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Blood Transfusion

Types, Indications and Complications
Vascular / Endovascular Surgery

History of Transfusions
• Blood transfused in humans since mid1600’s • 1828 – First successful transfusion • 1900 – Landsteiner described ABO groups • 1916 – First use of blood storage • 1939 – Levine described the Rh factor

Transfusion Overview
• Integral part of medical and surgical treatment • Most often used in Hematology/Oncology, and other specialties as well (surgery, ICU, etc) • Objectives
– – – – Blood components Indications for transfusion Safe delivery Complications

Blood Components
• Prepared from Whole blood collection or apheresis • Whole blood is separated by differential centrifugation
– Red Blood Cells (RBC’s) – Platelets – Plasma
• Cryoprecipitate • Others

• Others include Plasma proteins—IVIg, Coagulation Factors, albumin, Anti-D, Growth Factors, Colloid volume expanders • Apheresis may also used to collect blood components

Differential Centrifugation
First Centrifugation
Closed System

Whole Blood Main Bag

Satellite Bag 1

Satellite Bag 2

First

RBC’s

Platelet-rich Plasma

Differential Centrifugation
Second Centrifugation

RBC’s

Platelet-rich Plasma

Second

RBC’s

Platelet Concentrate

Plasma

Whole Blood
• Storage
– 4° for up to 35 days

• Indications
– Massive Blood Loss/Trauma/Major Operations.

• Considerations
– Use filter as platelets and coagulation factors will not be active after 3-5 days – Donor and recipient must be ABO identical

RBC Concentrate
• Storage
– 4° for up to 42 days, can be frozen

• Indications
– Many indications—ie anemia, hypoxia, etc.

• Considerations
– Recipient must not have antibodies to donor RBC’s (note: patients can develop antibodies over time) – Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl) – Usually transfuse over 2-4 hours (slower for chronic anemia

Platelets
• Storage
– Up to 5 days at 20-24°

• Indications
– Thrombocytopenia, Plt <15,000 – Bleeding and Plt <50,000 – Invasive procedure and Plt <50,000

• Considerations
– Contain Leukocytes and cytokines – 1 unit/10 kg of body weight increases Plt count by 50,000 – Donor and Recipient must be ABO identical

Plasma and FFP
• Contents—Coagulation Factors (1 unit/ml) • Storage
– FFP--12 months at –18 degrees or colder

• Indications
– Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange transfusion, massive transfusion

• Considerations
– Plasma should be recipient RBC ABO compatible – Account for time of heating. – Usual dose is 20 cc/kg to raise coagulation factors approx 20%

Cryoprecipitate
• Description
– Precipitate formed/collected when FFP is heated at 4°

• Storage
– After collection, refrozen and stored up to 1 year at -18°

• Indication
– – – – Fibrinogen deficiency or dysfibrinogenemia vonWillebrands Disease Factor VIII or XIII deficiency DIC (not used alone)

• Considerations
– ABO compatible preferred (but not limiting) – Usual dose is 1 unit/5-10 kg of recipient body weight

Granulocyte Transfusions
• Prepared at the time for immediate transfusion (no storage available) • Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, and recovery of BM is expected • Donor is given G-CSF ( Colony Stimulating Factor ) • Complications
– Severe allergic reactions

Leukocyte Reduction Filters
• Used for prevention of transfusion reactions • Filter used with RBC’s, Platelets, FFP, Cryoprecipitate • Other plasma proteins (albumin, colloid expanders, factors, etc.) do not need filters • May reduce RBC’s by 5-10% • Does not prevent Graft Verses Host Disease (GVHD)

RBC Transfusions
Preparations
• Type
– Typing of RBC’s for ABO and Rh are determined for both donor and recipient

• Screen
– Screen RBC’s for atypical antibodies – Approx 1-2% of patients have antibodies

• Crossmatch
– Donor cells and recipient serum are mixed and evaluated for agglutination

Compatibility
Patient Blood Gp Compatible with Approx % in UK

O A B AB

O A and O B and O AB, A, B and O

47 42 8 3

RBC Transfusions
Administration
• Dose
– Usual dose of 10 cc/kg infused over 2-4 hours – Maximum dose 15-20 cc/kg can be given to hemodynamically stable patient

• Procedure
– – – – May need Premedication . Filter use—routinely leukodepleted Monitoring—VS q 15 minutes, clinical status Do NOT mix with medications

• Complications
– Rapid infusion may result in Pulmonary edema – Transfusion Reaction

Platelet Transfusions
Preparations
• ABO antigens are present on platelets
– ABO compatible platelets are ideal – This is not limiting if Platelets indicated and type specific not available

• Rh antigens are not present on platelets
– Note: a few RBC’s in Platelet unit may sensitize the Rh- patient

Platelet Transfusions
Administration
• Dose
– May be given as single units . – Usual dose is approx 4 units/m2

• Procedure
– Should be administered over 20-40 minutes – Filter use – Premedicate if hx of Transfusion Reaction

• Complications—Transfusion Reaction

Transfusion Complications
• Acute Transfusion Reactions (ATR’s) • Chronic Transfusion Reactions • Transfusion related infections

Acute Transfusion Reactions
• • • • • • Hemolytic Reactions (AHTR) Febrile Reactions (FNHTR) Allergic Reactions TRALI ( Acute Lung Injury ) Coagulopathy with Massive transfusions Bacteremia

Frequency of Transfusion Reactions
Adverse Effect
Acute Hemolytic Rxn

Frequency
1 in 25,000

Comments
Red cells only

Anaphylactic hypotensive 1 in 150,000 Including IgA Febrile Nonhemolytic Allergic Delayed Hemolytic RBC alloimmunization WBC/Plt alloimmunization 1 in 200 1 in 1,000 1 in 2,500 1 in 100 1 in 10 Common Common Red cells only Red cells only WBC and Plt only

Acute Hemolytic Transfusion Reactions (AHTR)
• Occurs when incompatible RBC’s are transfused into a recipient who has pre-formed antibodies (usually ABO or Rh) • Antibodies activate the complement system, causing intravascular hemolysis • Symptoms occur within minutes of starting the transfusion • This hemolytic reaction can occur with as little as 1-2 cc of RBC’s • Labeling error is most common problem • Can be fatal

Symptoms of AHTR
• • • • • • • High fever/chills Hypotension Back/abdominal pain Oliguria Dyspnea Dark urine Pallor

What to do?
If an AHTR occurs
• • • • • • STOP TRANSFUSION ABC’s Maintain IV access and run IVF (NS or LR) Monitor and maintain BP/pulse Give diuretic Obtain blood and urine for transfusion reaction workup • Send remaining blood back to Blood Bank

Blood Bank Work-up of AHTR
• • • • • Check paperwork to assure no errors Check plasma for hemoglobin Repeat crossmatch Repeat Blood group typing Blood culture

Labs found with AHTR
• • • • Hemoglobinemia Hemoglobinuria Hyperbilirubinemia Abnormal DIC panel

Monitoring in AHTR
• Monitor patient clinical status and vital signs • Monitor renal status (BUN, creatinine) • Monitor coagulation status (DIC panel– PT/PTT, fibrinogen, D-dimer/FDP, Plt, Antithrombin-III) • Monitor for signs of hemolysis (LDH, bili, haptoglobin)

Febrile Nonhemolytic Transfusion Reactions (FNHTR)
• Definition--Rise in patient temperature >1°C (associated with transfusion without other fever precipitating factors) • Occurs with approx 1% of PRBC transfusions and approx 20% of Plt transfusions • FNHTR caused by alloantibodies directed against HLA antigens • Need to evaluate for AHTR and infection

What to do?
If an FNHTR occurs
• • • • • STOP TRANSFUSION Use of Antipyretics Use of Corticosteroids for severe reactions Use of Narcotics for shaking chills Future considerations
– – – – May prevent reaction with leukocyte filter Use single donor platelets Use fresh platelets Washed RBC’s or platelets

Washed Blood Products
• • • • • PRBC’s or platelets washed with saline Removes all but traces of plasma (>98%) Indicated to prevent recurrent or severe reactions Washed RBC’s must be used within 24 hours Does not prevent GVHD

Allergic Nonhemolytic Transfusion Reactions
• Etiology
– May be due to plasma proteins or blood preservative/anticoagulant – Best characterized with IgA given to an IgA deficient patients with anti-IgA antibodies

• Presents with urticaria and wheezing • Treatment
– Mild reactions—Can be continued after antihistamine – Severe reactions—Must STOP transfusion and may require steroids or epinephrine

• Prevention—Premedication (Antihistamines)

TRALI
Transfusion Related Acute Lung Injury
• Clinical syndrome similar to ARDS • Occurs 1-6 hours after receiving plasmacontaining blood products • Caused by WBC antibodies present in donor blood that result in pulmonary leukostasis • Treatment is supportive • High mortality

Massive Transfusions
• Coagulopathy may occur after transfusion of massive amounts of blood (trauma/surgery) • Coagulopathy is caused by failure to replace plasma • See electrolyte abnormalities
– Due to citrate binding of Calcium – Also due to breakdown of stored RBC’s

Bacterial Contamination
• More common and more severe with platelet transfusion (platelets are stored at room temperature) • Organisms
– Platelets—Gram (+) organisms, ie Staph/Strep – RBC’s—Yersinia, enterobacter

• Risk increases as blood products age (use fresh products for immunocompromised)

Chronic Transfusion Reactions
• Alloimmunization • Transfusion Associated Graft Verses Host Disease (GVHD) • Iron Overload • Transfusion Transmitted Infection

Alloimmunization
• Can occur with erythrocytes or platelets • Erythrocytes
– Antigen disparity of minor antigens (Kell, Duffy, Kidd) – Minor antigens D, K, E seen in Sickle patients

• Platelets
– Usually due to HLA antigens – May reduce alloimmunization by leukoreduction (since WBC’s present the HLA antigens)

Transfusion Associated GVHD
• Mainly seen in infants, BMT patients • Etiology—Results from engraftment of donor lymphocytes of an immunocompetent donor into an immunocompromised host • Symptoms—Diarrhea, skin rash, pancytopenia • Usually fatal—no treatment • Prevention—Irradiation of donor cells

Transfusion Associated Infections
• • • • Hepatitis C Hepatitis B HIV CMV
– CMV can be diminished by leukoreduction, which is indicated for immunocompromised patients

Prevention
Leukocyte Depletion Filter Febrile Transfusion Reactions
Alloimmunization

Gamma Irradiation

CMV Negative

Single Donor Platelets (Apheresis)

X1
X

X
X

CMV
Transfusion Related GVHD

?2
X

X

1 In PRBC transfusion 2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood

Summary
• Blood Components
– Indications – Considerations

• Preparation and Administration of blood products • Acute and chronic transfusion reactions

Transfusion Reaction Summary
• • • • • • • AHTR can be fatal Stop the Transfusion Monitor for symptoms and complete evaluation FNHTR is a diagnosis of exclusion TRALI (ARDS-like reaction) Chronic Transfusion reactions Prevention methods – using filters, irradiation and premedication

Q1- With regard to hemolytic transfusion reactions , Which of the following is true ? A. B. C. D. They generally caused by ABO incompatibility . Urticaria and pruritus are the commonest symptoms . Acidification of urine prevents precipitation of hemoglobin Intra venous diphenylhydramine shoud be given immediately.

Q1- With regard to hemolytic transfusion reactions , Which of the following is true ? A. B. C. D. They generally caused by ABO incompatibility . Urticaria and pruritus are the commonest symptoms . Acidification of urine prevents precipitation of hemoglobin Intra venous diphenylhydramine shoud be given immediately.

Q2- The most common cause of transfusion reaction is :

A. Air embolism. B. Contaminated blood. C. Human Error. D. Unusual circulating anti-bodies.

Q2- The most common cause of transfusion reaction is :

A. Air embolism. B. Contaminated blood. C. Human Error. D. Unusual circulating anti-bodies.

Q3- The most common clinical manifestation of a hemolytic transfusion is :
A. Flank pain. B. Jaundice. C. Oliguria. D. A shaking chills.

Q3- The most common clinical manifestation of a hemolytic transfusion is :
A. Flank pain. B. Jaundice. C. Oliguria. D. A shaking chills.

Q4- The most common fatal infectious complication of a blood transfusion is :

A. AIDS. B. CMV. C. Malaria. D. Viral Hepatitis.

Q4- The most common fatal infectious complication of a blood transfusion is :

A. AIDS. B. CMV. C. Malaria. D. Viral Hepatitis.

Q5- One unit of Fresh blood arises the Hb% concentration by :

A. 0.1 gm% B. 1 gm% C. 2 gm% D. 2.2 gm%

Q5- One unit of Fresh blood arises the Hb% concentration by :

A. 0.1 gm% B. 1 gm% C. 2 gm% D. 2.2 gm%

Thank you all…