Transcript Basics of Transfusion Therapy - Medical College of Wisconsin

Basics of
Transfusion
Therapy
Resident Education
Lecture Series
Hemoglobin Level and Symptoms
HGB (GM%)
SYMPTOMS
9-11
MINIMAL
7.5
EXERTIONAL DYSPNEA
6.0
WEAKNESS
3.0
DYSPNEA AT REST
2-2.5
HEART FAILURE
LINMAN
NEJM 279:812, 1968
RBC Transfusion: Indications

Acute Blood Loss

Symptomatic Anemia

Suboptimal O2 Capacity

Exchange (SS, Co)
RBC Transfusion: The Bathtub Principle
Kidney
Kidney
Kidney
100
100
100
30
30
40
0
0
0
Blood Volume
Blood Volume
Blood Volume
Pre-Transfusion Testing

BLOOD TYPING:
 ABO,
D Antigens only
(Other antigens are weak immunogens)

ANTIBODY SCREEN:
 Patient

serum vs. cell panel
CROSSMATCH
 Major:
Patient Serum vs. Donor Cells
RBC Products

PRBC
MOST TRANSFUSIONS

WHOLE BLOOD
ACUTE BLEEDING
EXCHANGE
PLASMA NEEDED

WASHED
REMOVE PLASMA

FROZEN
RARE RBC PHENOTYPE
IRRADIATED
CMV NEGATIVE
IMMUNODEFICIENT
IMMUNODEFICIENT
SERONEGATIVE, NEONATE


RBC Transfusion Volume

Usual:
Up to 15cc/Kg in 3-4 hours

Unusual:
Acute Hemorrhage:
replace ongoing losses
Chronic Anemia, Heart Failure, îBP
2cc/Kg/Gm HGB
Diuretic
Exchange
Transfusion Volume

10cc/Kg PRBC
10cc/kg
2.4 GM%

2.4 GM% in HGB
=
X cc/kg
Desired HGB rise
PRBC cc = Blood Volume x (HGBF- HGBI)
HGBT
BV=70cc/KG, 80-90cc/KG newborn
Hemolytic Transfusion Reactions

Acute HTR
 Fatal

Acute HTR
Delayed HTR
1/25,000
1-4/1,000,000
1/5-10,000
Symptoms and Signs of Acute
Hemolytic Reactions








Severe Back Pain
Substernal Tightness, Dyspnea
Hypotension / Circulatory collapse
Vomiting, diarrhea
Icterus
Hemoglobinuria
Renal shutdown
Diffuse Oozing from wounds/punctures
Response to Suspected Hemolytic
Reaction



Stop Transfusion
Hydrate
Specimens to Blood Bank
 Unit/Bag
 Serum
 Red cells
 Urine
Acute Hemolysis: Diagnosis





Do a direct antiglobulin test on posttransfusion sample
Obtain post-transfusion blood and urine and
inspect visually
Recheck paperwork
Recheck ABO type of unit and pre-and posttransfusion specimens
Run urinalysis - to check for hemoglobinuria
Cause of Acute HTR

ABO incompatibility:source of error
 10%
at phlebotomy/labeling
 23% in Transfusion Lab
 67% transfusion administration (at the
bedside)
Nonhemolytic Transfusion Reactions

Leukocyte Associated

FNHTR
 Transfusion GVHD
 Neonatal Neutropenia
Citrate Toxicity
 Hypothermia
 Circulatory Overload


Immunoglobulin Associated




Urticaria/Fever
Ig E
TRALI
Platelet Associated
Post transfusion Purpura
 Neonatal Thrombocytopenia

Metabolic/ Physical


Massive Transfusions



Haemostatic Abnormalities
Metabolic complications
Hgb-O2 Curve Shift
TRANSFUSION-RELATED INFECTION
Risk of TransfusionTransmitted Infection
HIV
Hepatitis C
Hepatitis B
Hepatitis A
HTLV I/II
Bacteria
1 in 2,000,000
1 in 2,000,000
1 in 175,000
Rare
1 in 3,000,000
1/3,000 (for platelets)
Malaria, T Cruzi, Babesia, Yersinia,
Syphilis, Lyme, CJD, West Nile Virus…??
Post Transfusion HCV
Percent
Incidence
Chronic
Cirrhosis
5-10
50
20
Number
150-300,000
75-150,000
15-30,000
Neonatal Post Transfusion CMV

Incidence:
25% of seronegative infants
receiving >50ml CMV
seropositive blood

Severity
50% severe or lethal manifestations
Neonatal Transfusion CMV
Prevention by Filtering Blood
Seroconvert/Total
Filtered PRBC:
0/30
Unfiltered PRBC:
9/42
Gilbert, L1:98:228, 1989
Prevention of Post Transfusion
Infection






Don’t Transfuse
Minimize Transfusion
Limited Donors (dedicated units)
Autologous Transfusions
Erythropoetin
Donor Screening: HIV Ab, HIV NAT, HCV Ab,
HCV NAT, HBV Ag, Ab, HBc Ab, VDRL, West
Nile NAT, HTLVI/II Ab, CMV Ab, Bacterial
Culture (Platelets)
Strategies to Decrease Operative RBC
Transfusion
Hemostasis
Hemodilution
Cell salvage
DDAVP
Autologous Transfusion
Erythropoetin
Neutropenia: infection risk
% patient days with
infection
60
50
40
30
Relapse
20
10
Remission
0
0
1
100
2
3
100-500
500-1000
PMNs (/microL)
Bodey. Ann Int Med 64:328, 1966.
4
1000
5
WBC Indications 2004

PMN:

Ly:
Newborn Sepsis
Congenital/Acquired Neutropenia
PMN Dysfunction
Refractory Gram Negative Sepsis
Disseminated Varicella-Zoster
WBC transfusion:
Logistics
Donors Receive G-CSF +/- Decadron
 2-3 Hour Cytapheresis
 1010 Cells by Standards
 Donors pretested for ID markers
 Cells decay rapidly: limited value at
> 6 hours post-collection
 Quantitative impact limited

Fresh Frozen Plasma
200-250 ml of plasma containing all
clotting factors, AT III, Protein C & S.
 Compatibility Important
 Can Give: A plasma to A or O patient
B plasma to B or O patient
O plasma to O patient
AB plasma to anyone

Indications: FFP

Replacement of Coagulation Factors
 Abnormal Bleeding with coagulopathy
 Multiple factor deficiency:





Isolated factor deficiency-no concentrate


Liver disease
DIC
Reversal of Warfarin
Dilutional
Factor XI, XIII
Replacement of regulatory proteins
 TTP,

Hereditary angioedema
Not indicated for: volume expansion, reversal of
Heparin, correction of INR < 1.5
Guidelines: FFP Use



Usual dosing: Adult 10ml/Kg
Peds 10-15ml/Kg
15-20% rise in factor levels
Usually does not correct laboratory
coagulation status to “normal”
Cryoprecipitate






10-15 ml per unit (bag)
Fibrinogen
250 mg
Factor VIII 80-120 units
Von Willebrand Factor 40-70% of FFP
Factor XIII 20-30% of FFP
Fibronectin 20-40 mg
Cryoprecipitate: Dosing



1-2 Units / 10 Kg
Expect 60-100 mg/dl rise in fibrinogen
Goal: Fibrinogen 70-100 mg/dl
Platelets: Risk of Spontaneous
Hemorrhage
Count
> 40,000
20-40,000
5-20
<5
Site
Minimal
GI Mucosa
Skin, Mucus Membranes
CNS, Lung
vWD
Bleeding time (min)
40
WAS
30
AA
ASA
20
U
r
e
m
i
a
ITP
10
0
0
50
100
150
200
Platelets (/microL)
Harker. NEJM 287:155, 1972.
250
300
Prophylactic Platelet TX Guidelines
Platelet Count/μl
0-5,000
5-10,000
11-20,000
>20,000
Recommendation
Always
If Febrile of Minor Bleeding
If coagulopathy or minor
procedure
If Major Bleed or invasive
procedure
Transfused Platelets/Survival
6 units = 1 single donor unit (SDP);
available as ¼, ½ and full SDP
 Dose: child 1 unit/5-6 kg



adult 1 unit/8-10 kg
Lifespan: 7-10 Days Native
2-3 Days Transfused
Factors shortening Lifespan:
 Fever,
Sepsis
 HLA, Platelet Specific Abs
 DIC
 Product Age?
TRAP Trial
Effect of Leukodepletion on Alloimmunization
No Rx
pooled
Filter
Pooled
UV-B
Pooled
Filter
SDP
131
137
130
132
LCYTX-AB 45%
18%
21%
17%
LYCTX-AB 13%
refractory
3%
5%
4%
Number
When in Doubt: Call the Transfusion
Service!
266-2119
From ABP
Certifying Exam Content Outline

2. Transfusion and collection of blood

Understand the risk of transmitting infectious
diseases during blood transfusion(s)

Recognize that erythrocyte transfusions may be
associated with hemolytic, febrile, and urticarial
reactions

Understand the role of erythrocyte transfusions
in the management of anemia
Credits

Bruce Camitta MD
M W Lankiewicz MD