Hemat8-Tranfusion Medicine

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BLOOD COMPONENT THERAPY

• Dr. Samy Marouf

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BLOOD COMPONENT THERAPY

• It is the transfusion of specific blood
  components required by the patient.
• Principles
• Use blood products only when it is essential.
• Replace only the deficient component, if
  possible.
• Identify the cause and if possible, treat it.
• Use alternative , IV fluids

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Blood components
WB
PLT
PRBC
FFP
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Platelets rich plasma
Platelets concentrate
2nd centrifugation
Whole blood
1stcentrifugation
FFP for clinical use
Red Cell concentrate
FFP for fractionation
Fresh plasma
Optimal additive solution
Cryoprecipitate
Red cells in OAS
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Blood COMPONENTS AVAILABLE FROM THE BLOOD BANK

• Whole blood
• Packed RBCs
• Random donor Platelets
• Single donor platelets (Apheresis)
• Fresh Frozen Plasma (FFP)
• Cryoprecipitate

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Whole Blood

• 450 ml of whole blood with 63 ml of anticoagulant
• need for oxygen carrying capacity and volume
  replacement
• no viable platelets or WBC
• decreased labile coagulation factors (Factor V
  and VIII)
• Not available since it is not efficient
  utilization of blood

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Whole Blood

• Expected gain 1 gm /dl
• active bleeding gt30
• Neonatal exchange transfusion

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Packed Red Blood Cells (PRBCs)

• 200-250 ml of RBCs and 50 ml of plasma
• Hematocrit 55-70 depending on anticoagulant
• shelf life 35 to 42 days depending on the
  anticoagulant
• treatment of symptomatic anemia where oxygen
  carrying capacity is needed

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Packed Red Blood Cells (PRBCs)

• Indications
• 1- Acute blood loss (100 blood volume 5 Liters
  of blood)
• a Amount of Loss
• i - gt 15 with severe cardiac or
  Respiratory disease.
• ii 15 30 with preexisting
  Anemia , or continuous blood loss.
• iii- gt 30 blood loss.

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• b- Hb i- lt 7 gm/ dl.
• ii - lt 8 gm/dl in elderly with
  cardiovascular or Resp. disease.
• 3- Preoperative Transfusion
• a- Treat cause of anemia.
• b- Avoid cause of bleeding .
• c- Follow Maximum Surgical blood usage list.
• 4- Chronic Anemia
• a- Treat cause of anemia.
• b- Erythropoietion therapy.

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• c B- Thalassemia Hb. Maintained gt 9.5 gm/ dl.
• d sickle cell disease
• i if Hb lt 7 gm/ dl.
• ii if Hb lt 10 gm/ dl. In cases with
• - Cerebro vascular accid. or at high risk.
• - Acute chest or abdominal syndrome.
• - pre operative for major surgery.
• - pregnancy .
• - priapism.
• Dose 10 ml/kg

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Indication for Platelet Transfusion

• Decrease platelet production (Bone marrow
  failure)
• Therapeuticfor patient who are bleeding
  associated with BMF caused by either disease,
  therapy or irradiation.
• Prophylactic gt10x 109/L to decrease morbidity in
  patients with thrombocytopenia due to B.M.F.

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Indications for prophylactic Plateletstransfusion

• major bleed, major surgery gt100,000
• minor bleed, minor procedure gt50,000
• prevent spontaneous bleed gt 10,000

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Pooled Platelets

• are prepared from the platelet portion of 6 whole
  blood units plus 300 ml of plasma (potential for
  6 infectious disease exposures) expires after 5
  days
• 6 X 5 X 10 E10 3.0 x 10 E 11 platelets
• 6 x 5000 rise /RD plt 30,000
• transfuse the patient with platelets from many
  donors to see which platelets will raise the
  platelet count

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Plateletpheresis

• donated by a single donor
• 3.0 x 10 E11 platelets plus 300 ml of plasma,
  expires after 5 days
• raises the platelet count 30,000
• used for all platelet transfusions until less
  than 10,000 platelet increase

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Low Post-transfusion Increment to Platelets

• Definition it is failure to obtain satisfactory
  response to platelet transfusion of unselected
  platelet components.

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Low Post-transfusion Increment to Platelets

• 1 hour post (platelet recovery) poor
• platelet alloantibodies
• platelet autoantibodies
• hepatosplenomegaly
• 24 hour post (platelet survival) poor
• infection bleeding
• DIC fever

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Administration of Platelet Concentrate

• ABO compatible platelet are preferred but not
  necessary.
• Platelet concentrate should be transfused as soon
  as possible after reaching the ward with standard
  blood transfusion sets with 170 mm filters.
• The transfusion should normally be completed
  within 30 minutes.
• Observation during platelet transfusion should
  include pulse temperature before after
  transfusion.

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Fresh Frozen Plasma (FFP)

• 200-250 ml of plasma frozen at -18C within 8
  hours of collection
• no platelets are present
• contains all coagulation factors
• an unconcentrated source of fibrinogen
• use Cryo to correct a low fibrinogen level
• needs 20-30 min lead time to thaw prior to use

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FFP Continued

• Definite indication
• Replacement of single or multiple factor
  deficiencies
• Immediate reversal of warfarin effect
• Vitamin K deficiency
• Acute disseminated intravascular coagulation
• Thrombotic thrombocytopenic purpura
• not used if non bleeding or for volume
  replacement
• indicated when PT/PTT are gt17/55 sec

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Cryoprecipitate (Cryo)

• a white precipitate that forms when FFP at -18C
  is thawed to 4C
• volume is 10 to 15 ml
• adult dose is 10 to 20 pooled units
• 30 minutes is needed for thawing and pooling

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Cryoprecipitate continued

• Cryoprecipitate can be used for the replacement
  of all of the following
• vWF vWD
• Factor VIII Hemoplilia A
• Factor XIII Factor XIII def
• Fibrinogen dec. fibrinogen
• head injury, massive bleed, trauma,

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GRANULOCYTE CONCENTRATES

• Prepared by cytopheresis
• Donor prepared by administering cortisol
  (releases marginating pool) and hydroxyethyl
  starch (facilitates RBC/WBC separation)
• 1 X 1010 WBCs in 200 to 600 mL plasma
• Storage at RT for 24 hours
• ABO/Rh compatible HLA compatible

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Criteria for use lt 500 WBC/mm3 -active infection
(as evidenced by fever) not responding to
antibiotics myeloid hypoplasia with reasonable
chance for survival Limited usage usually for
neonates with sepsis (immature WBCs)
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Leukocyte Reduced blood component
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Leukocyte Reduced RBCs

• RBCs with 99.99 of WBCs removed by leukocyte
  reduction filter
• prevents repeated nonhemolytic febrile
  transfusion reactions
• reduces immunosuppression of recipient by donor
  WBC
• All cellular components are leukoreduced now

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Leukocyte Reduced RBCs continued

• decreases post-operative surgical infections due
  to reduced immunosuppression
• prevents or delays HLA alloimmunization
• identical to CMV seronegative blood
• does not prevent graft versus host disease, only
  gamma irradiation prevents graft versus host
  disease

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Indications for Leukocyte Reduced RBC continued

• after second nonhemolytic febrile transfusion
  reaction
• newly diagnosed leukemics
• long term multiple transfused patients
• sickle cell disease
• aplastic anemia
• thalassemia

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Irradiated blood component
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(Gamma) Irradiated RBCs

• RBCs and platelets are exposed to gamma
  irradiation at 2500 rads for 4.5 minutes
• this inactivates the T lymphocytes in the donor
  unit and prevents graft versus host disease in an
  immunocompromised recipient

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Indications for Gamma Irradiated

• bone marrow transplant recipients
• congenital immunodeficiency syndromes
• intrauterine transfusions
• transfusions from all blood relatives
• Hodgkins disease
• WBC products (to neutropenic patient)
• (never Stem Cells)

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Massive Transfusion
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Massive Transfusion

• Definition transfusion of a volume of blood
  equal to the patient total blood volume in less
  than 24 hours
• Problem of massive transfusion
  thrombocytopenia , coagulation factor depletion ,
  O2 affinity changes , hypocalecaemia ,
  hyperkalemia , acid base disturbance ,
  hypothermia
• Managemant (saline, Ringer,albumin HES)
  

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Massive Transfusion

• Give blood products as a ratio
• 1 dose 1 dose 1 dose 1 dose
• 5 RBC 2 FFP 6 RD PLT 10 Cryo
• ________________ (1 PPH) _________
• Hgb(10gm)
• PT PTT(lt1.5 N)
• Plt Ct (50000/ul))
• Fib(gt100mg)

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AUTOLOGOUS TRANSFUSION
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AUTOLOGOUS TRANSFUSION

• Definition It is the use of patient own blood.
  Autologous transfusion is alternative to
  allogenic transfusion in elective surgery (T C)
  ,3 types (predeposite transfusion ,acute
  normovolaemic hemodilution , intraoperative blood
  salavage
• Advantages no risk of viral infection ,all
  immunological reaction ,decrease post-operative
  infection ,tumor recurrence

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AUTOLOGOUS TRANSFUSION

• Disadvantages 50 discarded , not used for other
  patients , volume overload, bacterial
  contamination, clerical errors
• Exclusion criteria unconfirmed date ,poor
  venous access, infection , anemia , hemodynaemic
  instability

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AUTOLOGOUS TRANSFUSION

• Blood donation schedule
• safety
• Donor and pre-transfusion test
• Storage

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Blood warmers
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Blood warmers

• Hypothermia is defined as the core body
  temperature below 35 C.
• Possible side effects of hypothermia are cardiac
  arrhythmia homeostasis abnormalities from
  impaired platelet function and slowed enzymatic
  reactions in the coagulation cascade
  vasoconstriction , dehydration , lack of oxygen
  to tissues increased red cell release of
  potassium and (with blood component transfusion)
  citrate toxicity. The metabolism of drugs is also
  impaired.

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• Advantages of blood warning devicesThe primary
  advantage of using blood warming devices during
  massive transfusion is to prevent the
  complications caused by hypothermia thus
  improving survival rates and patient outcomes
  including decreased length of hospitalization.Hyp
  othermia impairs immune function may promote
  surgical-wound infection and delay wound
  healing.Disadvantages and complication
• 1-Risk of hemolysis.2-Risk of
  sepsis.3-Decreased infusion rate.5-Expense.

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• Indication for use
• Massive transfusions (1 unit /10 minutes).
  Trauma situations in which core-re-warming
  measures are indicated. Administration rate gt50
  ml/minute for 30 minutes or more (adults).
  Administration rate gt15 ml/kg/hour (children).
  Exchange transfusion of a newborn.

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• Warning
• Do not warm blood components by placing on or
  near a radiator heater patient-warming blanket
  or in a conventional microwave oven or plasma
  thawer. Do not allow the unit to sit at ambient
  room temperature for prolonged periods to warm
  up. Do not place blood components under running
  hot tap water or in an unmonitored or improvised
  warm water bath. Do not return blood components
  that have been warmed to inventory

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Non infectious COMPLICATION OF BLOOD TRANSFUSION
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Transfusion Reaction
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Acute Hemolytic Transfusion Reaction

• a clerical error (wrong specimen, wrong patient)
• 1 in 6,000 to 25,000 transfusions
• back pain, chest pain, fever, red urine,
  oliguria, shock, DIC, death in 1 in 4
• stop the transfusion

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Administration
Identity check
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Work up of An AHTR

• start normal saline
• treat patient symptomatically
• send blood bag and tubing to culture
• send red top and purple top tubes
• urine specimen for hemoglobinuria
• DAT is positive

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Non Hemolytic Febrile Transfusion Reaction

• NHFTR (1100)
• Recipient has WBC antibodies to Donor WBCs
  contained within RBCs and Plateletpheresis
  products
• DAT is negative
• rise in temperature by 2F or 1C
• other causes for fever are eliminated
• blood that is hanging can be restarted ??

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Allergic (Urticarial) Transfusion Reaction

• Recipient has antibodies to the Donors plasma
  proteins (1 in 1000)
• offending protein is not identified
• urticaria, itching, flushing, wheezing
• this is the only transfusion reaction where the
  blood that is hanging can be restarted after
  treatment with Benadryl
• if symptoms continue then STOP

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Anaphlyactic Transfusion Reaction

• anaphylactic reaction (1 in 150,000)
• 1 in 700-900 people never made IgA
• occurs when exposed to normal blood products
  which contain IgA
• bronchospasm, vomiting and diarrhea and vascular
  collapse
• treat with Epinepherine, Solu-Medrol,

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Circulatory Overload

• marginal cardiovascular status
• given blood components too rapidly
• develops acute shortness of breath, heart
  failure, edema (1 10,000)
• systolic BP increases 50 mm
• infuse slowly, not to exceed 4 hours
• split the unit of RBC and give half

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Transfusion Related Acute Leukocyte Lung Injury

• TRALI reaction (110,000)
• Donor plasma contains WBC antibodies that when
  transfused to the recipient cause agglutination
  of recipients WBC in the pulmonary capillary
  beds
• Chest X ray looks like ARDS
• Donor removed from donating blood

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Blood Used on Emergency Basis
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Blood Used on Emergency Basis

• Blood used on Emergency Basis
• for a patient that is bleeding out
• and the blood type is unknown
• group O, Rh negative, uncrossmatched
• recipient may have an unexpected antibody
• after 5 min use ABO and Rh type specific blood

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Sepsis from Bacterial Comtamination

• Platelets
• skin contaminants most common cause
• plateletpheresis 1 in 5000
• pooled platelets 1 in 1000
• RBC
• Sepsis from RBC due to Yersinia, Enterics or
  Gram Positive 1 in 3,000,000

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Knowing is not enough we must apply. Willing
is not enough we must do."