Download Blood Products by CJ Duren RN

Blood Products
In-service
By CJ Duren, RNII
June 24, 2010
Blood Products…
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Whole Blood
Whole blood contains red cells, white cells, and platelets (~45% of volume) suspended in
plasma (~55% of volume).
Red cells (PRBC)
Red cells, or erythrocytes, carry oxygen from the lungs to your body’s tissue and take
carbon dioxide back to your lungs to be exhaled.
Platelets (PLT)
Platelets, or thrombocytes, are small, colorless cell fragments in the blood whose main
function is to interact with clotting proteins to stop or prevent bleeding.
Plasma (Also known as Fresh Frozen Plasma [FFP])
Plasma is a fluid, composed of about 92% water, 7% vital proteins such as albumin,
gamma globulin, anti-hemophilic factor, and other clotting factors, and 1% mineral salts,
sugars, fats, hormones and vitamins.
Cryoprecipitated AHF (Cryo)
Cryoprecipitated Antihemophilic Factor (Cryo) is a portion of plasma rich in clotting factors,
including Factor VIII and fibrinogen. It is prepared by freezing and then slowly thawing the
frozen plasma.
Some Alternative Blood Products and Uses…
These can be administered
for blood volume
expansion, prevention of
infection in patients with
hypogammaglobulinemia
and for replacement of
other specific coagulation
Factors:
-Albumin,
-Gamma Globulin
-Factor IX Concentrate
(containing factors II, VII, IX
and X).
-Specific Hyperimmune
Gamma
Globulin preparations
Other Uses:
Whole blood-Open heart
surgery, newborns
Red blood cells-Trauma,
anemia, surgery
Platelets-Cancer patients
receiving chemotherapy
Fresh frozen plasmaMassive transfusions
Plasma-Burns
Cryoprecipitate-Hemophilia
What is Massive Transfusion…
• Definition
Massive transfusion is arbitrarily defined as the replacement of a
patient's total blood volume (> 10 units of RBCs) in less than 12-24
hours, or as the acute administration of more than half the patient's
estimated blood volume per hour due to more than 30%-40% blood
loss. Massive Transfusion may be necessary because a patient may
be in hypovolemic shock, from trauma, which can ultimately lead to
widespread cellular dysfunction and organ damage.
• Aim of Treatment
The aim of treatment is the rapid and effective restoration of an
adequate blood volume and to maintain blood composition within
safe limits with regard to hemostasis, oxygen carrying capacity,
oncotic pressure and biochemistry. Uncontrolled hemorrhage after
traumatic injury is the most common cause of potentially preventable
death, which can occur within the first few hours after injury.
Red Blood Cells…
Red blood cells contain hemoglobin, a complex iron-containing protein that
carries oxygen throughout the body and gives blood its red color.
The percentage of blood volume composed of red blood cells is called the “hematocrit”.
Packed RBCs (pRBC):
Less than 7 days Old is Optimum for Usage…
The primary purpose for transfusing red blood cells is to provide a mechanism for the increased
transport of oxygen (via increased red cell mass) and increase blood volume.
The main difference between whole blood and red cell concentrate (pRBC) is the approximate
hematocrit of each 40% and 70%, respectively. The higher the hematocrit the more viscous the
blood. In a trauma patient actively bleeding, the higher hematocrit pRBCs are used to help with
volume expansion.
In their liquid state, Whole Blood and pRBCs have a storage shelf life of 21 days
Why use pRBCs instead of Whole Blood in a Trauma?
Clotting factors significantly deteriorate with total loss of functioning granulocytes and platelets
when whole blood is stored. Thus it is more beneficial to use stored components of whole blood
than the actual whole blood. It all depends on what’s going on with your patient.
Stored Whole Blood:
•Increased oxygen affinity
•Increased hydrogen ions
•Increased potassium
A decrease of oxygen
released to tissues
Platelets (PLT)
For actively bleeding trauma patients,
too large of a volume of whole blood would
be
needed to correct a platelet deficiency
Each unit of platelet concentrate is obtained from an individual unit of fresh whole blood and is usually
prepared in a volume of approximately 50 ml of plasma.
Platelet concentrates may be stored in this volume @ 22ºC for up to 72 hours without a reduction in
pH to less
than 6.0, a level below which platelets do not appear to be hemostatically functional.
As a general rule, one unit of platelet concentrate will raise the platelet count in the average-sized
adult by approximately 5 x 109/liters, measured 1 hour after infusion.
It is preferable to give platelets from ABO-compatible donors. However, satisfactory clinical results
may be obtained with ABO incompatible platelets, and one should not hesitate to use them if
ABO-compatible platelet concentrates are not available.
To prevent thrombocytopenia due to decreased platelet production or increased platelet loss.
Platelets Continued…
Rh IMMUNIZATION: Rhesus (D) Antigen
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Patients with the Rhesus (D) antigen are said to be Rh+ and those without are Rh-
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Platelets (or thrombocytes) are very small cellular components of blood that help the
clotting process by sticking to the lining of blood vessels.
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Platelets are made in the bone marrow and survive in the circulatory system for an average
of 9–10 days before being removed from the body by the spleen.
Platelets are vital to life, because they help prevent massive blood loss resulting from trauma,
as well as blood vessel leakage that would otherwise occur in the course of normal, day-today activity.
Transfusion Associated Infection Risks…
The risk of acquiring an infectious disease through blood transfusion has not been totally
eliminated even though the level and sensitivity of testing today makes transfusion
very safe. Physicians/hospital staff should report all instances when an infectious
disease is reasonably likely to have been transmitted by a blood transfusion.
Risks of blood transfusion can be divided into two catagories: Infectious and nonInfectious
Note: Platelets stored at 22ºC have minimal bacterial contamination risks
It is preferable to give platelets from ABO-compatible donors. However, satisfactory clinical results
may be obtained with ABO incompatible platelets, and one should not hesitate to use them if
ABO-compatible platelet concentrates are not available.
Platelets do not contain the Rhesus (D) antigen, but all platelet preparations contain a small quantity
of red cells (approximately 0.4 ml per unit of platelet concentrate).
Rhesus (D) antigen…
• Platelets do not contain the Rhesus (D) antigen, but all platelet
preparations contain a small quantity of red cells
(approximately 0.4 ml per unit of platelet concentrate).
The Rh immunization of an Rh negative woman could occur
following:
• the infusion of platelet concentrates
• from an Rh-positive donor.
If platelets from an Rh positive donor must be given to an Rh-negative
woman of childbearing age or a girl who has not reached the
childbearing age, it is recommended that Rh immunoglobulin be
administered with or immediately after the platelets, to females of
reproductive age (under 50) while the hemostatic effect of the platelets
is still present and to avoid sensitization and risk of hemolytic disease
of the newborn in subsequent pregnancy.
Non-Infectious
Risks…
Infectious Risks…
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Parvovirus B19
GBV-C virus (also called hepatitis
G)
Transfusion-transmitted virus (TTV)
SEN virus
Prions including Creutzfeldt-Jakob
and variant
Lyme Disease
Bacterial infections including:
malaria, Chagas disease,
ehrlichiosis, babesiosis, and
syphilis
Other BLOODBORNE PATHOGENS
(Extremely Rare)
• Hepatitis B (HBV)
Hepatitis C (HCV)
Human Immunodeficiency Virus
(HIV)
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The noninfectious risks associated with
blood products are generally
immunologically mediated.
Reactions can occur as a result of the
antibodies that are constitutive (Anti-A or
Anti-B) or ones that have been formed
as a result of prior exposure to donor
RBCs, WBC, platelets, or proteins.
The noninfectious adverse reactions include:
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Acute hemolytic transfusion reaction
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Delayed hemolytic transfusion reaction
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Minor allergic reactions
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Anaphylactic/-toid reactions
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Febrile reactions
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Transfusion related acute lung injury
Risks of Blood Transfusions…
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Acute hemolytic reaction-Intravascular Hemolysis caused by complement fixing IgM antibodies,
which can be life threatening (10.2%)
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Transfusion transmissible infections- Risks are very low: for example, 1.66 per million units for hepatitis
B, 0.80 for hepatitis C, and 0.14 for HIV, in donations entering the UK blood supply, 1996-2003w4 (1.8%)
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Allergic Reaction- Occurs as a result of the body's reaction to plasma proteins in donated blood
Febrile Reaction- The patient spikes a fever during the transfusion or within 24 hours because of cytokines
released from white blood cells. It is more common in patients who have had previous transfusions and in
multigravida women. All donated blood is now leucodepleted, reducing the likelihood of this complication
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Circulatory Overload
Iron Overload- Patients dependent on transfusion are more at risk
Transfusion Related Acute Lung Injury- This serious complication is caused by donor blood containing
antibodies to white blood cells. This causes the white cells to adhere to the microvasculature of the lungs and
trigger an inflammatory reaction producing severe pulmonary edema (6.2%)
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Delayed Transfusion Reactions- Occur more than 24 hours after transfusion-these are almost always
delayed haemolytic reactions caused by pre-existing IgG red cell antibodies (9.7%)
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Graft versus Host Disease- White blood cells in the transfused blood attack the tissues of an
immunocompromised recipient (0.5%)
Fresh Frozen Plasma (FFP):
Approximate Volume per Bag is 200ml…
Contains all coagulation factors (Factors: I (fibrinogen), II (prothrombin), V, VII,VIII, IX
(Christmas Factor), X, XI, XIII). Coagulation factor deficiency is the primary cause of
coagulopathy in massive transfusion because of dilution of coagulation factors following
volume.
Administered to replace coagulation factors not available as specific concentrates and to
prevent bleeding problems after trauma or liver transplants
Fresh frozen plasma is prepared from fresh whole blood within 6 hours of collection of the
blood from individual donors.
Stored at -30ºC or lower, FFP can last (shelf life) up to 12 months in the blood bank. If freeze
preserved it can last up to 10 years in storage. This temperature maintains the stability of
coagulation factors, Factor V and Factor VIII.
After thawing, Factor V and Factor VIII rapidly deteriorate. 20 minutes is needed for complete
thawing, therefore give as soon as possible
The plasma administered should be ABO compatible with the recipient’s blood but it does not
need to be blood group specific; therefore no cross matching needed.
Cryoprecipitate (CRYO):
Approximate Volume: 10ml per Bag…
Cryoprecipitate is the precipitate that remains when the FFP is thawed slowly at 4° C.
Mainly includes: concentrated Factor VIII (antihemophilic globulin), von Willebrand factor, Factor XIII
and fibrinogen---thus, the reason for administration in massive bleeding or Hemophilia A.
CRYO stored at minimum -20ºC can last up to 3 months and @ -30ºC it can be stored up to 1 year.
Takes 20 minutes to thaw slowly and completely. It can be thawed in 10 minutes using a 37ºC water
bath, but watch the temperature. If water bath temperature gets higher than 37ºC, loss of Factor
VIII activity occurs.
CRYO must be administered promptly after thawing.
Cryoprecipitate units are usually labeled with the ABO group of the donor, and it is preferable, but not
essential, to give units that are blood group compatible.
What’s Needed for Pediatrics…
Leukocyte Depletion…
All components other than granulocytes should be leukocyte depleted (not more than 5 X10 6 leukocytes per unit) at the
time of manufacture (level IV evidence, grade C recommendation). In an emergency and where seronegative
blood components are not available, transfusion of leuko-depleted components is an acceptable, although less
desirable. White cells can be removed by washing, irradiation, or leukofiltration.
CMV Negative…
Blood transfused in the first year of life should be cytomegalovirus (CMV) seronegative. Those at greatest risk of
transfusion transmitted CMV are fetuses and infants weighing under 1.5 kg, immunodeficient patients and stem
cell transplant recipients.
Irradiated…
It is essential to irradiate all red cell and platelet components (with the exception of frozen red cells) for:
1) Intrauterine transfusion (IUT)
2) Exchange transfusion (ET) of red cells after IUT
3) Top-up transfusion after IUT
4) When the donation is from a first- or second-degree relative
or a human leukocyte antigen (HLA)-selected donor
5) When the child has proven or suspected immunodeficiency
Washed…
Washed red blood cells have reduced potassium. This is especially good for young infants that require massive
transfusion.
How many platelets and white blood cells are there in for every unit of whole red blood?
For every 600 red blood cells, there are about 40 platelets and one white cell.
Where are red blood cells made?
Manufactured in the bone marrow, red blood cells are continuously being produced and broken down. They
live for approximately 120 days in the circulatory system and are eventually removed by the spleen.
How much do blood
products cost?
For Jehovah’s Witnesses…
Risks of Massive Hemorrhage…
Trauma Surgery:
– Ongoing bleeding and
resuscitation
– Dilutional coagulopathy
– DIC due to inadequate
resuscitation
– Hypothermia leading to
coagulopathy
Labs to Send…
Use EBL (estimated blood loss) and
Coagulation Surveys to
guide administration of
CRYO and FFP.
Send individual lab draws as needed:
• PT/PTT
• Fibrinogen Level
• Platelets
• HgB (Hemoglobin)
• HCT (Hematocrit)
• D-Dimer
Cultural/Religious Considerations…
Accepts Blood Products:
Native Americans
Catholics
Hispanics
Hinduism
Judaism
Protestant
Seventh Day Adventist
Generally Does Not Accept Blood Products:
Jehovah’s Witnesses
Recommendations…
Patient survival rates improve when the ratio of blood products is 1:1 packed
RBCs to FFP @ 6 hours, 24 hours and 30 days. This ratio also results in
fewer ICU days, decreased ventilator days, and decreased total hospital
length stay.
The MTP ratio also helps avoid the
lethal triad that can occur during resuscitation:
Hypocalcemia
Additional Information About
Massive Transfusion Blood…
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The blood products will be transfused by alternating blood with clotting factors, if
available.
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Any unused blood will be returned immediately to the Blood Bank as it is not used.
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The Blood Bank will continue to prepare MTPs until the Trauma Team indicates that the
packs are no longer needed.
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Females < 45 years of age will receive a maximum of 6 units of Rh negative (unless
otherwise instructed) and then be switched to Rh positive RBCs.
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If the recipients are 4 months to 3 years of age, they are considered massively transfused
after receiving 5 units of packed cells in a 24 hour period