Title: Transfusion Medicine Overview
1Transfusion Medicine Overview
- Brenda J. Grossman, MD, MPH
- Medical Director, Transfusion Medicine Services
- Saint Louis University Hospital
2Overview
- Blood Donation and Component Preparation
- Pretransfusion testing
- Direct Antiglobulin Testing
- Transfusion Reactions
- Transfusion-transmitted Diseaes
3Blood Component Units Processed and Transfused ,
2001
National Blood Donor Resource Center, 2003
4Overview of Transfusion Medicine Services at SLUH
- Blood Donation and Apheresis Service
- Whole Blood and Plateletpheresis collection
- Therapeutic Cytapheresis
- Therapeutic Plasmapheresis
- Peripheral Blood Stem Cell Collection
- Transfusion Therapy
- Therapeutic Phlebotomy
- Blood Bank
- Compatibility Testing
- Acquiring Special Products
- Modifying Products
- Distribution of Products for Transfusion
5Volunteer Blood Donor Eligibility
- Age 17 or older
- Typically 110 lbs
- In good health
- Temperature 37.5C (99.5F)
- Pulse 50-100
- Blood Pressure 180/100
- Hb/HCT 12.5 g/dl / 38
- No skin lesions or signs of IV drug use
6Volunteer Donations
- Medical History
- Mini physical exam
- Hb determination
- Phlebotomy
- Eat and Drink
7And if we are lucky..
8Blood Collection and Manufacturing
9Centrifugation
10Plasma/Red Cell Separation
11Red Blood Cells
- Composed of RBC with reduced amount of plasma
- Primary indicationrestore or maintain
oxygen-carrying capacity to meet tissue demands - O2 content (Hb x 1.39 x sat) (pO2 x
0.003) - O2 delivery is dependent on C.O., Hb conc. and
oxygen demand therefore do not use Hb level as
sole indicator for transfusion - Assess clinical status before transfusion
12Red Blood Cells
- Composed of RBC with reduced amount of plasma
- Primary indicationrestore or maintain
oxygen-carrying capacity to meet tissue demands) - O2 delivery is dependent on C.O., Hb conc. and
oxygen demand therefore do not use Hb level as
sole indicator for transfusion - Assess clinical status before transfusion
13Red Blood Cells
- Plasma removed (less than 30cc remain)
- CPD/CP2D- 21 day shelf life
- CPDA-1-35 day shelf life
- AS-42 day shelf life
- Hct 80
- Stored at 1-6C
- Transport at 1-10C
- 1 unit should increase Hb by 1g/dL
14Contraindications and Precautions with RBC and WB
transfusions
- WB transfusion for normovolemic anemia
- Volume expansion
- Non-Symptomatic anemia
- Chronic anemia
- Nutritional anemia
15RBC TransfusionsAdministration Issues
- 170-260 microns removes fibrin clots, coagulated
protein and cellular debris accumulated during
storage - Initial volume of Red Blood Cells or Whole Blood
should be transfused slowly (1 mL/kg/hour) to
monitor the recipient for any untoward reactions - Entire red blood cell component must be
transfused within 4 hours.
16Administration of RBC Components
- Blood Warming
- Maintain RBC at 37C
- A unit returned to blood bank that is gt 10C may
not be reissued - Only normal (0.9 USP) saline may be administered
with blood components
17RBC TransfusionsSpecial RBC components
- RBC, Leukocyte Reduced
- RBC, Washed
- RBC, Irradiated
- RBC, CMV seronegative
18Platelet Rich Plasma Separation
19Plasma/platelet separation
20Plasma
- Indications
- Active bleeding with a proven coagulopathy
- Congenital deficiency of Factor II, V, X or XIII
- Emergency reversal of Warfarin
- TTP/HUS replacement
- Contraindication
- Volume expander
- Protein Supplementation
- Factor replacement for which factor concentrates
available
21Fresh Frozen Plasma (FFP)
- Plasma placed at -18º C within 8 hours if
collected in CPD, CP2D, CPDA-1 or within 6 hours
if collected in ACD - Expiration date 1 year if frozen
- Expiration date 24 hours after thawing
- Contains stable and labile coagulation factors at
1U/mL - 1 unit should increase clotting factors by 2 in
a 70kg person
22Plasma Frozen with 24 hours of collection
- Plasma placed at -18º C within 24 hours of
collection - Essentially equivalent to Fresh frozen plasma
23Random Donor Platelets
- Sometimes called platelet concentrates
- Separated from WB by differential centrifugation
- Stored at 20-24C/ continuous agitation
- 5 day shelf-life
- Administered in pools of 4-6 units (50mL/unit)
- ? 5.5 X1010 platelets per unit in at least 90 of
units - In absence of decrease platelet survival, a unit
should raise 5000-10000/µL
24Plateletpheresis donation
- 1-2 products
- Takes 2 hours
- No aspirin for 36 hours
25Platelet, Pheresis
- Prepared by apheresis
- Stored at room temperature/ continuous agitation
- 5 day shelf-life
- Administered as one unit/dose (? 200 mL-400mL)
- ? 3 X 1011 platelets/unit in at least 90 of
units - In absence of decrease platelet survival, a unit
should raise 30,000-50,000/µL
26Platelet Components
27Blood Bank Storage
28Blood Bank
- Compatibility testing
- ABO/Rh
- Screening
- Crossmatching
- Antibody identification
29Pretransfusion Testing
- ABO Group and Rh Type
- Forward patients RBC and reagent antiserum
- Reverse-patients serum and reagent A and B RBC
- Antibody Screen (IAT)
- Patients serum and reagent O RBCs (2 or 3)
- Crossmatch
- Patients serum and donor RBC
- Immediate Spin vs. complete crossmatch
30ABO Group
- Most significant blood group system in
transfusion - A, B, AB, O
- All are formed from precursor molecule with H
antigen
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32Rh Type
- Second most significant blood group system in
transfusion - 85 Caucasian population Rh /15 Rh-
- Most immunogenic blood group
- Antibodies always result of a previous pregnancy
or transfusion with incompatible antigens- IgG - -80 of D negative person who receive D-positive
blood will form antibodies - May causes HDN and AHTR
33Antibody Screen (IAT)
34Direct Antiglobulin Test (DAT)
35What causes a positive DAT ?
- Autoantibody to intrinsic RBC antigens
- Alloantibodies in recipient circulation to
transfused cells - Alloantibodies in donor plasma to recipients RBC
- Alloantibodies in maternal circulation which
cross the placenta and coat fetal cells - Antibodies against certain drugs which bind RBC
membrane (e.g. Pencillin)
36What causes a positive DAT ?(Contd)
- Adsorbed proteins which attach to RBC modified by
drugs (e.g. cephlasporin) - Complement components bound to RBC after drugs
(e.g. quindine) - Non RBC immunoglobulins in hypergamma patients or
after IVIG - Antibodies produced by passenger lymphocytes in
transplant organs and HPC
37What does a positive DAT mean?
- Positive DAT does not necessarily mean shortened
RBC survival - -DAT can detect 100-500 molecules of IgG/ red
cell - -Positive DAT without clinical problems occur in
11000-114,000 blood donors and in 1-15 of
hospital patients
38What does a positive DAT mean?
- -Immune-mediated hemolysis is the shortening of
RBC survival by immune mechanisms - -If marrow can compensate, it may not result in
anemia - -Blood bank must rely on other lab data to
determne if hemolytic anemia is occurring- e.g
Hb, Retic count, RBC morphology, bilirubin,
haptoglobin, LD levels - -Serologic findings suggest only whether
hemolysis has an immune basis.
39Determing the cause of positive DAT
- Complement only
- In vitro complement activation
- Drug
- Paroxymal Cold Hemglobinuria
- Donath Landsteiner test
- Ig G alone or with complement
- Elution to determine pattern of reaction
40Defining the cause of a DAT with elution
- Positive eluate
- Autoantibody usually panagglutin
- Alloantibody- RBC Ag specific
- Negative Eluate
- Drug
- anti-A or anti-B (unless test with A or B cells)
41Transfusion issues with Warm Autoantibodies
- May be difficult to rule out underlying
alloantibodies - Transfusion may stimulate autoantibody and
increasing hemolysis - Transfusion may suppress compensatory
erythropoiesis - Transfusion should not be withheld solely for
serological incompatibility - Patient should be carefully monitored throughtout
transfusion - If antibody shows strong specificity and ongoing
active hemolysis then blood lacking the antigen
may be selected
42Irradiation
- To prevent GVHD
- Severely compromised patients
- Blood relatives
- HLA matched products
- All cellular or non-frozen products except stem
cells
43CMV Safe Blood
- CMV is a ubiquitous virus
- 60 of population harbors virus
- If transplant recipient and donor are negative
for the virus then blood components must be
CMV-safe - Leukoreduction
- CMV testing
44Transfusion Reactions
45Categories of Transfusion ReactionsAcute
- Immunologic
- Hemolytic
- Febrile
- Allergic
- Anaphylactic
- TRALI
- Non-immunologic
- Circulatory Overload
- Hemolytic
- Physical
- Bacterial contamination
- Air embolus
- Metabolic reaction
46Categories of Transfusion ReactionsDelayed (gt 24
hours)
- Immunologic
- Alloimmunization
- RBC
- HLA
- Hemolytic
- GVHD
- Post-transfusion Purpura
- Immunomodulation
- Non-immunologic
- Iron overload
- Viral infections
- HCV
- HBV
- HIV
- HTLV
- Other organisms
- Malaria, Chagas, Babesiosis, etc.
47Protocol for ALL acute transfusion reactions
- STOP THE TRANSFUSION immediately
- Maintain IV assess with 0.9 NaCl
- Check blood component for patient ID
- Notify Blood Bank(BB)
- Send blood sample and urine to BB
- Keep blood unit in case culture becomes necessary
- Support patient as necessary
48Most common cause of an acute hemolytic
transfusion reaction is Clerical Error- Be very
careful with your patient identification
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51Transfusion-transmitted Diseases
52Current Risk of Transfusion-Transmitted Diseases
Stramer Arch Pathol Lab MedVol 131, May 2007
53Other Infectious Risk
54Blood Bank Distribution
55Transfusion Service
56Questions?