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Transfusion Medicine Overview

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Blood Donation and Apheresis Service. Whole Blood and Plateletpheresis collection ... Prepared by apheresis. Stored at room temperature/ continuous agitation. 5 ... – PowerPoint PPT presentation

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Title: Transfusion Medicine Overview


1
Transfusion Medicine Overview
  • Brenda J. Grossman, MD, MPH
  • Medical Director, Transfusion Medicine Services
  • Saint Louis University Hospital

2
Overview
  • Blood Donation and Component Preparation
  • Pretransfusion testing
  • Direct Antiglobulin Testing
  • Transfusion Reactions
  • Transfusion-transmitted Diseaes

3
Blood Component Units Processed and Transfused ,
2001
National Blood Donor Resource Center, 2003
4
Overview 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

5
Volunteer 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

6
Volunteer Donations
  • Medical History
  • Mini physical exam
  • Hb determination
  • Phlebotomy
  • Eat and Drink

7
And if we are lucky..
8
Blood Collection and Manufacturing
9
Centrifugation
10
Plasma/Red Cell Separation
11
Red 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

12
Red 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

13
Red 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

14
Contraindications and Precautions with RBC and WB
transfusions
  • WB transfusion for normovolemic anemia
  • Volume expansion
  • Non-Symptomatic anemia
  • Chronic anemia
  • Nutritional anemia

15
RBC 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.

16
Administration 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

17
RBC TransfusionsSpecial RBC components
  • RBC, Leukocyte Reduced
  • RBC, Washed
  • RBC, Irradiated
  • RBC, CMV seronegative

18
Platelet Rich Plasma Separation
19
Plasma/platelet separation
20
Plasma
  • 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

21
Fresh 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

22
Plasma Frozen with 24 hours of collection
  • Plasma placed at -18º C within 24 hours of
    collection
  • Essentially equivalent to Fresh frozen plasma

23
Random 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

24
Plateletpheresis donation
  • 1-2 products
  • Takes 2 hours
  • No aspirin for 36 hours

25
Platelet, 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

26
Platelet Components
27
Blood Bank Storage
28
Blood Bank
  • Compatibility testing
  • ABO/Rh
  • Screening
  • Crossmatching
  • Antibody identification

29
Pretransfusion 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

30
ABO Group
  • Most significant blood group system in
    transfusion
  • A, B, AB, O
  • All are formed from precursor molecule with H
    antigen

31
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32
Rh 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

33
Antibody Screen (IAT)
34
Direct Antiglobulin Test (DAT)
35
What 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)

36
What 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

37
What 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

38
What 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.

39
Determing 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

40
Defining 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)

41
Transfusion 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

42
Irradiation
  • To prevent GVHD
  • Severely compromised patients
  • Blood relatives
  • HLA matched products
  • All cellular or non-frozen products except stem
    cells

43
CMV 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

44
Transfusion Reactions
45
Categories of Transfusion ReactionsAcute
  • Immunologic
  • Hemolytic
  • Febrile
  • Allergic
  • Anaphylactic
  • TRALI
  • Non-immunologic
  • Circulatory Overload
  • Hemolytic
  • Physical
  • Bacterial contamination
  • Air embolus
  • Metabolic reaction

46
Categories 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.

47
Protocol 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

48
Most common cause of an acute hemolytic
transfusion reaction is Clerical Error- Be very
careful with your patient identification
49
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50
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51
Transfusion-transmitted Diseases
52
Current Risk of Transfusion-Transmitted Diseases
Stramer Arch Pathol Lab MedVol 131, May 2007
53
Other Infectious Risk
54
Blood Bank Distribution
55
Transfusion Service
56
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