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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 – – – – – – 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 – – – – – – • • • • 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 – – – – 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 • • • • 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 • • • • • • • • • • 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 • • • • 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 • • • • • • • • • Hepatitis ( C,B,A ,D etc ) HIV HTLV CMV E-Barr HHV Creutzfeldt-Jakob or variant CJD (therotical) Parvovirus • • • • • • • Malaria Lyme ? (not enough evidence) Chagas Babesiosis Sy Toxoplasmosis West Nil virus