I.

Introduction Transfusion Medicine Proper selection and utilization of blood components Removal of blood/ blood components For tx and prevention of dse Indications for transfusion: 1. Replacement of oxygen- carrying capacity (eg: anemic px) 2. Replacement of hemostatic components (eg: coagulation factors/ platelets) 3. Replacement of circulating volume (eg: active bleeding)

Advantages: More specific Effects and danger of circulatory overload are less (transfusion of whole blood) The available blood supply is more effectively used. One unit of blood can be used by several patients.

Whole blood

Packed RBC

Plasma

Fresh Frozen Plasma (Thawing)

II.

Blood Preservatives To prolong the corresponding shelf-life of stored blood Preservative Shelf-life ACD: Acid Citrate Dextrose 21 CPD: Citrate Phosphate 21 Dextrose CPDA-1: CPD + Adenine 35 RBC Additives (Adsol) 42 High concentration of Dextrose Adenine Mannitol (+/-) Saline Adenine- enhances ATP production Dextrose- provides energy Mannitol- RBC stabilizing agent

Platelets

WBC

Cryoprecipitate

III. Biochemical Changes in Stored Blood pH Potassium ATP Hemoglobin 2,3- DPG Sodium IV. Blood Components Blood products which are made directly from a unit of blood using different methods of physical separation Component Therapy Using only specific portions of the blood

SY 2011-2012

Subject: Pathology (CP) Topic: Blood Transfusion Lecturer: Dr. Joan Pascual Date of Lecture: September 01, 2011 Transcriptionist: ^-^ Pages: 14

Single bag set up (1 unit)

Triple bag set up (packed RBC, plasma and its components)

Double bag set up (packed RBC and plasma)

Plasma Extractor- separate plasma from packed red cells

V. Blood Preparations A. Products Containing RBC

Whole blood Centrifuge: Hard Spin Packed RBC

BLOOD COMPONENT Whole Blood (Stored/ Fresh) - RBC, plasma, WBC, platelets

Plasma
Packed RBC

pRBC - Fresh blood with of the plasma taken out - Produced by centrifugation of whole blood - contains pRBC with reduced plasma volume (20-25% or original unit), WBC, Platelets

Washed pRBC - pRBC that has undergone several saline washings to remove up to 99% of WBC - Contains RBC, minimal platelets, no plasma

Leukocyte-Poor RBC - pRBC with 80-90% of WBC removed by several methods, such as: sedimentation, centrifugation, microaggregate blood filtration

CHARACTERISTICS

VOLUME

- 520mL (with preservatives) - 400-450mL (real blood component)

260mL

250mL

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Frozen (Deglycerolized) RBC - pRBC frozen to prolong storage life - contains only RBC & 5% of WBC, no plasma or platelets * Preparation: Addition of glycerol prevents crystallization of intracellular water at low temperature Thawed & washed before use (up to 20% of RBCs are lost during thawing) 250mL

Irradiated RBC - red cells exposed to gamma radiation - radiation is done to destroy donor lymphocytes & prevent GVHD (Graft vs. Host Disease) in immunocompromised patients

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SHELF-LIFE STORAGE

1-35days 1-6 C
0

24H (after washing)

EFFECT INDICATIONS

1 unit raises Hgb by 1g/dL and Hct by 0.3% Active bleeding with >25% - Anemia due to bld loss destruction or poor production of RBC - Chronic anemia - Anemia in patients with CHF

- PNH (Paroxysmal Nocturnal Hemoglobinemia) complement is removed - Repeated febrile nonhemolytic transfusion

- 10 years at -65C or colder - 24 hours at 1-6C after washing ---------- Repeated febrile non- Same as Washed pRBC hemolytic reactions due - Autologous transfusions to leukoagglutinins (agglutinins present in WBC) ---

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- Recipients of autologous or allogenic bone marrow grafts - Severe congenital immunodeficiency syndromes involving T-lymphocytes - Donation to

- Debilitated patients - Neonates & infants -

ADVANTAGES

- Provides both red cells and volume replacement - Reduces the exposure to multiple donors

- Less risk for volume overload - Contains less anticoagulant, ammonia, & electrolyte - Contains less antibodies & plasma proteins

DISADVANTAGES

- Indiscriminate use can availability of components to multiple patients - May cause hypovolemia & CHF in patients who are not actively bleeding - Does not contain any functioning platelets (because platelets are nonviable after 48 hours) - Factors V & VII are decreased - Increase in potassium is dangerous to patients with renal disease - Citrate accumulation leading to hypercalcemia, which can lead to development of MI (because citrate binds to Ca)

- Slower infusion rate

reactions due to leukocyte antibodies & other plasma proteins Emergency transfusion of Group O RBCs to patients of other ABO groups Prevention of anaphylactic reactions in IgA-deficient patients Reduces risk of febrile reactions due to WBC & platelets Washing reduces formation of microaggregates The product is almost devoid of plasma Eliminates anticoagulants & unwanted metabolites Preparation is timeconsuming & laborintensive

immunocompetent firstdegree relatives of immunocompromised patients

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- Allows storage of rare blood types - Enables blood bank to maintain a large inventory of blood type - Eliminates 95% of WBC, platelets & plasma proteins - Prevents febrile reactions & immunization - Costly & tedious - Significant time is lost during thawing - Once thawed, cells must be used within 24 hours

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B. Platelets

Whole blood Soft spin Packed RBC

PLATELET COMPONENT QUALITY CONTROL VOLUME PREPARATION SHELF-LIFE STORAGE EFFECTS INDICATIONS

Hard spin

Plasma Platelet concentrate

Platelet Immunologic Refractory State Pxs receiving repeated platelet transfusions Pxs develop HLA-Ab against transfused platelets, hence, platelets from HLA-matched donors should be used * HLA- Human Leukocyte Antigen

Platelet-rich Plasma
10

NOT EFFECTIVE C.

Platelet Concentrate - Contains at least 5.5 x 10 platelets in 75% of PC units tested - 50mL donor plasma and 10M WBC - Must be separated from freshly collected blood within 8H (inactivated within 48H) 5days 0 20-24 C with gentle agitation (using a platelet rotator) 3 - Adults: 4,000/mm /unit 3 - Children: 7,000/mm /unit - Prophylactically correct thrombocytopenia to prevent catastrophic haemorrhage - Bleeding pxs in surgery/ trauma with platelets <75,000 - Bleeding pxs with qualitative platelet d/os - Conditions causing rapid platelet destruction: DIC, ITP, Gram (-) Septic Shock

Plasma, Plasma Components and Derivatives PLASMA non-cellular, straw-colored fluid portion of anti-coagulated whole blood when the WB is allowed to settle or is centrifuged COMPOSITION OF PLASMA: Water Electrolytes Proteins: Albumin, Globulins, Coagulation Factors

Others: (Not discussed in the table) Fibrinogen Plasma protein fraction (PPF) Albumin Immune serum globulins PLASMA COMPONENT CHARACTERISTICS Stored Plasma --Fresh Frozen Plasma (FFP) - plasma from fresh whole blood immediately separated and frozen - contains plasma proteins, all coagulation factors, complement, 90% water, 6-8% protein, carbohydrates, lipids 200-260 ml Cryoprecipitate - material that does not become totally liquid when FFP is thawed - contains 80 units of: Factor VIII, Von Willebrand Factor, Factor XIII, Fibrinogen, Fibronectin, Other plasma proteins 10-15mL Coagulation Factor Concentrates - prepared from a pool of donor blood and lyophilized

VOLUME

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PREPARATION

- Prepared from 1 unit of WB using a plasma extractor

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SHELF- LIFE STORAGE INDICATIONS

40 days (or less) from the date of WB collection 1-6C - Blood volume expansion - Coagulation defects

ADVANTAGES

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- 1 year at -18C or colder - After thawing, store at 1-6C and use within 24 hours - Bleeding due to liver disease, DIC, or massive transfusion (where hemorrhage is secondary to factor deficiency) - In single or multiple coagulation deficiencies, either prophylactically or as treatment of bleeding - Replacement of factor deficiency when specific component therapy is not available or appropriate (factors II, V, VII, IX, X or XI) ---

- FFP thawed slolwly at 1-6 C (not 300 37 C as when preparing it for transfusion) - Centrifuge - Remove liquid plasma leaving 15mL of plasma and the remaining product is 0 refrozen and stored at -18 C or below - 1 year at -18C or colder - Use within 6 hours after thawing - Should not be refrozen once thawed - factor VIII deficiency - von Willebrand disease - Factor XIII deficiency - Hypofibrogenemia - Replacement of fibronectin lost in burns & traumatic shock

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----1. Factor VIII Concentrate Haemophilia A 2. Factor IX Concentrate Haemophilia B Hemophilia A pxs with Factor VIII inhibitors Factor II, VII, X deficiency if FFP cannot be used ---

DISADVANTAGES

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- Should not be used as a plasma expander or source of protein nutrition or immunoglobulins - Should be ABO compatible with recipients RBC (crossmatching not required)

- Preferable to FFP in correction of bleeding disorders because of smaller volume - Cannot be used for bleeding disorders other than those specified

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Fresh frozen plasma (FFP)

Whole blood Centrifuge Packed RBC Plasma Freeze at -180C Fresh Frozen Plasma

VI. Blood Collection A. Donor Registration Name Date of birth Address B. Donor Selection 1. Donor criteria Medical hx PE 2. Deferral- act of putting off to a future time TYPE Permanent DESCRIPTION Can NEVER donate CAUSES Drug abuse Chronic alcoholism (potential for liver dse) Prolonged bleeding Unexplained wt loss (>5kg x 6mos) High risk sexual bvr (continuing exposure to hepatitis, HIV/AIDS, STD) High risk occupation (prostitutes) STD Severe lung dse Severe liver dse (hepatitis, jaundice of unknown origin) Cardiac dses CA

Date of donation Consent form

Basic qualification

Temporary NOT ALLOWED to donate at a PARTICULAR TIME Past exposure to HIV, AIDS or Hepatitis Diagnosed/ treated malaria Alcohol intake Vaccination (depends on vaccine administered) Medications (eg: aspirin) <16y/o; >65y/o Athletes with PR <50bpm Hyper/hypotension Hazardous occupation (eg: construction) Skin lesions at venepuncture site Past exposure to unhygienic skin piercing (eg: tattoo can donate if tattoo is already >1year; for safety: REJECT) Pregnancy Major operation Previous donation Blood transfusion Fever PR: 50-11bpm, regular rhythm BP: 90-160mmHg (systolic); 60100mmHg (diastolic) Hgb: 12.5g/dL

3.

Basic qualifications Good health, 16-55y/o Wt: 50kgs (450mL donation); 40kgs (250mL donation) Afebrile (during the time of examination)

C.

Blood Screening Tests 1. ABO Typing 2. Rh Typing 3. VDRL (Syphilis)- Venereal Dse Research Laboratory Test

4. 5. 6. 7.

Malarial Smear HBsAg- surface Ag of Hepatitis B Virus HCV- Hepatitis C Virus HIV- Human Immunodeficiency Virus

D. Phlebotomy 405-495mL of bld is withdrawn in 7-10min Bld is collected in a bag containing 63mL CPDA-1/ CPD preservatives 30mL drawn into pilot tube 0 Stored at 1-6 C except in platelet preparation Donor rxn: o Vaso-vagal rxns: bradycardia, dizziness, diaphoresis, pallor, nausea, vomiting o Hyperventilation: may lead to respiratory alkalosis and convulsions o Hematoma o Hypotension (d/t hypovolemia): tachycardia, hypotension, loss of consciousness Precautions: o Check phlebotomy site o Allow patient to remain reclining in bed for next 24H o Increase fluid intake for the next 4 hours

o o

May resume normal activities after 30 minutes if donor is feeling well, except for persons working with heavy machinery or at heights. Blood volume rapidly returns to normal with adequate fluid intake, complete blood volume restoration should take less than 12 hours

VII. Blood Transfusion infusion of bld components A. Safety Checks Prior to Transfusion Proper identification Check data in donor bag (ABO, Rh Type, expiratioin date) Check bld in donor bag (appearance) B. During Transfusion Monitor VS q15min (before, during, after transfusion) Check speed of transfusion (60gtts/min; 1unit x 3-4H)

Check IV line for transfusion (0.9% NSS) Check transfusion devices (eg: filters)

Check for s/sxs that might be confused with a transfusion rxn

VIII. Special Types of Transfusions and Related Procedures TYPE OF Autologous Transfusion Hemapheresis TRANSFUSION DESCRIPTION - a procedure in which whole - Transfusion of blood & blood blood is removed from a products derived from the person, anticoagulated, and recipients own blood separated into components - unwanted portions are returned to the donor - makes use of: Cell/ plasma separators, plasmapheresis machine USES - To obtain blood - Rare blood types components needed for - For patients who reacts transfusion adversely to homologous - To remove pathologic blood elements, cells, & dissolved - For patients who refuse plasma factors circulating in homologous blood due to the blood religious beliefs (e.g. Jehovahs Witnesses) - To avoid harmful effects of infection, hemolytic reactions, & non-hemolytic reactions

Massive Transfusion - Infusion of blood equivalent to patient blood volume (8-10 units) within 24 hours or replacement of of the patients blood volume at any one time

Neonatal Hemotherapy - blood transfusion in neonates (from birth to 4 months)

Exchange Transfusion - small amounts of blood are removed from the baby & replaced with donor blood, until 1 or 2 total blood volume exchange is completed

Emergency Transfusion - If the patient cannot receive blood of his own ABO Group, then an alternative ABO Group is used

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- to replace blood lost during blood examinations in infants (bld <7days old should be used to maximize 2,3-DPG levels)

ADVANTAGES

- Components can be obtained in large quantities and more frequently from a single donor

TYPES

1. PLATELET PHERESIS for extracting platelets 2. GRANULOCYTOPHERESIS for extracting granulocytes 3. PLASMA PHERESIS for extracting plasma

- Prevents transfusiontransmitted diseases - Eliminates alloimmunization to cellular elements & plasma proteins - Eliminates GVHD (Graft Versus Host Disease) 1. PRE-SURGICAL / PREDEPOSIT PHLEBOTOMY - patient is bled as often as every 72 hours prior to surgery - iron supplements are given

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- Hemolytic Disease of the Newborn - To remove unbound IgG antibody, excess bilirubin, & uncoated RBC - To correct anemia & replace fetal RBC with adult RBC (which is better capable of releasing oxygen to the tissues) - Sepsis - Diffuse Intravascular Coagulopathy (DIC) - Polycytemia - Respiratory Distress Syndrome - Hyperammonemia - Toxin removal ---

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4. THERAPEUTIC PLASMA PHERESIS plasma exchange. (Ix: polycythemia vera)

OTHERS

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2. INTRA-OPERATIVE SALVAGE - blood is aspirated from operative site, filtered & washed, & transfused to the patient within 6H - use: For massive bleeding, when blood is not readily available - Disadvantage: blood may be contaminated 3. NORMOVOLEMIC HEMODILUTION - Bld is collected intraoperatively into bld collection bags and replaced by saline - Collected bld is returned at or near the end of the procedure (<8H after collection) - Bld is recycled ---

ADVERSE CONDITIONS: 1. Circulatory overload 2. Complications related to physical / biochemical changes in stored blood: - Bleeding due to deterioration of platelets, Factor V, & Factor VII in stored WB - Decreased 2,3-DPG in stored blood (shifts oxygen dissociation curve to the left; Hgb doesnt readily release oxygen to the tissues freely) - Increased Ammonium & Potassium (dangerous to patients with renal & liver dses) - Citrate toxicity & hypocalcemia - Hypothermia may lead to ventricular fibrillation

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DONOR BLOOD REQTS: 1. Must be negative for the RBC antigen to which the mother has the corresponding antibody 2. Must be ABO- and Rhcompatible with the infants blood group 3. Must be crossmatched with the mothers serum - if the mothers specimen is not available, Type O blood must be used - Rh(+) blood may be given to Rh(+) infants whenever the mother lacks anti-D 4. Must be < 7 days old

Rh (-) BLOOD SHOULD BE RESERVED FOR: - Rh (-) females of child-bearing age - Rh (-) patients, because Rh(-) blood is rare - For those who have exhibited anti-Rh antibodies

SELECTION OF ABO GROUP COMPATIBLE FOR EXCHANGE TRANSFUSION MOTHERS GROUP INFANTS GROUP DONOR GROUP O, A, B O O O or B A O A or AB A A or O O or A B O B or AB B B or O A AB A or O B AB B or O AB AB AB, A, B, O

EMERGENCY TRANSFUSION PATIENTS GROUP A B AB O ABO GROUPS ST 1 CHOICE O O A&B No alternative Rh TYPE Rh (-) Yes Yes 2 CHOICE None None O
ND

PATIENTS TYPE Rh (-) Rh (+)

Rh (+) Emergency only Yes

IX. Transfusion Reactions the adverse symptoms produced by an erythrocyte incompatibility between a patient & a unit of donor blood Causes of fatal rxns: Misidentification of patients Mistakes in blood typing Mislabeling of blood samples Inaccurate antibody screening or in crossmatching Error in laboratory reports Types of Transfusion Reactions ACUTE A. HEMOLYTIC - Occurs within minutes to 24H of the transfusion

ACUTE HEMOLYTIC TRANSFUSION REACTIONS (AHTR) ABO/ Rh incompatibility Mechanism: infusion of incompatible red cells in the presence of existing Abs initiates Ag-Ab rxn with activation of complement, plasminogen, kinin and coagulation system lead to DIC AHTR Ag-Ab results in: o Neuroendocrine response (bradykinins) hypotension sympathetic NS o Complement activation hemolysis o Intrinsic pathway activation DIC Tx and prevention: o Give IV fluids to maintain intravascular volume o Monitor and maintain urine output >100mL/h using diuretics in addition to fluids o Treat hyperkalemia, and if present, bleeding caused by DIC o Prevention relies on error elimination Intravascular hemolysis Extravascular hemolysis Caused by rapid complement activation by IgM caused by IgG Abs that coat RBC removal by macrophages of the RES S/Sxs: lab findings: o fever with/without chills o increased LDH o pain at transfusion site o spherocytes on PBS o low back pain o increased unconjugated bilirubin o hypotension o facial flushing o DIC

B. NONHEMOLYTIC

o Shortness of breath o Acute renal failure Lab findings: o Hemoglobinemia o Decreased serum haptoglobulin o Increased LDH o hemoglobinuria FEBRILE NON-HEMOLYTIC BACTERIAL TRANSFUSION REACTIONS (FNHTR) CONTAMINATION 0 0 - >/1 C increase in T (take VS - most commonly before/ during transfusion) associated with - Most commonly associated with transfusion of platelets platelet transfusions (because they are stored 0 - Abs in the recipient that react at 20-24 C x 5days) or with donor leukocytes RBCs cytokine release and pyogenic - storage makes the bld soluble factors more prone to - s/sxs: contamination o fever - sources of contamination: o chills skin, bld bag, o n/v phlebotomists bacteria o uneasiness/ discomfort - s/sxs: (similar with sepsis) typically developing during/ o fever, chills within 1-2H of transfusion o hypotension - tx and prevention: o n/v o antipyretics o SOB o leukocyte-reduced RBCs and o Voluminous bloody platelets (for recurrent diarrhea FNHTR) o Shock, renal failure, DIC - Tx and prevention: o Broad spectrum antibiotic therapy o Adhere to proper procedures for collecting, storing, and handling bld products o Inspect all components before transfusing (clots, hemolyzed, discoloured)

ALLERGIC REACTIONS - Caused by substances in the donor bld to which the recipient is allergic (recipient Abs against donor Ags) - Activation of recipient mast cells/ basophils (histamine) - s/sxs: o mild allergic rxn: pruritus and localized urticarial (hives) during or shortly after the transfusion o severe allergic or anaphylactic rxns: (rapid and dramatic in onset within 1H of starting transfusion) generalized urticarial angioedema respiratory distress (bronchospasm/ laryngeal edema) GI sxs (n/v, cramps, diarrhea) Profound hypotension - Prevention: o If possible, determine the allergen and use bld products lacking the allergen o Pre-medicate before transfusion if allogenic plasma must be transfused which is not allergen free o Predeposit autologous bld/ components before elective surgery o Provide washed allogenic cellular components

TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) - Caused by donor Abs to recipient leukocyte Ags complement activation and clustering of granulocytes in the recipients lung microvasculature endothelial damage and capillary leakage - s/sxs: (similar to ARDS) o severe bilateral pulmonary edema, hypoxia, fever, tachycardia, hypotension, cyanosis o typically develops 16H post transfusion of plasma-containing bld compoents (because plasma contains leukocyte Ag)

TRANSFUSION RELATED CIRCULATORY OVERLOAD (TRACO) - d/t rapid transfusion of large volume of bld - may also occur when small amt of bld is transfused to pxs with abnormal cardiac fxn - s/sxs: o SOB o Tachycardia o Hypertension o Headache o Edema - Tx and prevention: o Give diuretics and O2 o Adm future transfusions very slowly

DELAYED Develop within days to months or even years after the transfusion

A. HEMOLYTIC

B. NONHEMOLYTIC

DELAYED HEMOLYTIC TRANSFUSION REACTIONS (DHTR) Typically caused by IgG Abs against RBC Ags that developed in response to a previous transfusion/ pregnancy Anamnestic response causes abs to quickly increase in titer and coat RBCs Removal of Ab- coated RBCs by macrophages of the RED extravascular hemolysis s/sxs: (often mild, may even be asymptomatic) o fever (most common) o pain o post-transfusion jaundice and hyperbilirubinemia o anemia (with spherocytes in PBS) o +/- renal failure o Sudden drop in Hgb with no evidence of haemorrhage/ hemodilution Anemia, fever, recent tranasfusion suggestive of DHTR INFECTIOUS DISEASE TRANSMISSION TRANSFUSION ASSOCIATED GRAFT-VERSUS-HOST DISEASE (TA-GVHD) Mos after receiving bld d/t bld transfused to immunocompromised/suppressed recipient Hepatitis B,C immunocompetent T lymphocytes transfused to an immunodeficient recipient HIV recognize host Ags as foreign Malaria usually seen in pxs who received transplant CMV s/sxs: (develops 1-2wks after transfusion) Syphilis o lymphocytic infiltrates in intestine, skin, liver o rash (trunk to extremities) o diarrhea, n/v o fever o elevated liver fxn test o pancytopenia of the bone marrow

Factors that influence whether a transfusion reaction will be acute/ delayed: Number of incompatible red cells infused Ab class/ subclass Intravascular Hemolysis

Achievement of optimal temperature for binding

Extravascular Hemolysis

RBC Iron Globin chain Heme

Hgb: binds haptoglobin (plasma protein) Binds transferrin

RBC Heme Bilirubin (excreted through bile duct)

Iron, ferritin, hemosiderin, globin chains

Binds hemopexin

Investigation of Transfusion Reactions 1. Stop transfusion STAT! 2. Check ID (px and donor bld) 3. Obtain bld samples (px and donor) 4. Check for hemolysis (visual and chemical) 5. Do direct Coombs Test 6. Repeat ABO-Rh typing

7.

Others: a. b. c. d.

Serum haptoglobin/ bilirubin Haptoglobin binding capacity Urinalysis (to check for hemoglobinuria) Culture and gram-stain of donor bld

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