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Blood Transfusion
Teoman SOYSAL Prof. MD
Blood Donation
Healty adult donors
• 450 ml +/- 10% per whole blood donation
• Male: 5/year, Female : 4/year
• > 8 weeks between two donations
Apheresis:
Platelets
Plasma
White cells (or
subsets)
Red cells
The procedure
can be done for
treatment or
transfusion
purposes.
Blood Preservation
• Whole blood or red cells
1-Liquid phase storage : 1-6º C
• 63 ml anticoagulant-preservation liquid/unit
duration of preservation
– ACD: 3 weeks
– CPD: 3 weeks
– CPD-A1: 35 days
– RBC concentrate with SAG-Mannitol : 7 weeks
2- Frozen storage of red cells
• -80 to - 196 º C , with glycerol etc: Years
Blood Preservation
• Effects of storage
– Red cells: ATP, 2-3 DPG,
osmotic fragility and oxygen affinity
– Plasma : Hb, K, NH3 :
pH:
– Platelets: Lost in 2 days
– Coagulation factors:
Eg:
• FV: adequate levels for about 5 days
• FVIII: Below 80% of original level after 1-2 days
• FXI: Less than 20% of original level after 7 days
Blood Preservation
• Platelets:
– liquid phase :
1 - 5 days,
room temp.,
avoid light exposure
kept on special agitator
• Plasma : Use fresh or freeze
– frozen at -18 º C within 8 hrs of collection
Blood components & products
• Cell containing components
– Red cells:
• Whole blood( fresh or not)
• Red cells: packed red blood cells
washed red blood cells
frozen red blood cells
leukocyte – reduced red blood cells
– Platelets: Random donor platelets
Apheresis platelets ( single donor platelets)
– Granulocytes or mononuclear cells
– Peripheral blood progenitor cells
Blood components & products
• Plasma and products
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Plasma : fresh / fresh-frozen plasma
Cryopresipitate
Coagulation factor concentrates
Immunglobulin preperations
Albumin
others
Deciding blood transfusion;
• Severity of symptoms
• Cause of anemia
• Rapidity of anemia or symptoms
• Co-morbidities and the age of the patient
• Can we treat the anemia without transfusion?
And
• Is there enough time to wait for the response of
such a treatment ?
This is not a guide to be used in
every patient
• Hemoglobin >10 g/dL : Tx rarely needed
• Hemoglobin < 6-7 g/dL: Tx mostly necessary
• Hemoglobin : 6-10 g/dL: Dependable
Important:
• Symptoms related to anemia may
differ from one patient to another
for a given Hb level;
• The trigger for red cell
transfusion may differ from one
patient to another!!!!!
Indications for transfusion of blood or its components
• Whole blood: Acute massive bleeding
1 unit increases Hb: 1g/dl, Hct: 3%
• Fresh whole blood:
– Massively bleeding patient/shock
– Exchange transfusion, open heart surg, severe renal or hepatic failure,
• Red blood cells:
– (To increase the oxygen carrying capacity in case of symptomatic
anemia not treatable by other means or due to urgency of symptoms)
– Symptomatic anemia (May be due to different causes), post-bleeding
hypovolemia
– 1 unit increases Hb: 1g/dl, Hct: 3%
Indications for transfusion of blood or its components
• White cells reduced RBC’s:
< 5x106 WBC’s per unit
White cell filters
(before storage or before transfusion)
• An indication for RBC transfusion +
– To prevent reactions caused by WBC antibodies
• Febrile non-hemolytic transfusion reactions
– To prevent alloimmunization
– To prevent CMV transmission
Indications for transfusion of blood or its components
Washed RBC’s:
• An indication for RBC transfusion +
– Any need to prevent the recipient allo-immunisation to WBC’s ,
plasma antigens or any contraindication to infuse complement
• PNH
• IgA deficiency
• Prevention of anaphylaxis
• Washed units must be transfused no later than 24 hours
Frozen RBC’s:
• An indication for RBC transfusion +
– Autologous transfusion: rare blood groups,
– Catastrophy etc
Washed before infusion !!
Indications for transfusion of blood or its components
Blood Irradiation
To prevent transfusion related GVHD in;
• Congenital immune deficient states
• Bone marrow or stem cell transplantation
• Some cases of hematologic malignancies
– Hodgkin’s disease
– Purin analogue or anti-CD52 treatment
• Intra-uterin transfusion
• New borne exchange transfusion
• Transfusions between relatives
– first or second degree
• HLA matched platelets
Some of the indications for platelet transfusions
• Decreased platelet production because of bone marrow
failure or infiltration :bleeding or risk of bleeding
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Leukemia
MDS
Myelofibrosis
Malignant tm infiltration
Myelosupression
Aplastic anemia
Functional platelet disease and bleeding or risk of bleeding
Dilutional thrombocytopenia (after massive transfusion)
Cardiac by-pass surgery
Increased platelet destruction or consumption
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DIC
Drug induced
sepsis
ITP
Indications for transfusion of blood or its components
• Platelets:
Thrombocytopenia due to decreased platelet production
Platelet count/mm3
Bleeding /surgery
> 50.000,
< 50.000
10.000-20.000
No
Yes
No
Indication for plt transfusion
No
Yes
No
(if there is bleeding/fever/DIC/plt dysfunction) Yes
< 10.000
Yes or No
Yes
Some special conditions about platelet
transfusion
Disease status may change
Practical issues
the transfusion effectiveness:
• ABO matched platelets have a
longer in-vivo life span after
transfusion
• Use Rh- platelets for Rhrecipients (to prevent Rh
immunisations) or use antiRh(D) Ig if Rh+ component
used in such recipients
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DIC
Hypersplenism
Sepsis
Allo-immunisation
Cotraindicated in Thrombotic
Thrombocytopenic Purpura: Used
only in high risk bleeding
Not effective/useful in Immune
Thrombocytopenic Purpura: Used
only in high risk bleeding
Types of platelet concentrates
• Random donor plt concentrate (single unit)
– 5,5 x 1010 plts
– 5.000-6.000/mm3 plt increase after transfusion
• Pooled plt concentrate (eg:6 random units)
• Apheresis plts
– >3x1011 plts
– 30.000-50.000/mm3 increase after transfusion
• WBC reduction of platelets is indicated in the
same situations like red cells.
Indications for transfusion of blood or its
components/products
• Fresh frozen plasma ( contains all coag. Factors)
– Congenital or acquired coag.Factor deficiency
(bleeding or surgery)
– Oral anticoagulant overdose
– Plasma exchange (eg:TTP)
– After massive transfusion
– 10-20 ml/kg : to increase deficient factor level
about 20-30% from baseline
Indications for transfusion of blood or its
components/products
• Cryoprecipitate
– Includes FVIII, vWF, FXIII, fibrinogen and
fibronectin
– 80-120 units of FVIII,
≥150 mg fibrinogen and 20-30 % of FXIII that
is in one unit of plasma
– Can be used for the purpose of replacing the
deficient state of these factors in case of
bleeding or surgery
Practical Issues
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Is there a need for transfusion?
Which product should be used?
Number of units?
Re-check the blood types of the patient and donör
and be sure about the cross match
Read label, ID, inspect the product
Is irradiaton necesssary?
Temperature?
Filters?
Flow rate ? (start 5 ml/min-15 minutes , the rest 200-500ml/hr)
Drugs ?
Transfusion Reactions
• Immunologic reactions
• Non-immune reactions
or
• Acute reactions
• Late reactions
Hemolytic reactions
• Reasons: Mismatched transfusion
Transfusion of hemolysed blood
» During storage or warming etc
• May be acute or late
Acute hemolytic reaction
• Frequency up to 1/25.000
• 1/600.000 Tx mortal
• 40% symptomatic
• ABO mismatch
• IgM antibodies (anti-A or anti-B) ,complement
binding and intravascular hemolysis
• Early onset ( first 50-100 ml’s),seldom after 1-2 hrs
– pain at the infusion site, flushing, chest or back
pain,dyspnea,vomiting, fever-chills, hypotension and
tachicardia,bleeding, hemoglobinuria
• Complications: Acute Renal Failure, shock,DIC
Acute hemolytic reaction
• Stop transfusion,
• Take measures to keep normal BP and urine
output: hydration/diuretics,
• Re-check groups, re-cross, take blood cultures,
• Follow signs of hemolytic anemia, antiglobulin
tests,renal function and DIC tests,
• Treat accordingly (eg: dialysis/ICU etc)
Delayed hemolytic reaction
• 1/2500-1/6000
• Onset: 3-21 days after transfusion
• Reason: Rh, Kidd etc mismatches
– Previous alloimmunization and anamnestic response
• Coombs + ( do not confuse with OIHA)
• Jaundice or absence of the expected
increase in red cell values.
• Frequently undetected
• Treatment : none
Febrile reactions
• 0,5- 3% of all transfusions
• Cause: Antibodies against white cell/plt/plasma antigens
• Fever-chills, increased pulse rate during or
after transfusion
• Antipyretics/antihistamines
• Stop transfusion if there is doupt about
hemolysis
• Prophylaxis: White cell reduction
Allergic reactions
• Cause:Antibodies against donor plasma
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proteins
Pruritus,urticaria,edema,anaphylaxis,broncho
spasm
IgA deficient patients are under the greatest
risk
Treat according to the type of reaction
For IgA deficient patients: use washed or
frozen red cells instead of regular red cells or
whole blood.
Pulmonary hypersensitivity
reaction/TRALI
• 1/5000 frequency
• Cause : Leukocyte incompatibility and
agglutination of white cells inside the pulmonary
vascular area leading to complement activation and
endothelial damage- pulmonary edema.
• Fever-chills,tachycardia,chest pain, hemoptysis,
BP fall within 4 hrs of transfusion
• Respiratory support may be necessary
Transfusion Related Graft- versus Host Disease
• Cause: Immune deficient recipient transfused
with viable lymphocytes which are engrafted
and start allo-reaction against mismatched HLA
and other antigens of the recipient.
• High fatality with skin,liver and gut symptoms,
pancytopenia and infections
• Prophylaxis: Blood irradiation
• Treatment: immunosupressive drugs
• Mortality high
Circulatory overload
• Old aged or premature/ new borne or
patients with cardiopulmonary compromise
are under risk.
• Clinics: Acute heart failure
• Treatment: As acute myocardial failure
• Prophylaxis: Slow infusion rate, low
volume of transfusion
Bacterial Contamination
• Bacterial contamination may cause a reaction with
symptoms resembling Acute Hemolytic Reaction
without LAB findings of hemolysis.
• May be fatal:
– Mortality: Plt constr: 1/17.000 – 1/65.000
Red cells: <1/700.000
• Stop transfusion, take cultures, treat with IV
fluids and antibiotics , take support measures and
follow against shock, renal failure,DIC
Air embolism
• May cause acute respiratory and circulatory
failure
• Clump the tubing
• Change the posture of the patient:
– Left side / Trandelenburg (left side ,headdown, legs upside)
– Swan -Ganz catheter
• Patients with bone marrow failure ,
transfused chronically are under the risk of
transfusion hemosiderosis.
• Massive transfusion may cause:
– Citrate toxicity: Hypocalcemia
– Hyperkalemia
– Bleeding ( due to thrombocytopenia and /or
factor deficiency)
Transfusion transmitted
pathogens
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Hepatitis ( C,B,A ,D etc )
HIV
HTLV
CMV
E-Barr
HHV
Creutzfeldt-Jakob or
variant CJD (therotical)
Parvovirus
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Malaria
Lyme ? (not enough evidence)
Chagas
Babesiosis
Sy
Toxoplasmosis
West Nil virus