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Transcript
Administration of Blood and Blood Component Dr.Azarm Blood Products روشهاي صحيح مصرف خون به منظور كاهش ترانسفوزيونهاي غير ضروري Dr.Azarm چرا الزم است خون وفراوردههاي خوني صحيح و هدفمند مصرف شوند؟ ------------------------------------1خون ساختني نيست بلكه بايد اهدا شود. -2در همه جا خون فراوري نمي شود و در دسترس نمي باشد. -3هميشه اهدا كننده اماده وجود ندارد. -4عوارض انتقال خون هميشه بايد مد نظر باشد. Dr.Azarm نكات مهم • خون و فرآوردههاي خون بايد در اسرع وقت تزريق شود. • چنانچه فرآوردهاي براي 30دقيقه يا بيشتر در دماي اتاق قرار گيرد نبايد تزريق شود. • خون و فرآوردههاي خون نبايد در داخل يخچال اتاق پرستاري ذخيره شود مگر در مواقع خاص مانند اتاق عمل يا در اتاق .recovery • چنانچه به هر علت واحد خون) (RBCباز نشود و در دماي مناسب قرار داشته باشد و در فاصله زماني كمتر از 30دقيقه ،به بانك خون برگردد ميتوان از آن استفاده كرد. نكات مهم • خون نبايد در داخل ظرف حاوي آب داغ قرار گيرد زيرا اين عمل باعث هموليز گويچههاي سرخ و آزاد شدن پتاسيم از گويچههاي سرخ ميشود كه ميتواند براي زندگي بيمار مخاطرهآميز باشد. • فرآوردهاي كه ذوب شده نبايد دوباره منجمد شود و بايد هرچه زودتر مصرف شود .در صورتي كه به هر دليل تاخيري در تزريق رخ دهد ،بايد در دماي محيط نگهداري شده و در عرض 4ساعت مصرف شود. • توجه :مهمترين مرحله نظارت 15 ،دقيقه اول تزريق ميباشد. Whole Blood Dr.Azarm Whole Blood Description: • • • • • • • Up to 510 ml total volume 450 ml donor blood 63 ml anticoagulant-preservative solution Haemoglobin approximately 12 g/ml Haematocrit 35%–45% No functional platelets No labile coagulation factors (V and VIII) Infection risk Not sterilized, so capable of transmitting any agent present in cells or plasma which has not been detected by routine screening for transfusion-transmissible infections, including: HIV-1 and HIV-2, hepatitis B and C, other hepatitis viruses, syphilis, malaria and Chagas Storage • Between +2°C and +6°C in approved blood bank refrigerator, fitted with a temperature chart and alarm • During storage at +2°C and +6°C, changes in composition occur resulting from red cell metabolism • Transfusion should be started within 30 minutes of removal from refrigerator Indications • Red cell replacement in acute blood loss with hypovolaemia • Exchange transfusion • Patients needing red cell transfusions where red cell concentrates or suspensions are not available Contraindications Risk of volume overload in patients with: • Chronic anaemia • Incipient cardiac failure Administration • Must be ABO and RhD compatible with the recipient • Never add medication to a unit of blood • Complete transfusion within 4 hours of commencement RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’) Description • 150–200 ml red cells from which most of the plasma has been removed • Haemoglobin approximately 20 g/100 ml • Haematocrit 55%–75% Infection risk • Same as whole blood Storage • Same as whole blood Indications • Replacement of red cells in anaemic patients • Use with crystalloid replacement fluids or colloid solution in acute blood loss مواردي كه نياز به تزريق وجود ندارد • • • • • • • • :Aآنمي همراه با كمبود آهن :Bآنمي پرنيسيوز :Cكمبود تغذيهاي :Dعدم جذب گوارشي : Eترميم زخم :Fكمبود فوالت و B12 :Gآنمي همولتيك ارثي :Hبراي بهبود حال عمومي فقط هنگامي كه خونريزي فعال از دستگاه گوارش يا جاي ديگر بدن باشد نياز به تزريق داريم البته در چنين بيماراني هدف تصحيح هموگلوبين نيست بلكه هموگلوبين در حدي باشد كه بيمار عالئم حياتي پايدار داشته باشد. نوزادان و كودكان : در بيماران با سن كمتر از 4ماه هموگلوبين كمتر از 13گرم در دسيليتر همراه با بيماريهاي شديد و سيانوتيك قلب و ريه و يا نارسايي قلب هموگلوبين كمتر از 10گرم در دسيليتر همراه با بيماريهاي ريوي متوسط از دست رفتن سريع و حاد بيش از %10حجم خون هموگلوبين كمتر از 8گرم در دسي ليتر همراه با آنمي عالمتدار اين راهنماها يك پيشنهاد ميباشد و بايستي در مورد هر نوزاد به * تنهايي تصميم گيري كرد. در هموگلوبين كمتر از 10گرم در دسيليتر كه كانديد عمل جراحي بزرگ هستند. • • • • دركودكان با سن بيشتراز 4ماه هموگلوبين قبل از عمل جراحي كمتر از 8گرم در دسيليتر و يا هماتوكريت زير %25و يا هموگلوبين زير 8گرم در دسيليتر بعد از عمل كه همراه با عاليم و نشانههاي كم خوني باشد. كاهش و يا از دست رفتن سريع و حاد بيش از %15حجم خون يا وجود عاليم و نشانههاي هيپوولمي كه به تزريق مايعات كريستالوئيد يا كلوئيدي پاسخ نداده باشد. هموگلوبين كمتر از 13گرم در دسيليتر در بيماري شديد قلبي ريوي (سيانوز-دسترين تنفسي) هموگلوبين كمتر از 8گرم در دسيليتر در : • • • • • هموگلوبين كمتر از 8گرم در دسيليتر در : الف) بيماراني كه تحت شيميدرماني يا راديوتراپي هستند. (نارسايي مغز استخوان) ب ) بيماراني كه دچار كمخوني مزمن هستند كه به درمان طبي پاسخ ندادهاند يا عاليم و نشانههاي كم خوني دارند. عوارض بيماري سيكلسل نظير حوادث عروقي مغزيAcute ، chest syndromو آمادگي براي عمل جراحي. در بيماران بتاتاالسمي هموزيگوت و يا هتروزيگوت كه بيشتر از ساير انواع تاالسمي دچار آنمي شديد ميشوند براي جلوگيري از عوارضي مانند رشد نابهنجار استخوان و بهبود در سرعت رشد و كاهش بار آهن بهتر است هموگلوبين در محدودة 10گرم در دسيليتر كنترل شود .البته قبل از تزريق نبايد هموگلوبين بيشتر از 5/9گرم در دسيليتر باشد تا از افزايش بار آهن جلوگيري شود. Administration • Same as whole blood • To improve transfusion flow, normal saline (50–100 ml) may be added using a Ypattern infusion set RED CELL SUSPENSION Description • 150–200 ml red cells with minimal residual plasma to which ±100 ml normal saline, adenine, glucose,mannitol solution (SAGM) or an equivalent red cell nutrient solution has been added • Haemoglobin approximately 15 g/100 ml • Haematocrit 50%–70% • • • • Infection: risk Same as whole blood Storage: Same as whole blood Indications: Same as red cell concentrate Contraindications: Not advised for exchange transfusion of neonates. The additive solution may be replaced with plasma, 45% albumin or an isotonic crystalloid solution, such as normal saline • Administration : Same as whole blood • Better flow rates are achieved than with red cell concentrate or whole blood Frozen RBCs • Add cryoprotectant glycerol to RBCs followed by appropriate freezing (-65°C or lower) allows storage of RBCs for 10 years. • When Cells needed, unit thawed and washed with saline to remove glycerol. Washing “enters” storage bag-unit can be stored for only 24 hours at 1° to 6°C after thawing. • Used primarily to maintain supplies of uncommon RBC phenotypes needed by patients with alloantibodies against frequently occurring RBC antigens • Military uses to maintain emergent blood supplies. Leukocyte Poor RBCs Leukocyte-Reduced Red Blood Cells Description • A red cell suspension or concentrate containing <5 x 106 white cells per pack, prepared by filtration through a leucocyte-depleting filter • Haemoglobin concentration and haematocrit depend on whether the product is whole blood, red cell concentrate or red cell suspension • Leucocyte depletion significantly reduces the risk of transmission of cytomegalovirus (CMV) Indications • Minimizes white cell immunization in patients receiving repeated transfusions but, to achieve this, all blood components given to the patient must be leucocyte-depleted • Reduces risk of CMV transmission in special situations • Patients who have experienced two or more previous febrile reactions to red cell transfusion Contraindications • Will not prevent graft-vs-host disease: for this purpose, blood components should be irradiated where facilities are available (radiation dose: 25–30 Gy) Administration • Same as whole blood • A leucocyte filter may also be used at the time of transfusion if leucocyte-depleted red cells or whole blood are not available Washed RBCs • Washed RBCS are RBCs washed with saline to remove most of the plasma. • Washed RBCs are not leukoreduced. • Indications-patients who have had severe allergic reactions associated with transfusion or immunoglobulin A (IgA) deficiency. • Washed RBCs must be given through a standard blood filter, can transmit hepatitis and other infectious diseases • Because bag must be entered to introduce saline, washed RBCs must be given within 24 hrs of preparation. Irradiated WB or RBCs • Blood components exposed to standard dose of ionizing radiation to make viable lymphocytes unable to engraft (to reduce GvH) in premature newborns or highly immunocompromised patients (e.g., bone marrow or solid organ transplant). • “Although no significant adverse red cell structural events have been noted, mild functional impairment manifested by significant leakage of potassium and accumulation of plasma hgb has been noted after gamma irradiation.” • ASA Questions and Answers About Transfusion Practice- 2002 گرم كردن خون • • • • • • • • • در مواردي كه يك حجم خون و يا بيشتر طي 24ساعت جايگزين شود ،تزريق خون را ماسيو مينامند .يك حجم خون به ميزان ml/Kg 75يا حدود ml 5000تخمين زده ميشود. Exchange Transfusionنوزادان در صورتي كه بيمار داراي Abهاي واكنشدهنده در دماي سرد)(Cold Antibody باشد. زماني كه بيمار آريتمي داشته باشد. براي زماني كه خون با سرعت ml/minute50براي 30دقيقه يا بيشتر براي ml/Kg/hour15براي كودكان تنظيم شده باشد. بزرگساالن و سرعت براي بيماران در طول عمل جراحي Bypassدر فاز re-warming پالسمافرزيس درماني يا فرآيند Red cell exchange تزريق خون در نوزادان و كودكان سندرم رينود يا وازواكتيو ناشي از سرما Use of RBCs in Massive Transfusion • If 50-75% blood volume replaced by type 0 Blood (10 U RBCS in adult)• May need to continue with type 0 blood• “Otherwise, risk of major cross-match reaction increases. • Patient may have received enough anti-A or anti-B antibodies to precipitate hemolysis if A,B, or AB units subsequently given” • Smith, C.(2003)Current Practices in Fluid and Component Therapy ITACCS. Seminar-Massive Transfusion Massive Transfusion Give blood products as a ratio 1 dose : 1 dose : 1 dose : 1 dose 5 RBC : 2 FFP : 6 RD PLT : 10 Cryo ________________ (1 PPH) _________ Hgb PT PTT Plt Ct Fib FFP Description • Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder • Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin • Factor VIII level at least 70% of normal fresh plasma level FFP • Collected by centrifugation of whole blood, or by apheresis as a single donor unit (taken for plasma, or as a by product of RBC or platelet apheresis) • Must be frozen within 6 hours of collection,can be kept frozen for a year, takes 20-30 minutes to thaw, • Before use, should be thawed in the blood bank in water which is between 30°C to 37°C. Higher temperatures will destroy clotting factors and proteins • is then kept at 1-6° and transfused within 24 hours FFP • Need ABO Compatibility, but Rh Neg patients can receive Rh Pos FFP • 4-5 Units of platelets, one unit WB all have same a similar quantity of coagulation factors as unit of FFP (except for labile factors lost to cold storage in WB) Indications • Replacement of multiple coagulation factor deficiencies: e.g. —Liver disease —Warfarin (anticoagulant) overdose —Depletion of coagulation factors in patients receiving large volume transfusions • Disseminated intravascular coagulation (DIC) • Thrombotic thrombocytopenic purpura (TTP) Precautions • Acute allergic reactions are not uncommon, especially with rapid infusions • Severe life-threatening anaphylactic reactions occasionally occur • Hypovolaemia alone is not an indication for use FFP • Goal- to raise level of clotting factor to 30% of normal • Takes 10-15 cc/kg • Rapid reversal of coumadin 5-8cc/kg FFP (Vitamin K would take 12-18 hours) • Clin Anes Procedures-Mass Gen-2002 Cryoprecipitate Description • Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C and resuspending it in 10–20 ml plasma • Contains about half of the Factor VIII and fibrinogen in the donated whole blood: e.g. Factor VIII: 80–100 iu/pack; fibrinogen: 150– 300 mg/pack; factor XIII: 40 to 60 U/pack Cryoprecipitate • Shelf life-Frozen: 1 yr (<–30°C) Thawed: Give within 6 hours • Preferable to be ABO compatible (AABB) May have RBC fragments that can sensitize Rh-D neg patients Indications • As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of: — von Willebrand Factor (von Willebrand’s disease) — Factor VIII (haemophilia A) — Factor XIII • As a source of fibrinogen in acquired coagulopathies: e.g. disseminated intravascular coagulation Cryoprecipitate • A dose of 1 unit (bag) of cryoprecipitate per 710 kg body weight raises fibrinogen levels by at least 50 mg/dL. • The half-life of fibrinogen is 3 to 5 days; additional doses given on the basis of lab test results. Platelets Description Single donor unit in a volume of 50–60 ml of plasma should contain: • At least 55 x 109 platelets • <1.2 x 109 red cells • <0.12 x 109 leucocytes Unit of issue May be supplied as either: • Single donor unit: platelets prepared from one donation • Pooled unit: platelets prepared from 4 to 6 donor units ‘pooled’ into one pack to contain an adult dose of at least 240 x 109 platelets Infection risk • Same as whole blood, but a normal adult dose involves between 4 and 6 donor exposures • Bacterial contamination affects about 1% of pooled units Storage • Up to 72 hours at 20°C to 24°C (with agitation) unless collected in specialized platelet packs validated for longer storage periods; do not store at 2°C to 6°C • Longer storage increases the risk of bacterial proliferation and septicaemia in the recipient Indications • Treatment of bleeding due to: — Thrombocytopenia — Platelet function defects • Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure • • • • • • • در صورتي كه تعداد پالكتهاي بيمار كمتر از 000/10در ميكروليتر يا كمتر از 000/20در ميكروليتر و همراه با تب باشد. مواردي كه توليد پالكت در مغز استخوان كاهش يافته باشد و يا بين 000/10 -000/20در ميكروليتر باشد مانند بيماران داراي بدخيميهاي خوني و يا بيماراني كه تحت كموتراپي بودهاند. شمارش پالكت كمتر از 000/50در ميكروليتر براي جراحيهاي كوچك. شمارش پالكت كمتر از 000/80در ميكروليتر براي جراحيهاي بزرگ. شمارش پالكت كمتر از 000/50در ميكروليتر در بيماراني كه خونريزي فعال دارند. شمارش پالكت كمتر از 000/50در ميكروليتر در بيماراني كه تحت ترانسفوزيون وسيع قرار داشتهاند. شمارش پالكت كمتر از 000/50در ميكروليتر در بيماراني كه قرار است مورد اعمال تهاجمي قرار ميگيرند. • • • • • • شمارش پالكت كمتر از 000/100در ميكروليتردر بيماران كه داراي يكي از خصوصيات زير: :aخونريزي رتين :bخونريزي مغز :cافراد تحت جراحي باي پاس) (By-Passكه دچار خونريزي شدهاند. با زمان سيالن بيش از 5/7دقيقه با شمارش پالكت طبيعي، خونريزي يا اعمال جراحي تهاجمي در بيماران دچار اختالل كيفي پالكت در درمان لوكمي حاد براي جلوگيري از مرحله خونريزي وسيع ( )Episode Major Bleedingبه جز فاز انتهايي Platelet Transfusion: Response evaluation to plt transfusion: Corrected Count Increment: ( CCI) CCI= Plt increment multiply BSA/ Number of plt transfused Platelet Transfusion: Response Evaluation: CCI must be at least 7500 one hour and 4500 ,20 hours after transfusion. So if it doesn’t occur we can say that patient has platelet resistance. Contraindications • Not generally indicated for prophylaxis of bleeding in surgical patients, unless known to have significant preoperative platelet deficiency • Not indicated in: — Idiopathic autoimmune thrombocytopenic purpura (ITP) —Thrombotic thrombocytopenic purpura (TTP) — Untreated disseminated intravascular coagulation (DIC) — Thrombocytopenia associated with septicaemia, until treatment has commenced or in cases of hypersplenism Dosage • 1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult, 4–6 single donor units containing at least 240 x 109 platelets should raise the platelet count by 20–40 x 109/L • Increment will be less if there is: — Splenomegaly — Disseminated intravascular coagulation — Septicaemia Administration • After pooling, platelet concentrates should be infused as soon as possible, generally within 4 hours, because of the risk of bacterial proliferation • Must not be refrigerated before infusion as this reduces platelet function • 4–6 units of platelet concentrates (which may be supplied pooled) should be infused through a fresh standard blood administration set • Special platelet infusion sets are not required • Should be infused over a period of about 30 minutes • Do not give platelet concentrates prepared from RhD positive donors to an RhD negative female with childbearing potential • Give platelet concentrates that are ABO compatible, whenever possible Complications • Febrile non-haemolytic and allergic urticarial reactions are not uncommon, especially in patients receiving multiple transfusions PLATELET CONCENTRATES (collected by plateletpheresis) Description • Volume 150–300 ml • Platelet content 150–500 x 109, equivalent to 3–10 single donations • Platelet content, volume of plasma and leucocyte contamination depend on the collection procedure Unit of issue • 1 pack containing platelet concentrates collected by a cell separator device from a single donor Infection risk Same as whole blood Storage • Up to 72 hours at 20°C to 24°C (with agitation) unless collected in specialized platelet packs validated for longer storage periods; do not store at 2°C to 6°C Indications • Generally equivalent to the same dose of platelet concentrates prepared from whole blood • If a specially typed, compatible donor is required for the patient, several doses may be obtained from the selected donor Dosage • 1 pack of platelet concentrate collected from a single donor by apheresis is usually equivalent to 1 therapeutic dose Administration • Same as recovered donor platelets, but ABO compatibility is more important: high titre anti-A or anti-B in the donor plasma used to suspend the platelets may cause haemolysis of the recipient’s red cells That’s all, folks!
