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TRANSFUSION THERAPY

TRANSFUSION THERAPY

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Published by: oxidalaj on Sep 05, 2008
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TRANSFUSION THERAPY PRINCIPLES OF TRANSFUSION THERAPY 
Because of the potentially life-threatening consequences of blood type ABOincompatibility and disease transmission through blood products, transfusiontherapy is limited to occasions when it is absolutely necessary and stringentscreening techniques are used before transfusion begins. Blood productprocurement, storage, preparation, and testing are regulated by the Food and DrugAdministration, the American Association of Blood Banks, and the Joint Commissionon Accreditation of Healthcare Organizations.
Blood CompatibilityAntigens
 The surface membrane of the red blood cell (RBC) is characterized byglycoproteins known as antigens.
More than 400 different antigens have been identified on the RBC membrane.
 There are fewer than a dozen clinically significant antigens, and of these, onlytwo antigenic systems (ABO and Rh) require routine prospective matchingbefore the transfusion.
 The ABO blood group system is clinically the most significant because A andB antigens elicit the strongest immune response.
 The presence or absence of A and B antigens on the RBC membranedetermines the person's ABO group (see Table 27-1). The ability to make A orB antigens is inherited.
Antibody formation without specific exposure to antigen is unique to the ABOsystem. Antibody directed against the missing antigens is produced by age 3months in neonates.
TABLE 27-1 Blood Group Antigens and Antibodies of ABO SystemBLOODGROUPANTIBODY ON RBCANTIBODY INPLASMAAPPROXIMATE FREQUENCY OFOCCURRENCE IN POPULATION
AAanti-B45%BBanti-A8%ABA and Bnone3%Ononeanti-A and anti-B44%
Antibodies
Antibodies (or immunoglobulins) are proteins produced by B lymphocytes;they consist of two light and two heavy chains that form a Y shape.
Antibodies generally have a high degree of specificity, and interact only withthe antigen that stimulated their production.
 The five classes of immunoglobulins are determined by differences in theirheavy chains: immunoglobulin (Ig) G, IgA, IgM, IgD, IgE.
 The interaction of antibodies and antigens triggers an immune response, thehumoral immune response.
Antibodies against the A and B antigens are large IgM molecules. When theyinteract with and coat the A and B antigens on the RBC surface, theantibody/RBC complexes clump together (agglutinate).
Antibody/RBC complexes also activate the complement cascade, resulting inthe release of numerous active substances and RBC lysis. The largeantibody/RBC complexes also become trapped in capillaries, where they maycause thromboticcomplications to vital organs, and in the reticuloendothelial system, wherethey are removed from circulation by the spleen.
 The extent of the humoral response elicited by anti-A and anti-B interactionwith A and B antigens depends on the quantity of antibody and antigen.
 
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2Other Red Blood Cell Antigens
Non-ABO RBC antigen-antibody reactions usually do not produce powerfulimmediate hemolytic reactions, but several have clinical significance.
After A and B, D is the most immunogenic antigen. It is part of the Rhesussystem, which includes C, D, and E antigens.
D (Rh)-negative people do not develop anti-D without specificexposure, but have a high incidence of antibody development(alloimmunization) after exposure to D.
 Two common methods of sensitization to these RBC antigens are bytransfusion or fetomaternal hemorrhage during pregnancy anddelivery.
Anti-D can complicate future transfusions and pregnancies. For the D(Rh)-negative person, exposure to D should be avoided by the use of Rh-negative blood products. In the case of Rh-negative mother and Rh-positive fetus, prophylaxis for exposure to D uses Rh immunoglobulin(RhoGAM), which will prevent anti-D formation.
Exposure to RBC antigens from other antigenic systems (such as Lewis,Kidd, or Duffy) may also cause alloimmunization, which becomesclinically significant in people who receive multiple blood productsduring long periods.
Blood Transfusion OptionsAutologous Transfusion
Before elective procedures, the patient may donate blood to be set aside forlater transfusion. Patients may donate one unit every 3 to 4 days up to 3 daysprior to surgery provided hemoglobin greater than 11 g/dL.
Autologous RBCs can also be salvaged during some surgical procedures orafter trauma-induced hemorrhage by use of automated cell-saver devices orby manual suction equipment.
Autologous blood products must be clearly labeled and identified.
Autologous transfusion eliminates the risks of alloimmunization, immune-mediated transfusion reactions, and transmission of disease, making it thesafest transfusion choice.
NURSING ALERT
Patients who do not meet standard criteria for blood donation may still be eligible todonate autologous blood before elective surgeries. The nurse should encouragesuitable candidates toconsider this underused option.
Homologous Transfusion
With this most common option, volunteer donors' blood products areassigned to patients randomly.
Before donation, volunteer donors receive information about the process,potential adverse effects, tests that will be performed on donated blood,postdonation instructions, and education regarding risk for humanimmunodeficiency virus (HIV) infection and signs and symptoms.
Donors are screened against eligibility criteria designed to protect donor andrecipient (see Table 27-2).
TABLE 27-2 General Blood Donor Eligibility Criteria
Age17 yearsWeightMinimum 110 lb (49.9 kg)
 
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3
Vital signsAfebrile, normotensive, pulse 50-100, blood pressure < 180/100 mm HgHemoglobin12.5 g/dLHistoryTravel, exposures, and past illnesses or events may defer or disallowblood donation.
Examples:
travel to malarial areas, living in areasexposed to bovine spongiform encephalopathy, blood transfusion ortattoo within 12 months, recent surgery or pregnancy, cornealtransplant, history of hepatitis or unexplained jaundice, history or mostcancers, history of behaviors at high risk for human immunodeficiencyvirus.ImmunizationsRecent attenuated and live vaccines generally result in deferral.IllnessesA variety of current illnesses may defer or disallow blood donation.Examples: clotting disorders, sickle cell disease, systemic lupuserythematosus, multiple sclerosis, Lyme disease.
Directed Transfusion
In directed transfusion, blood products are donated by a person fortransfusion to a specified recipient.
 This option may be used in certain circumstances (eg, a parent who providessole transfusion support for a child), but in general, no evidence exists thatdirected donation reduces transfusion risks.
Blood Product ScreeningSerologic Testing
Routine laboratory testing is performed to assess the compatibility of aparticular blood product with the recipient before release of the blood productfrom the blood bank. (See Table 27-3, page 964.)
ABO group and Rh type: determines the presence of A, B, and Dantigens on the surface of the patient's RBCs.
Direct Coombs' test: determines the antibody attached to the patient'sRBCs.
Crossmatch (compatibility test): detects agglutination of donor RBCscaused by antibodies in the patient's serum.
Indirect Coombs' test: identifies lower molecular weight antibodies(IgG) directed against blood group antigens.
TABLE 27-3 ABO and Rh Compatibility Chart
 This chart identifies ABO and Rh compatibility when transfusing whole blood, redblood cells, and plasma. Components suspended in plasma, such as platelets andcryoprecipitate, usually follow plasma compatibility rules if the total volumeexceeds 120 mL for an adult patient.
WHOLE BLOOD
 
DonorRecipient
 ABOABRh positiveRhnegative A
[checkmark] 
B
 [checkmark] 
O
 [checkmark] 
 AB
 [checkmark] 
Rh positive
 [checkmark][checkmark]

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