Transcript Transfusion Therapy 章人欽 醫師 高雄捐血中心 台灣血液基金會

Transfusion Therapy
章人欽 醫師
高雄捐血中心
台灣血液基金會
Outline
• Blood provision
• About blood products
• Blood Groups and Compatibilities
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products
• Blood administration
Blood Safety
Donor
education
recruitment
screening
Blood
collection
Testings
NAT
Donor
suitability
Skin disinfection
compliance with
SOP
C.U.E
Prestorage LR (CMV
,Alloimmune,FNHTR)
Pathogen
reduction
Donor Retest
Quarantined, Retrieve
Donor remark
Storage
Distribution
Transportation
Monitor of
temperature
Inspection
Storage time
Bedside
use
1. Appropriate
Use of Blood
component
2. Hemovigilance
System
3. Look back
Blood provision

Pretransfusion sample
Collector
Venipuncture will only be performed by an
appropriately trained pathology collector,
medical officer, registered nurse or anaesthetic
or theatre technician, or a trainee in direct
supervision of one of the above. Patients must
be identified before sample collection
 Ask the patient (or parent) to state their name,
date of birth and address (outpatients)
 Inspect the patient ID bracelet (inpatients) and
confirm that these details match those on the
request form

Blood provision

Pretransfusion sample
Specimen labelling
must be labelled at the bedside before
leaving the patient
 specimens must have the following identifiers

•
•
•
•
•

Full Name (Surname and First name)
Date of birth
UR number (if known)
Date and time of collection
Collectors signature or initial on the request form
labelling of tubes in advance of collection is
not acceptable due to the risk of patient
specimen mismatch
Blood provision

Pretransfusion testing
• Group and Screen



Determines the ABO and Rh(D) group
Antibody screen to detect red cell antibodies
Checking for previous transfusion and blood group
records
Blood provision

Issue of blood products from the
blood bank
• Blood products should only be picked up
when the transfusion is ready to
commence in order to ensure appropriate
storage of blood products.
• Blood products must not be stored in
ward areas or domestic fridges.
• If the transfusion cannot commence
within 30 minutes, the product must be
returned to blood bank for storage
高醫輸血作業流程
不要愛睏喔 !!!
About blood products
• Blood products
– Blood Groups and Compatibilities
– Blood Component Therapy
• Blood product modifications
– Irradiation of blood products
– Leucocyte depletion of blood products
Blood Groups and Compatibilities
Many blood groups including ABO, Rh,
Kidd, Kell, Duffy, MNS and Lewis
 The most important of these are ABO
and RhD
 Transfusion with ABO incompatible
blood can lead to severe and
potentially fatal transfusion reactions
 RhD is highly immunogenic and can
lead to red cell hemolysis in certain
settings

Blood Groups and Compatibilities
ABO Blood Groups
Blood Group
ABO antigens present on
the red cell surface
ABO antibodies present
in the plasma
Type O
nil
anti-A and anti-B
Type A
A antigen
anti-B
Type B
B antigen
anti-A
Type AB
A and B antigens
nil
Blood Groups and Compatibilities

Rhesus D (RhD) Antigen
• More than 40 different kinds of Rh antigens
• The most significant Rh antigen is RhD. When
RhD is present on the red cell surface, the red
cells are called RhD positive.
• Antibodies to RhD develop only after an
individual is exposed to RhD antigens via
transfusion, pregnancy or organ
transplantation.
• As a general rule, RhD negative individuals
should not be transfused with RhD positive red
cells, especially RhD negative girls and women
of childbearing age.
Blood Groups and Compatibilities
Blood Compatibility - Are they Compatible?
Patient Type
Compatible Red Cell
Types
Compatible Plasma Types
(FFP & Cryoprecipitate)
A
A, O
A, AB
B
B, O
B, AB
O
O
O, A, B, AB
AB
AB, A, B, O
AB
RhD Positive
RhD Positive
RhD Negative
RhD Positive
RhD Negative
RhD Negative
RhD Negative
RhD Positive
RhD Negative
Blood Groups and Compatibilities

Avoiding ABO Incompatible Transfusions
• Most ABO incompatible transfusions occur as a
result of improper patient identification at
the time of collection of the pre-transfusion
sample or administration of the blood product.
• The pre-transfusion check is carried out at
the bedside by 2 members of clinical staff to
ensure the right blood is transfused to the right
patient.
• Positive patient identification prior to blood
sample collection and labelling the specimen
tube at the bedside is critical for accurate
sample collection
About blood products
• Blood products
– Blood Groups and Compatibilities
– Blood Component Therapy
• Blood product modifications
– Irradiation of blood products
– Leucocyte depletion of blood products
血液成份療法
(Blood Component Therapy)
血液成份製備流程圖
冷凍
血漿
冷凍血漿
冷凍血漿
8hr後分離
血漿
冷凍沉澱品
冷凍 新鮮冷凍血漿
8hr內分離
解凍離心
全血
白血球濃厚液
紅血球濃厚液
Buffy coat
20-24。C, 6hr 內分離
血小板濃厚液
富含血小板之血漿
6-8hr內製備
新鮮冷凍血漿
血液成份之貯存
全血 CPDA-1
35天
1º~6 ℃
紅血球濃縮液 CPDA-1
35天
1º~6 ℃
乏白血球紅血球
35天
1º~6 º
血小板
3-5天
20 º~24℃（室溫）
24小時
1年
5年
20 º~24℃
-20℃以下
-20℃以下
1年
-20℃以下
白血球
新鮮冷凍血漿
冷凍血漿
冷凍沉澱品
為什麼使用血液成份療法？
針對病人的特殊醫療
需要，給予所缺的成
份，並且將不必要的
成份濃度降至最低。
 有效率地利用給血者
的資源。

新鮮全血 (Fresh Whole Blood)
說明：
 自捐血日起3天內之全血稱為新鮮全血。
 紅血球約100 ml，血漿150 ml，抗凝劑
35 ml，捐血後第二天尚含所有凝血因子，
白血球及血小板，Ht 32-42%。
 容量：285 ml
 貯存 / 期效：4℃，35天
新鮮全血 (Fresh Whole Blood)
功能：每單位全血可提升Hb 0.5g / dl，含有
適量的2, 3 - DPG可增加釋氧能力，並含
適當之電解質濃度。
適應症：



新生兒輸血
新生兒換血治療
小兒科心臟血管手術
全血 (Stored Whole Blood)
主要成份：紅血球100 ml，血漿150 ml，抗凝
劑35 ml，安定凝血因子120單位，Ht 32-42 %。
但缺少factor Ⅴ、 Ⅷ 等不穩定因子，雖含白
血球及血小板，但無功能。
 容量：285 ml
 貯存/期效：4℃，35天
 功能：每單位全血可提升Hb 0.5 g / dl，補充
紅血球以增加攜氧能力，及擴張循環容積。

全血 (Stored Whole Blood)
適應症：
 休克伴隨急性大量出血或手術中出血大於1000
ml或失血量大於全血量之30 % 時，可輸給全
血，而全血量 = 體重（kg）x 70 ml。
 但因儲存3天以上的全血所含不安定凝血因子
Ⅴ、Ⅷ 及血小板均功能大減，故出血時，仍
建議採用血液成份療法取代全血，可同時輸給
病患packed RBC、FFP、和 platelet
concentrate。
 1000ml以內的失血，只需輸給packed RBC。
紅血球濃厚液（Packed RBC）
主要成份：紅血球約100 ml，血漿40 ml，
安定凝血因子40 單位，亦含白血球及血
小板，但無功能。
 容量：150 ml
 貯存 / 期效：4℃，35 天
 功能：每單位血可提升 Hb 0.5 g / dl，可
補充紅血球之攜氧能力。

紅血球濃厚液（Packed RBC）
適應症：
1. 500 ml以上的出血
2. 具症狀的貧血不能用外科治療 (脾切除)或
內科治療（iron、folate、維生素B12等) 改
善之情況。
3. Hb < 9 g / dl 時，包括開刀麻醉前必須矯正
的貧血，癌症病患，有症狀的心臟衰竭病
人，angina 的病人及慢性肺阻塞病人。
4. Hb < 8 g / dl 時，如長期慢性貧血病人。
洗滌紅血球濃厚液 (Washed RBC)

主要成份：

紅血球約 90 ml，含少量白血球 (每單位約含
WBC 1 x 108，即移除原有的 WBC的90%)，亦
含少量血小板 ，缺乏血漿及凝血因子。
容量：130 ml
 貯存 / 期效：4℃，24小時

洗滌紅血球濃厚液 (Washed RBC)


功能：每單位血可提升 Hb 0.5g / dl
適應症：
1. 血漿蛋白過敏（全身性蕁麻疹反應，
IgA 缺乏症）
2. 白血球抗體引起發燒發冷輸血反應
3. 陣發性夜間血紅素尿症（PNH）
冷凍去甘油紅血球濃厚液
（Frozen Deglyceride RBC）

主要成份：
紅血球約90 ml，缺血漿，凝血因子，白血球
及血小板，攜氧能力與新鮮全血相近。
容量：120 ml
 貯存 / 期效：
- 65℃，10年，解凍後置於 4 ℃，24小時

冷凍去甘油紅血球濃厚液
（Frozen Deglyceride RBC）
功能：每單位可提升Hb 0.5 g / dl
 適應症：
1. 稀有血型病患之輸血
2. 具多項異體抗體病人的輸血之自體輸
血
3. 陣發性夜間血紅素尿症（PNH）

減除白血球之紅血球濃厚液
（Leukocyte-Poor RBC）
主要成份：
將2U之紅血球濃厚液(含SAGM)，經
白血球過濾器(filter)去除絕大部分白
血球而成， 每袋WBC<5x106。
 容量：200~350 ml/袋 (2U)
 貯存/期效：1~6℃，採血後42天

減除白血球之紅血球濃厚液
（Leukocyte-Poor RBC）
功能：
每單位可提升 Hb 0.5g / dl
 可預防 Febrile nonhemolytic
transfusion reaction，HLA
alloimmunization，CMV，HTLV-Ⅰ之感
染
 可能預防 GVHD

減除白血球之紅血球濃厚液
（Leukocyte-Poor RBC）
適應症：
1. 需長期輸血，如chemotherapy，
thalassemia，aplastic anemia，
dyserythropoiesis的病人。
2. 避免TA-GVHD。
3. 避免因輸血引起CMV感染，如器官移植病 患，
骨髓移植病患，新生兒及免疫不全之病患。
（須 WBC < 1 x 107）
4. 發燒發冷反應二次以上，需再次輸血。

新鮮冷凍血漿(Fresh Frozen Plasma)

主要成份：
自250ml全血採集後8小時內所分離之血漿，
經急速冷凍而成，保存了所有血液凝固因
子，包括第V及VIII等不安定性因子。

容量：90-120 ml

貯存 / 期效：-18℃，1年，
經 30 ~ 37℃解凍後輸用。
新鮮冷凍血漿(FFP)之適應症：
1. Anti-thrombin Ⅲ缺乏
2. Coagulation factor 如Ⅱ、Ⅴ、Ⅶ、Ⅷ、
IX、X、XIII 之缺乏
3. Coumadin引起的副作用
4. DIC，TTP，hemolytic-uremic
syndrome
5. 大量輸血所造成凝血因子的稀釋
6. 因肝病而引發多項凝血因子缺乏
7. 新生兒的換血或輸血
Transfusion audit of fresh-frozen plasma in
southern Taiwan

The indications for FFP included the following:





surgery and invasive treatment of patients who had
activated partial thromboplastin time (APTT) and
prothrombin time (PT) elevated to 1·5 times the
normal level, with a bleeding tendency
disseminated intravascular coagulation (DIC)
plasma exchange for thrombotic thrombocytopenic
purpura (TTP)
massive transfusion with coagulopathy
exchange transfusion for newborns
Vox Sanguinis (2006) 91, 270–274
The change in red blood cell (RBC)-to-plasma ratio
and inappropriate requests for fresh frozen plasma
(FFP), before and after the intervention
Transfusion audit of fresh-frozen plasma in southern Taiwan
Vox Sanguinis (2006) 91, 270–274
Internal Medicine Journal 2005; 35: 283–288
Internal Medicine Journal 2005; 35: 283–288
冷凍血漿（Frozen Plasma）

主要成份：含安定凝血因子約 90單位，缺factor
Ⅴ、Ⅷ，亦無血小板及白血球。
容量：100-150ml
 貯存 / 期效：-18℃，五年
 功能：補充穩定性凝血因子。
 適應症：



須緊急中止口服抗凝劑(warfarin) 之抗凝效果時
某些疾病之血漿交換治療
冷凍血漿(FP)
Practice Guidelines for Blood Transfusion
2007 American National Red Cross
冷凍血漿(FP)
Practice Guidelines for Blood Transfusion
2007 American National Red Cross
冷凍沉澱（Cryoprecipitates）

製作及成份：

全血採血後8小時內依新鮮冷凍血漿分離程序於-80℃冷凍
櫃或乾冰酒精浴中急速冷凍後，於1-6℃解凍再經離心分離
移除血漿後的餘留不溶物，懸浮於血漿中；於1小時內再冷
凍於-20℃以下。

每單位約含45IU的factor VIII，125mg纖維蛋白原，40IU
von-Willebrand因子，fibronectin 23mg及20-30IU factor XIII

容量：15~20 ml

貯存 / 期效：-20℃，1年
冷凍沉澱（Cryoprecipitates）
適應症：
1. Coagulation factor Ⅷ 缺乏
2. Von Willebrand’s disease
3. DIC，Sepsis
4. Hypofibrinogenemia
(fibrinogen≦100 mg / dl，若出血時，
則≦150 mg / dl)
血小板濃厚液(Platelet Concentrate)
分為兩類，主要成份：
(a) 傳統血小板濃厚液，每1單位中含
血小板約 2~3 x 1010，並含少量白血球及紅血球。
(b) 分離術血小板(相當於12單位傳統血小板) ，每袋含
血小板 3 x 1011，亦含少量白血球及紅血球。
 容量：(a) 30 ~ 40 ml (b) 200 ~ 300 ml
 貯存 / 期效：20~24℃恆溫振盪器內，5 天


功能：(a) 每單位可提升血小板數 2500 /μl
(b) 每單位可提升血小板數 60000 /μl
血小板濃厚液 (Platelet Concentrate)
適應症：
1. 血小板 < 10,000 – 20,000 /μl，
白血病，癌症 之治療，再生不良性貧血
2. 血小板 < 80,000 -100,000 /μl，
要腦部開刀的 病人
3. 血小板 < 50,000 /μl，
接受外科手術之病人
4. 血小板 < 50000 /μl，
具出血傾向，應提升至5萬
血小板濃厚液 (Platelet Concentrate)
適應症：
5. 大量輸血及DIC，因缺少血小板引起
的出血，ITP有危及生命的出血
6. 先天性血小板機能不良者
7. 後天性血小板機能不良者(uremia)
8. 心臟手術使用心肺機引起血小板功能
不良
Platelet transfusion

Blood Group?  Principles
Platelet Product Group
Patient’s
ABO Group
First Choice
O
O
A
Second
Choice
Third
Choice
A
B
O
B
B
A
O
AB
AB
B or A
O
Platelet transfusion

Platelet Administration
• Use a fresh administration set for platelets.
Do not transfuse though a standard filter
straight after red cells as platelets will get
caught up in fibrin strands /debris etc.
• Platelet transfusion must be completed
within 4 hours of spiking pack. Occasionally
platelets are given over 30 minutes, but this
may contribute to an increased risk of some
reactions (fever/chill) and fluid overload.
• In patients receiving multiple other fluids etc
give at a rate of 3ml/kg/hr over 2-3 hours.
白血球濃厚液
(White Blood Cells Concentrate)
血液採集6小時內,將室溫(20~24°C)存放之
新鮮血液離心分離出之buffy coat稱之
 成分:1單位 - 250ml全血製作而來，體積
20~30ml，含1x109 白血球，混含部份血小
板及紅血球
 貯存 / 期效：

20~24℃，24小時，在6小時內
儘速輸用。
白血球濃厚液 (WBC Concentrate)

功能：
治療 neutropenia 時合併之嚴重細菌或黴菌感染。

適應症：病人需要有所有下列的情形，
1. 嗜中性球減少症 ( neutrophils < 500 /μl)。
2. 持續高燒 24小時，以第3代抗生素治療無效者。
3. 骨髓檢查顯示 myeloid series 再生不良。
4. 病人骨髓功能有復原的機會。
白血球濃厚液 (WBC Concentrate)
注意事項：
1.此血液製品中混有血小板濃厚液，對病人有
益，因缺乏白血球的病人亦常缺乏血小板。
2.連續輸用一星期後，觀察病人恢復的情況，有
部分病人發生持續高燒及嚴重肺部反應，此時
應立即停止輸用白血球。
3.輸白血球濃厚液和輸血漿相同，亦有疾病傳播
的危險。
4.不需做預防的輸注。

Volumes and rates for
transfusion of blood products
很專心喔!!
About blood products
• Blood products
– Blood Groups and Compatibilities
– Blood Component Therapy
• Blood product modifications
– Irradiation of blood products
– Leucocyte depletion of blood products
Blood product modifications

Irradiation of blood products
 by
gamma irradiation of cellular blood
products (whole blood, red blood cells,
platelets, granulocytes)
 using a dedicated blood irradiator with a
long half-life gamma emitting source
 to prevent Transfusion Associated GraftVersus Host Disease (TA-GVHD)
occurs 10-14 days post transfusion
 fever, skin rash, hepatitis, diarrhea and
pancytopenia
 fatal in more than 90% of cases

Blood product modifications

Irradiation of blood products

Irradiation of RBCs and whole blood
results in reduced post transfusion red cell recovery
and increases the rate of efflux of intracellular
potassium  no clinically significant effect on red
cell pH, glucose, 2,3 DPG levels or ATP
 Packs irradiated within 14 days of collection expire
28 days after collection
 Packs irradiated more than 14 days after collection
expire either 5 days after irradiation OR at original
expiry of pack, whichever comes first
 In patients where hyperkalemia is a concern, red
cells should be transfused within 24 hours of
irradiation. Examples include large volume neonatal
transfusion such as exchange transfusion, ECMO or
rapid large volume transfusion

Blood product modifications

Irradiation of blood products
 Irradiation
of platelets
has not been shown to cause any clinically
significant change in platelet function.
 Platelets may be irradiated at any stage
during their 5 day storage life.

 Irradiation
of granulocytes
conflicting evidence of irradiation damage to
granulocytes.
 Granulocytes should be transfused as soon
as possible after collection and irradiation.

Blood product modifications

Irradiation of blood products
 Labelling
About blood products
• Blood products
– Blood Groups and Compatibilities
– Blood Component Therapy
• Blood product modifications
– Irradiation of blood products
– Leucocyte depletion of blood products
Blood product modifications

Leucocyte depletion - 1
 Removal
of white cells from cellular
blood products (whole blood, red blood
cells, platelets) to a level of <1 x 106 per
pack
 Why?
Reduces alloimmunisation and platelet
refractoriness
 Reduces frequency of recurrent febrile reactions
 Reduces the risk of CMV transmission
 Reduces the risk of potential immunomodulatory
effects

Blood product modifications

Leucocyte depletion - 2

Which patients?

Immunocompromised patients
1) Hematology/Oncology patients
2) Malignancy
3) Transplant recipients (bone marrow and solid
organ)
4) Severe Combined Immune Deficiency Syndrome
(SCIDS), Common Variable Immune Deficiency
(CVID)



Patients requiring chronic transfusion
Patients less than 12 months of age
Intrauterine and exchange transfusions
Blood product modifications

Leucocyte depletion - 3
 Which
filter should I use?
Blood product modifications

Leucocyte depletion
 Fresh
-4
Frozen Plasma (FFP) and
cryoprecipitate have extremely low
numbers of viable cells and do not
require leucocyte depletion - they
should be administered via a
standard filter.
白血球去除過濾器之使用
白血球去除過濾器之使用
Accumulation of extracellular sVEGF (ng/unit) in WB and
SAGM blood during storage for 35 days at 4°;C.
Transfusion, Vol. 39, No. 10, 1078-1083, October 1999
有這樣舒服嗎?
Outline
• Blood provision
• About blood products
• Blood Groups and Compatibilities
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products
• Blood administration
Blood administration
•
•
•
•
•
Patient preparation
Pretransfusion check
Blood Transfusion Record
Transfusion Tag
Care and monitoring of transfused
patients
Blood administration

Patient Preparation
 appropriate IV access
 written order for transfusion
 benefits/risks of transfusion
discussed
 an opportunity to have any
questions answered
Blood administration

Pretransfusion check - 1
 Safe
transfusion
a
final patient identity check at the
patient bedside before blood
administration
 to ensure the right blood is given to
the right patient.
 Signing
 the
the blood transfusion record
check has been completed prior to
transfusion
 no discrepancy was identified
Blood administration

Pretransfusion check - 2



Check blood product for any signs of leakage,
clumps or abnormal color
Patient identification
 Check name, DOB and UR on the Blood
Transfusion Record and pack tag/label and on
the patient's wristband. Are they identical?
Blood product identification
 Check the pack number on the Blood
Transfusion Record, pack tag/label and the
product. Are they identical?
Blood administration

Pretransfusion check - 3

Blood Group
 Check the blood group (ABO and RhD) on the
Blood Transfusion Record (this form reports
compatibility), pack tag/label and the product. Do they
match?


Check expiry date on the pack
Check medical orders



product type, special requirements (eg irradiation, leucocyte
depletion)
administration requirements (eg volume, rate)
Complete documentation


sign, date, time the Blood Transfusion Record
file in the patient's medical record
Blood administration

Blood Transfusion Record
Blood administration

Transfusion Tag
Blood administration

Care and monitoring
 temperature,
pulse, respiratory rate
and blood pressure should be
measured and recorded:
before the start of each pack of blood or
blood product
 at 15 minutes after commencement
 hourly during transfusion
 at the completion of each pack


may require more frequent observations
particularly in unstable or unconscious
patients
Blood administration

Care and monitoring
more frequent vital signs should be taken if
the patient has an unstable underlying
condition or the patient becomes unwell or
shows signs of a transfusion reaction
 Patients should be observed during the first
15 minutes of transfusion as some lifethreatening reactions may occur after the
infusion of only a small amount of blood.
 Where possible, patients should be informed of
possible symptoms of a transfusion reaction
and should inform staff immediately if they feel
unwell during transfusion.

General Transfusion Practices
How to manage blood transfusion?


Pretransfusion-IV route and
sampling
Manage Blood transfusion
謝謝聆聽 !!
捐血快樂 用血安全