPHENHYDRAMINE
s
FEVER
s
HEMOLYSIS
s
Collect 2 ml of EDTAanticoagulated bloodfrom donor and recipient.(Pigtails on stored bloodcan be used.)
s
Centrifuge the bloodsamples for 1 minute(1000 rpm); remove theplasma to prelabeledtubes.
s
Wash the donor cells:Make a 2% suspension ofred blood cells by taking0.1 ml of the red bloodcells and adding 5 ml of0.9% saline; mix thesuspension.
s
Centrifuge the suspensionfor 1 minute. Discard thesupernatant. Resuspendthe red blood cells inanother 5 ml of 0.5%saline. Repeat thisprocedure twice more.
s
Place two drops of therecipient
s plasma orserum and two dropsof the donor cellsuspension in a 3-mltest tube. Mix well andincubate tubes for 30minutes at roomtemperature. Centrifugefor 1 minute at 1000 rpm.
s
For controls, follow thesame procedure as in theprevious step but placethe recipient
s cells withthe recipient
s plasma orserum and the donor
scells with the donor
splasma or serum.
s
To read the tubes:
s
Check for agglutination.
s
Check for hemolysis.
s
Place a drop from thetube on a slide and ex-amine under the micro-scope for agglutination.
Major Crossmatch

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