basics of transfusion therapy resident education lecture series

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

LINMANNEJM 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

30

0

100

40

0

Blood Volume Blood VolumeBlood Volume

100

30

0

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 BLEEDINGEXCHANGEPLASMA NEEDED

WASHED REMOVE PLASMA

FROZEN RARE RBC PHENOTYPE

IRRADIATED IMMUNODEFICIENT CMV NEGATIVE 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 HGBDiureticExchange

Transfusion Volume

10cc/Kg PRBC 2.4 GM% in HGB

10cc/kg = X cc/kg 2.4 GM% Desired HGB rise

PRBC cc = Blood Volume x (HGBF- HGBI)

HGBT

BV=70cc/KG, 80-90cc/KG newborn

Hemolytic Transfusion Reactions

Acute HTR 1/25,000Fatal Acute HTR 1-4/1,000,000

Delayed HTR 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/BagSerumRed cellsUrine

Acute Hemolysis: Diagnosis

Do a direct antiglobulin test on post-transfusion sample

Obtain post-transfusion blood and urine and inspect visually

Recheck paperwork Recheck ABO type of unit and pre-and

post-transfusion specimens Run urinalysis - to check for

hemoglobinuria

Cause of Acute HTR ABO incompatibility:source of error

10% at phlebotomy/labeling23% in Transfusion Lab67% transfusion administration (at the

bedside)

Nonhemolytic Transfusion Reactions

Leukocyte Associated FNHTR Transfusion GVHD Neonatal Neutropenia

Immunoglobulin Associated Urticaria/Fever Ig E TRALI

Platelet Associated Post transfusion Purpura Neonatal

Thrombocytopenia

Metabolic/ Physical Citrate Toxicity Hypothermia Circulatory Overload

Massive Transfusions Haemostatic Abnormalities Metabolic complications Hgb-O2 Curve Shift

TRANSFUSION-RELATED INFECTION

Risk of Transfusion-Transmitted Infection

HIV 1 in 2,000,000Hepatitis C 1 in 2,000,000Hepatitis B 1 in 175,000Hepatitis A RareHTLV I/II 1 in 3,000,000Bacteria 1/3,000 (for platelets)

Malaria, T Cruzi, Babesia, Yersinia, Syphilis, Lyme, CJD, West Nile Virus…??

Post Transfusion HCV

Percent Number

Incidence 5-10 150-300,000Chronic 50 75-150,000Cirrhosis 20 15-30,000

Neonatal Post Transfusion CMV

Incidence:25% of seronegative infantsreceiving >50ml CMVseropositive 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

HemostasisHemodilutionCell salvage

DDAVPAutologous Transfusion

Erythropoetin

Neutropenia: infection risk

0

10

20

30

40

50

60

0 1 2 3 4 5

PMNs (/microL)

% p

ati

en

t d

ay

s w

ith

in

fec

tio

n

100 100-500 500-1000 1000

Relapse

Remission

Bodey. Ann Int Med 64:328, 1966.

WBC Indications 2004

PMN:Newborn SepsisCongenital/Acquired

NeutropeniaPMN DysfunctionRefractory Gram Negative

Sepsis Ly: 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 patientO plasma to O patientAB plasma to anyone

Indications: FFP

Replacement of Coagulation Factors Abnormal Bleeding with coagulopathy

Multiple factor deficiency: Liver disease DIC Reversal of Warfarin Dilutional

Isolated factor deficiency-no concentrate 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 VIII80-120 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 Site > 40,000 Minimal20-40,000 GI Mucosa 5-20 Skin, Mucus Membranes < 5 CNS, Lung

0

10

20

30

40

0 50 100 150 200 250 300

Platelets (/microL)

Ble

edin

g t

ime

(min

)

ITP

AA

WAS

ASA

Uremia

vWD

Harker. NEJM 287:155, 1972.

Prophylactic Platelet TX Guidelines

Platelet Count/μl Recommendation

0-5,000 Always 5-10,000 If Febrile of Minor Bleeding 11-20,000 If coagulopathy or minor

procedure >20,000 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 TrialEffect of Leukodepletion on Alloimmunization

No Rxpooled

FilterPooled

UV-BPooled

FilterSDP

Number 131 137 130 132

LCYTX-AB 45% 18% 21% 17%

LYCTX-ABrefractory

13% 3% 5% 4%

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 MDM W Lankiewicz MD