BLOOD COMPONENT THERAPY

2010

Terry Gernsheimer, MD

Contributor: Meghan Delaney, DO

©1995-2010 Puget Sound Blood Center

921 Terry Avenue Seattle, WA 98104-1256

Puget Sound Blood Center Transfusion Service and Physician on Call for Consultation (206) 292-6525

University District Laboratory (206) 522-2462 East Side Laboratory (425) 453-4560

South Center Laboratory (425) 656-7900

TRANSFUSION CONSULTATIONS The Puget Sound Blood Center Transfusion Services Laboratories operate 24 hours a day. Questions about samples, procedures, blood component orders or delivery should be directed to the University District Laboratory (from UWMC, Seattle Children's Hospital, Northwest Hospital, & Swedish Ballard) or the Central Transfusion Laboratory (from other hospitals). A Blood Center physician with full responsibility for transfusion services is on call at all times to resolve problems or provide medical consultation. The Blood Center physician on call may be paged by contacting any of the Transfusion Service Laboratories.

BLOOD COMPONENT THERAPY

2010

Terry Gernsheimer, MD

Contributor: Meghan Delaney, DO

©1995-2010 Puget Sound Blood Center

921 Terry Avenue Seattle, WA 98104-1256

Puget Sound Blood Center Transfusion Service and Physician on Call for Consultation (206) 292-6525

University District Laboratory (206) 522-2462 East Side Laboratory (425) 453-4560

South Center Laboratory (425) 656-7900

TRANSFUSION CONSULTATIONS The Puget Sound Blood Center Transfusion Services Laboratories operate 24 hours a day. Questions about samples, procedures, blood component orders or delivery should be directed to the University District Laboratory (from UWMC, Seattle Children's Hospital, Northwest Hospital, & Swedish Ballard) or the Central Transfusion Laboratory (from other hospitals). A Blood Center physician with full responsibility for transfusion services is on call at all times to resolve problems or provide medical consultation. The Blood Center physician on call may be paged by contacting any of the Transfusion Service Laboratories.

RED BLOOD CELLS Description ne unit of red blood cells ( BC) contains appro imately 2 mL red blood cells, mL ptisol AS (a solution added to e tend storage life) and mL plasma. All red blood cell transfusions must be AB h compatible with the recipient, so, in dire emergency, type negative can be used for all patients. BC do not provide viable platelets, nor do they provide clinically significant amounts of coagulation factors.

BC must be stored between C and have a shelf life of 42 days. ndications

BC are indicated for patients with symptomatic anemia who are not treatable, within a reasonable amount of time considering their symptoms, with specific therapy such as iron, vitamin B 2, folic acid or erythropoietin. Therapeutic ffect n a ilogram adult, each unit should increase the hematocrit by 4 .

EMERGENCY RED BLOOD CELL USAGE Many hospitals in the Puget Sound area have a limited supply of uncrossmatched type BC's to be used for a bleeding patient in dire emergency. Type , h negative BC's can be transfused to people of any type with only a slight ris of hemolysis. This ris increases in patients who have previously been transfused or pregnant and may have formed antibodies. Type , h positive BC's can be used for women who are beyond childbearing age and in males over the age of . When h positive

BC s are used in an h negative patient, there is a chance of D immuni ation, and therefore should be used only in life threatening emergencies. When type , h positive BC's are available, the following algorithm should be followed . or all patients under 16, use type , h negative BC's. 2. or females under 50, use type , h negative BC's. . or males older than 16 and omen beyond childbearing, use type , h positive BC's. 4. f the supply of the appropriate h type has been e hausted, BC's of the other type should be used. hogam should be given within 4 hours of giving h positive blood to an h negative woman of childbearing age. f large amounts of h positive blood has been given red cell e change may be necessary. f no uncrossmatched blood is available, type BC's of the appropriate h type that is being held for another patient may be used in life threatening emergency. The Puget Sound Blood Center must be informed immediately that this has occurred so that these units can be replaced. A signed ustification is needed for all use of uncrossmatched blood.

S ecial Considerations in Pediatric Red Cell Transfusions There is concern for to icity of red cell additive solutions containing adenine & mannitol to cause liver & renal dysfunction if given in large doses. The storage age of the red cell unit can affect e tracellular potassium in the unit too much potassium can cause cardiac to icity. or these reasons, the choice of red cell products is based on the dose. Definitions outine or small volume transfusion typically mL g ( ndications outine transfusion, anemic N CU patient from blood draws) Large volume transfusion 2 2 mL g

( ndications UT, cardiac surgery with bypass, CM , trauma) nfant blood protocol sample from baby 4m used until baby is 4m, to

prevent e cess phlebotomy. Products ( ) Pedi pac BC CPD Divided Unit

olume mL ( 4of a regular si ed rbc unit plus preservative) Preservative CPD (contains anticoagulant citrate, phosphate, de trose,

does not contain mannitol or adenine) Shelf life days fresh , e pires on day Attributes Leu oreduced, HbS negative, rradiated (if child 4m or if

indicated otherwise) HCT of unit ndications Used for small or large volume transfusions

Dose mL g will increase Hb 2 g dL or Hct (2) Assigned ali uots BC AS Divided Unit

olume 4 mL ( of a regular si ed rbc unit plus preservative) Preservative Additive ptisol AS (similar as CPD, plus mannitol &

adenine) Shelf life 42 days, one set of units assigned to one patient Attributes Leu oreduced, HbS negative, rradiated (if child 4m or if indicated otherwise) HCT of unit ndications Used for small volume transfusions, reduces donor e posure

because all ali outs are ept for one patient. Dose mL g will increase Hb . g dL

( ) econsituted Whole Blood Used for manual e change transfusions. AS leu ocyte reduced, HbS negative, irradiated red cells and AB P. Platelets are not supplied in this product post procedure platelet count should be obtained.

PLATELETS Description Platelets are essential for the initial phase of hemostasis. Platelet concentrates also contain about mL of plasma and small numbers of red blood cells and leu ocytes. Platelet units must be maintained at room temperature and agitated during storage. Pooled random donor latelet concentrates are prepared from platelets that have been harvested by centrifuging units of whole blood. Up to units of platelets, each from a separate donor, can be pooled into a single bag for transfusion. Platelets e pire 4 hours after pooling. All units are from the same AB type. f AB compatible platelets are unavailable, AB incompatible platelets can be substituted with very little ris . The usual adult dose is 4 units of pooled random donor platelets. A heresis latelets are collected from a single donor and are e uivalent to 4 pooled units. An apheresis platelet concentrate contains 2 4 mL of plasma. They may be collected as a random unit (random apheresis platelets) or be obtained for a specific recipient from a family member or a volunteer HLA compatible directed donor. Apheresis platelets e pire 4 hours after processing for release from the blood center unless incubated storage is available at the local hospital.

RED BLOOD CELLS Description ne unit of red blood cells ( BC) contains appro imately 2 mL red blood cells, mL ptisol AS (a solution added to e tend storage life) and mL plasma. All red blood cell transfusions must be AB h compatible with the recipient, so, in dire emergency, type negative can be used for all patients. BC do not provide viable platelets, nor do they provide clinically significant amounts of coagulation factors.

BC must be stored between C and have a shelf life of 42 days. ndications

BC are indicated for patients with symptomatic anemia who are not treatable, within a reasonable amount of time considering their symptoms, with specific therapy such as iron, vitamin B 2, folic acid or erythropoietin. Therapeutic ffect n a ilogram adult, each unit should increase the hematocrit by 4 .

EMERGENCY RED BLOOD CELL USAGE Many hospitals in the Puget Sound area have a limited supply of uncrossmatched type BC's to be used for a bleeding patient in dire emergency. Type , h negative BC's can be transfused to people of any type with only a slight ris of hemolysis. This ris increases in patients who have previously been transfused or pregnant and may have formed antibodies. Type , h positive BC's can be used for women who are beyond childbearing age and in males over the age of . When h positive

BC s are used in an h negative patient, there is a chance of D immuni ation, and therefore should be used only in life threatening emergencies. When type , h positive BC's are available, the following algorithm should be followed . or all patients under 16, use type , h negative BC's. 2. or females under 50, use type , h negative BC's. . or males older than 16 and omen beyond childbearing, use type , h positive BC's. 4. f the supply of the appropriate h type has been e hausted, BC's of the other type should be used. hogam should be given within 4 hours of giving h positive blood to an h negative woman of childbearing age. f large amounts of h positive blood has been given red cell e change may be necessary. f no uncrossmatched blood is available, type BC's of the appropriate h type that is being held for another patient may be used in life threatening emergency. The Puget Sound Blood Center must be informed immediately that this has occurred so that these units can be replaced. A signed ustification is needed for all use of uncrossmatched blood.

S ecial Considerations in Pediatric Red Cell Transfusions There is concern for to icity of red cell additive solutions containing adenine & mannitol to cause liver & renal dysfunction if given in large doses. The storage age of the red cell unit can affect e tracellular potassium in the unit too much potassium can cause cardiac to icity. or these reasons, the choice of red cell products is based on the dose. Definitions outine or small volume transfusion typically mL g ( ndications outine transfusion, anemic N CU patient from blood draws) Large volume transfusion 2 2 mL g

( ndications UT, cardiac surgery with bypass, CM , trauma) nfant blood protocol sample from baby 4m used until baby is 4m, to

prevent e cess phlebotomy. Products ( ) Pedi pac BC CPD Divided Unit

olume mL ( 4of a regular si ed rbc unit plus preservative) Preservative CPD (contains anticoagulant citrate, phosphate, de trose,

does not contain mannitol or adenine) Shelf life days fresh , e pires on day Attributes Leu oreduced, HbS negative, rradiated (if child 4m or if

indicated otherwise) HCT of unit ndications Used for small or large volume transfusions

Dose mL g will increase Hb 2 g dL or Hct (2) Assigned ali uots BC AS Divided Unit

olume 4 mL ( of a regular si ed rbc unit plus preservative) Preservative Additive ptisol AS (similar as CPD, plus mannitol &

adenine) Shelf life 42 days, one set of units assigned to one patient Attributes Leu oreduced, HbS negative, rradiated (if child 4m or if indicated otherwise) HCT of unit ndications Used for small volume transfusions, reduces donor e posure

because all ali outs are ept for one patient. Dose mL g will increase Hb . g dL

( ) econsituted Whole Blood Used for manual e change transfusions. AS leu ocyte reduced, HbS negative, irradiated red cells and AB P. Platelets are not supplied in this product post procedure platelet count should be obtained.

PLATELETS Description Platelets are essential for the initial phase of hemostasis. Platelet concentrates also contain about mL of plasma and small numbers of red blood cells and leu ocytes. Platelet units must be maintained at room temperature and agitated during storage. Pooled random donor latelet concentrates are prepared from platelets that have been harvested by centrifuging units of whole blood. Up to units of platelets, each from a separate donor, can be pooled into a single bag for transfusion. Platelets e pire 4 hours after pooling. All units are from the same AB type. f AB compatible platelets are unavailable, AB incompatible platelets can be substituted with very little ris . The usual adult dose is 4 units of pooled random donor platelets. A heresis latelets are collected from a single donor and are e uivalent to 4 pooled units. An apheresis platelet concentrate contains 2 4 mL of plasma. They may be collected as a random unit (random apheresis platelets) or be obtained for a specific recipient from a family member or a volunteer HLA compatible directed donor. Apheresis platelets e pire 4 hours after processing for release from the blood center unless incubated storage is available at the local hospital.

ndications

. To revent bleeding due to thrombocyto enia The threshold of thrombocytopenia at which bleeding may occur will vary depending on the patient's clinical condition. n general, spontaneous bleeding does not occur until the platelet count falls below , , µL. The recommended trigger for prophylactic platelet transfusions in patients undergoing chemotherapy or hematopoietic stem cell transplantation is

, µL. ther coe isting clinical conditions may increase this threshold .

2. In a bleeding atient a platelet count above , should be maintained. In a surgical atient, the necessary platelet count varies depending on the procedure. or most surgeries , , µL will be ade uate. or high ris procedures, such as neurologic or ophthalmologic surgeries, , µL is recommended

. Abnormal latelet function may be congenital, or due to medications, sepsis, malignancy, tissue trauma, obstetrical complications, e tra corporeal circulation, or organ failure such as liver or idney disease. Spontaneous bleeding may then occur at higher platelet counts. f platelet dysfunction is present, the patient with a disrupted vascular system (e.g. trauma or surgery) will re uire a higher platelet count to achieve hemostasis. 4 Family donor or HLA matched latelets are indicated when patients have become refractory to random donor platelet transfusions due to alloimmuni ation.

. n several situations platelet transfusions may not be indicated unless there is significant bleeding. n autoimmune thrombocyto enias (e.g. TP) transfusion increments are usually poor and platelet survival is short. Platelet transfusions may be contraindicated in patients with thrombotic thrombocyto enic ur ura (TTP) unless there is clinically significant bleeding.

. n ediatric atients, the usual platelet dose is unit whole blood platelet per g child, or mL g. A , µL rise is e pected. Therapeutic ffect

E ected Platelet Increment

unit 4 units units . 4. .

lb 2 g

22, ul , ul 2, ul

lb 4 g

, 4 , ,

lb g

,4 , 44,

2 lb g

, 22, ,

n a patient with a normal si ed spleen and without platelet antibodies. The survival of transfused platelets averages to days but will decrease if a consumptive process is present. Correction of a prolonged bleeding time in platelet dysfunction will depend on whether a condition e ists that will affect the transfused platelets as well (e.g., antiplatelet agents, uremia).

FRESH FRO EN PLASMA (FFP) AND THAWED PLASMA Description ne unit of P or thawed plasma is the plasma ta en from a unit of whole blood. P is fro en within eight hours of collection. P contains all coagulation factors in normal concentrations. Thawed plasma may be transfused up to days after thawing and contains slightly decreased levels of actor ( ) and decreased actor levels (4 ). Plasma is free of red blood cells, leu ocytes and platelets. ne unit is appro imately 2 mL and must be AB compatible. h factor need not be considered. Since there are no viable leu ocytes, plasma does not carry a ris of CM transmission or raft s. Host Disease ( HD). ndications

Plasma transfusion is indicated in patients with documented coagulation factor deficiencies and active bleeding, or who are about to undergo an invasive procedure. Deficiencies may be congenital or ac uired secondary to liver disease, warfarin anticoagulation, disseminated intravascular coagulation, or massive replacement with red blood cells and crystalloid colloid solutions.

P should not be used for Hemophilia B ( actor ) deficiency unless actor concentrate is not available. P, but not thawed plasma, can be

used for actor deficiency. ecombinant or actor concentrates should be used to replace actor . Usually, there is an increase of at least . times the normal PT or PTT, or an N ≥ . before clinically important factor deficiency e ists.

This corresponds to factor levels of normal. Reversal of arfarin anticoagulation with plasma is indicated only if significant bleeding or ris is present. ften it will re uire recurrent transfusion to maintain normal factor levels. therwise, reversal can be achieved by giving itamin or holding warfarin two to three days prior to a planned procedure. apid reversal for life threatening bleeding may be achieved with recombinant actor a (Novo ).

Plasma is indicated in the treatment of thrombotic thrombocyto enic ur ura (TTP), usually in con unction with plasma e change.

Plasma should not be used for volume e pansion unless the patient also has a significant coagulopathy and is bleeding. Pediatric

atients dosing is mL g, to provide 2 rise in factor levels.

Plasma - Dosage

olume of Unit Plasma 2 2 mL mL plasma contains u coagulation factors

1 Unit contains 220 u coagulation factors actor recovery with transfusion 4

1 Unit rovides 80 u coagulation factors g . plasma volume of dL ( . L) u 2. u dL 2. (of normal u dL) dL

In a 70 g Patient: 1 Unit Plasma increases most factors 2 5 4 Units Plasma increase most factors 10

nitial dose of P

cc g (round up to nearest 2 cc) units P 2 cc unit P

ndications

. To revent bleeding due to thrombocyto enia The threshold of thrombocytopenia at which bleeding may occur will vary depending on the patient's clinical condition. n general, spontaneous bleeding does not occur until the platelet count falls below , , µL. The recommended trigger for prophylactic platelet transfusions in patients undergoing chemotherapy or hematopoietic stem cell transplantation is

, µL. ther coe isting clinical conditions may increase this threshold .

2. In a bleeding atient a platelet count above , should be maintained. In a surgical atient, the necessary platelet count varies depending on the procedure. or most surgeries , , µL will be ade uate. or high ris procedures, such as neurologic or ophthalmologic surgeries, , µL is recommended

. Abnormal latelet function may be congenital, or due to medications, sepsis, malignancy, tissue trauma, obstetrical complications, e tra corporeal circulation, or organ failure such as liver or idney disease. Spontaneous bleeding may then occur at higher platelet counts. f platelet dysfunction is present, the patient with a disrupted vascular system (e.g. trauma or surgery) will re uire a higher platelet count to achieve hemostasis. 4 Family donor or HLA matched latelets are indicated when patients have become refractory to random donor platelet transfusions due to alloimmuni ation.

. n several situations platelet transfusions may not be indicated unless there is significant bleeding. n autoimmune thrombocyto enias (e.g. TP) transfusion increments are usually poor and platelet survival is short. Platelet transfusions may be contraindicated in patients with thrombotic thrombocyto enic ur ura (TTP) unless there is clinically significant bleeding.

. n ediatric atients, the usual platelet dose is unit whole blood platelet per g child, or mL g. A , µL rise is e pected. Therapeutic ffect

E ected Platelet Increment

unit 4 units units . 4. .

lb 2 g

22, ul , ul 2, ul

lb 4 g

, 4 , ,

lb g

,4 , 44,

2 lb g

, 22, ,

n a patient with a normal si ed spleen and without platelet antibodies. The survival of transfused platelets averages to days but will decrease if a consumptive process is present. Correction of a prolonged bleeding time in platelet dysfunction will depend on whether a condition e ists that will affect the transfused platelets as well (e.g., antiplatelet agents, uremia).

FRESH FRO EN PLASMA (FFP) AND THAWED PLASMA Description ne unit of P or thawed plasma is the plasma ta en from a unit of whole blood. P is fro en within eight hours of collection. P contains all coagulation factors in normal concentrations. Thawed plasma may be transfused up to days after thawing and contains slightly decreased levels of actor ( ) and decreased actor levels (4 ). Plasma is free of red blood cells, leu ocytes and platelets. ne unit is appro imately 2 mL and must be AB compatible. h factor need not be considered. Since there are no viable leu ocytes, plasma does not carry a ris of CM transmission or raft s. Host Disease ( HD). ndications

Plasma transfusion is indicated in patients with documented coagulation factor deficiencies and active bleeding, or who are about to undergo an invasive procedure. Deficiencies may be congenital or ac uired secondary to liver disease, warfarin anticoagulation, disseminated intravascular coagulation, or massive replacement with red blood cells and crystalloid colloid solutions.

P should not be used for Hemophilia B ( actor ) deficiency unless actor concentrate is not available. P, but not thawed plasma, can be

used for actor deficiency. ecombinant or actor concentrates should be used to replace actor . Usually, there is an increase of at least . times the normal PT or PTT, or an N ≥ . before clinically important factor deficiency e ists.

This corresponds to factor levels of normal. Reversal of arfarin anticoagulation with plasma is indicated only if significant bleeding or ris is present. ften it will re uire recurrent transfusion to maintain normal factor levels. therwise, reversal can be achieved by giving itamin or holding warfarin two to three days prior to a planned procedure. apid reversal for life threatening bleeding may be achieved with recombinant actor a (Novo ).

Plasma is indicated in the treatment of thrombotic thrombocyto enic ur ura (TTP), usually in con unction with plasma e change.

Plasma should not be used for volume e pansion unless the patient also has a significant coagulopathy and is bleeding. Pediatric

atients dosing is mL g, to provide 2 rise in factor levels.

Plasma - Dosage

olume of Unit Plasma 2 2 mL mL plasma contains u coagulation factors

1 Unit contains 220 u coagulation factors actor recovery with transfusion 4

1 Unit rovides 80 u coagulation factors g . plasma volume of dL ( . L) u 2. u dL 2. (of normal u dL) dL

In a 70 g Patient: 1 Unit Plasma increases most factors 2 5 4 Units Plasma increase most factors 10

nitial dose of P

cc g (round up to nearest 2 cc) units P 2 cc unit P

Therapeutic ffect Usually an increase in factor levels of at least will be

needed for any significant change in coagulation status, so the usual dose is four units, but the amount will vary depending on the patient's si e and clotting factor levels. Hematology consultation is advised concerning the dose of plasma.

Recommended Coagulation Parameters for Common Procedures

Plt

Count INR

Lumbar Puncture , .

Paracentesis , 2.

Thoracentesis , .

Transbronchial Lung Biopsy

, .

Subclav Line , .

enal Biopsy , .

Liver Biopsy , .

Hic mann, roshong Catheters

, .

These numbers assume normal latelet function Conditions that may

affect platelet function include renal failure, medications, leu emias and myelodysplasias, and congenital disorders. Bleeding Time is a oor

redictor of surgical bleeding The Usefulness of Platelet Function Analysis (PFA) in redicting surgical bleeding is un no n CRYOPRECIPITATE (CRYO) Description Cryoprecipitate is prepared from plasma and contains fibrinogen, von Willebrand factor, factor , factor and fibronectin. Cryoprecipitate is the only ade uate fibrinogen concentrate available for intravenous use. Cryoprecipitate is available in pre pooled concentrates of si units. ach unit from a separate donor is suspended in mL plasma prior to pooling. or use in small children, up to 4 single units can be ordered.

ach unit provides about mg of fibrinogen. ndications for Cryoprecipitate

Cryoprecipitate is indicated for bleeding or immediately prior to an invasive procedure in patients with significant hypofibrinogenemia ( mg dL). Cryoprecipitate should not be used for patients with von Willebrand disease or Hemophilia A ( actor deficiency) unless they do not (or are not nown to) respond to DDA P and recombinant and or virally inactivated preparations are not available. t is not usually given for

actor deficiency, as there are virus inactivated concentrates of this protein available. Cryoprecipitate is sometimes useful if platelet dysfunction associated with renal failure does not respond to dialysis or DDA P.

Usage and Therapeutic ffect

Cryo reci itate Dosage

bag contains mg ibrinogen bags ( pool) contains 2 mg ibrinogen ecovery with transfusion 6 bag ool cryo reci itate rovides 1560 mg Fibrinogen g . plasma volume of dL ( . L) mg 4 mg dL provided by bag pool of cryoprecipitate dL

In a 70 g Patient: 6 bags (1 ool) of cryo raises Fibrinogen 45 mg dL

Fibrinogen re lacement ffect can be monitored by fibrinogen level assay and clinical response. Pediatric dosing for cyroprecipitate is unit per g child, which should increase fibrinogen by mg dL. To re lace factor III or von Willebrand factor: When specific factor concentrates are unavailable, the usual adult dose is a pool of 2 bags. Appro imately units of factor and von Willebrand factor are provided per bag. A single donor may be used repeatedly for a young or mildly affected patient to limit donor e posures. Fibrin glue: Although single units of cryoprecipitate are available for use in the preparation of fibrin glue to be applied locally for surgery, commercially available, virally inactivated concentrates have a higher fibrinogen concentration and are preferred for this purpose (Tisseel ). A patient may donate autologous plasma for processing into cryoprecipitate prior to a planned surgical procedure. TRANSFUSION RELATED RIS S nfectious is Unit

Blood Centers began clinical trials in April to screen blood with a PC test for HC NA and H DNA. Although confirmed data are not available, the current estimated ris s unit are H , , Hepatitis C , , The most recent estimated ris s unit for other viral transmissions are Hepatitis B , , HTL & 4 , West Nile irus (WN ) can be transmitted by blood transfusions but the ris is e tremely low. PC testing is performed to detect WN . At the current time no cases of WN in humans has been reported in Washington State. arely, Chagas disease (Trypanosoma cruzi) has been transmitted through transfusion. Testing is done on donors who have lived in or were born in endemic areas (Central & South America). n CM sero-negative, immunosuppressed transplant and H positive patients, the ris of CM infection is high. n the ing County area the CM sero positive incidence in the donor population is about . Leu ocyte depletion of blood is e uivalent to CM sero negative blood in preventing CM infection through transfusion, but is more e pensive and indicated only if CM sero negative blood or platelets are not available. n some organ transplant recipients CM sero negative blood is transfused to prevent infection with secondary strains.

Therapeutic ffect Usually an increase in factor levels of at least will be

needed for any significant change in coagulation status, so the usual dose is four units, but the amount will vary depending on the patient's si e and clotting factor levels. Hematology consultation is advised concerning the dose of plasma.

Recommended Coagulation Parameters for Common Procedures

Plt

Count INR

Lumbar Puncture , .

Paracentesis , 2.

Thoracentesis , .

Transbronchial Lung Biopsy

, .

Subclav Line , .

enal Biopsy , .

Liver Biopsy , .

Hic mann, roshong Catheters

, .

These numbers assume normal latelet function Conditions that may

affect platelet function include renal failure, medications, leu emias and myelodysplasias, and congenital disorders. Bleeding Time is a oor

redictor of surgical bleeding The Usefulness of Platelet Function Analysis (PFA) in redicting surgical bleeding is un no n CRYOPRECIPITATE (CRYO) Description Cryoprecipitate is prepared from plasma and contains fibrinogen, von Willebrand factor, factor , factor and fibronectin. Cryoprecipitate is the only ade uate fibrinogen concentrate available for intravenous use. Cryoprecipitate is available in pre pooled concentrates of si units. ach unit from a separate donor is suspended in mL plasma prior to pooling. or use in small children, up to 4 single units can be ordered.

ach unit provides about mg of fibrinogen. ndications for Cryoprecipitate

Cryoprecipitate is indicated for bleeding or immediately prior to an invasive procedure in patients with significant hypofibrinogenemia ( mg dL). Cryoprecipitate should not be used for patients with von Willebrand disease or Hemophilia A ( actor deficiency) unless they do not (or are not nown to) respond to DDA P and recombinant and or virally inactivated preparations are not available. t is not usually given for

actor deficiency, as there are virus inactivated concentrates of this protein available. Cryoprecipitate is sometimes useful if platelet dysfunction associated with renal failure does not respond to dialysis or DDA P.

Usage and Therapeutic ffect

Cryo reci itate Dosage

bag contains mg ibrinogen bags ( pool) contains 2 mg ibrinogen ecovery with transfusion 6 bag ool cryo reci itate rovides 1560 mg Fibrinogen g . plasma volume of dL ( . L) mg 4 mg dL provided by bag pool of cryoprecipitate dL

In a 70 g Patient: 6 bags (1 ool) of cryo raises Fibrinogen 45 mg dL

Fibrinogen re lacement ffect can be monitored by fibrinogen level assay and clinical response. Pediatric dosing for cyroprecipitate is unit per g child, which should increase fibrinogen by mg dL. To re lace factor III or von Willebrand factor: When specific factor concentrates are unavailable, the usual adult dose is a pool of 2 bags. Appro imately units of factor and von Willebrand factor are provided per bag. A single donor may be used repeatedly for a young or mildly affected patient to limit donor e posures. Fibrin glue: Although single units of cryoprecipitate are available for use in the preparation of fibrin glue to be applied locally for surgery, commercially available, virally inactivated concentrates have a higher fibrinogen concentration and are preferred for this purpose (Tisseel ). A patient may donate autologous plasma for processing into cryoprecipitate prior to a planned surgical procedure. TRANSFUSION RELATED RIS S nfectious is Unit

Blood Centers began clinical trials in April to screen blood with a PC test for HC NA and H DNA. Although confirmed data are not available, the current estimated ris s unit are H , , Hepatitis C , , The most recent estimated ris s unit for other viral transmissions are Hepatitis B , , HTL & 4 , West Nile irus (WN ) can be transmitted by blood transfusions but the ris is e tremely low. PC testing is performed to detect WN . At the current time no cases of WN in humans has been reported in Washington State. arely, Chagas disease (Trypanosoma cruzi) has been transmitted through transfusion. Testing is done on donors who have lived in or were born in endemic areas (Central & South America). n CM sero-negative, immunosuppressed transplant and H positive patients, the ris of CM infection is high. n the ing County area the CM sero positive incidence in the donor population is about . Leu ocyte depletion of blood is e uivalent to CM sero negative blood in preventing CM infection through transfusion, but is more e pensive and indicated only if CM sero negative blood or platelets are not available. n some organ transplant recipients CM sero negative blood is transfused to prevent infection with secondary strains.

Bacterial contamination was previously estimated to occur in 2 platelet concentrates and , rbc units. Bacterial testing ofplatelet

concentrates has significantly decreased this ris from platelet transfusions. Transfusion eactions A transfusion should be sto ed immediately henever a transfusion reaction is sus ected A hemolytic transfusion reaction occurs following transfusion of an incompatible blood component. Most are due to naturally occurring antibodies in the AB antigen system. An acute hemolytic transfusion reaction may cause hemoglobin induced renal failure and a consumptive coagulopathy (D C). Signs and symptoms include fever, hypotension, nausea, vomiting, tachycardia, dyspnea, chest or bac pain, flushing and severe an iety. Hemoglobinuria may be noted and, in the anestheti ed patient, may be the first sign of hemolysis. The diagnosis can be uic ly made by centrifuging a tube of blood and e amining the plasma for a reddish discoloration. A fresh sample of blood should be sent to the Blood Center for testing and all paper wor and the patient s identification chec ed. Treatment involves fluids, diuresis and transfusion support for bleeding. A fatal hemolytic transfusion reaction occurs about once in

, transfusions. Most errors are clerical or due to misidentification of a patient at the bedside. Delayed hemolytic transfusion reactions usually occur in patients who have been previously sensiti ed to an antigen through transfusion or pregnancy. They can result in symptomatic or asymptomatic hemolysis several days after a subse uent transfusion due to an anamnestic recall of the antibody. Transfusion of h positive red blood cells to an h negative woman of childbearing age can result in sensiti ation and hemolytic disease of the newborn in future pregnancies. Febrile transfusion reactions usually occur due to sensiti ation to antigens on cell components, particularly leu ocytes. Leu ocyte depletion of red blood cells by filtration may be helpful in patients for whom this is a problem. Leu ocyte reduced single donor pheresed platelets are a possible alternative to leu ocyte depletion by filtration of pooled random donor platelets and are comparable in cost. ccasionally, removal of most of the plasma (volume reduction) may be necessary to remove cyto ines in platelet preparations for patient with persistent febrile reactions. arely, a febrile episode during a transfusion, particularly with platelets, is due to bacterial contamination. enerally these reactions are

uite severe with high fever, rigors and or other systemic symptoms such as hypotension, nausea or vomiting. f a bacterially contaminated component is suspected, the transfusion should be stopped and the bag sent for gram stain and culture. The Blood Center should be notified. The patient should have blood cultures obtained and, if appropriate, antibiotic therapy begun. Transfusion Related Acute Lung In ury (TRALI) occurs when donor plasma contains an antibody, usually against the patient's HLA or leu ocyte specific antigens. Less often, the patient may have antibodies against donor leu ocytes in the component. Symptoms of dyspnea, hypotension and fever typically begin minutes to hours after transfusion and the chest ray shows diffuse non specific infiltrates.

entillatory support may be re uired for several days before resolution. Therapy is primarily supportive. The Blood Center should be notified so that the donor may be tested for antibodies against the patient. Urticarial and allergic ty e reactions are the most common, usually due to allergies to specific proteins in the donor s plasma and can be avoided with future transfusions by pretreatment with antihistamines or steroids. nly if severe (anaphyla is), are washed BC s and platelets to

remove all plasma indicated. gA deficiency should be considered in the case of anaphylactic reactions. mmune Modulation

Transfusions have been nown to induce immune tolerance following the observation made more than 2 years ago that multiply transfused idney transplant recipients had an increased graft survival rate. n addition, some studies suggest that transfusion may increase the rate of post operative bacterial infection. There is also evidence from animal studies that transfusion increases the ris of metastatic disease, although data in humans are inconclusive. Sensiti ation to foreign donor HLA antigens, or alloimmuni ation, can lead to poor platelet transfusion increments. Patients may respond to pheresed platelets from HLA matched donors or family members. HLA alloimmuni ation also decreases the li elihood of finding a compatible donor for heart or renal transplant. emoval of donor leu ocytes has been shown to decrease the immunomodulatory effects of blood transfusions but the clinical usefulness is clear only in the prevention of alloimmuni ation in patients undergoing chemotheraphy for AML. BLOOD COMPONENT MODIFICATION CM Sero negative CM sero negative patients who are, or will be, severely immunosuppressed due to transplantation should receive only CM seronegative platelets and red blood cells to prevent primary CM infection. Premature infants and low birth weight neonates should receive CM sero negative blood components regardless of serology. Leu ocyte depletion of blood is e uivalent to CM screening but is more e pensive and indicated only if CM sero negative blood is not available. rradiation (gamma)

nactivation of lymphocytes prevents transfusion induced HD due to engraftment of donor cells in an immunosuppressed patient.

Leu ocyte reduction ( leu opoor ) emoval of leu ocytes by filtration of platelets and red blood cell concentrates is indicated for febrile transfusion reactions and when CM sero negative components are indicated but not available. Leu ocyte depletion may prevent alloimmuni ation to platelets and should be used in patients who are e pected to need platelet transfusions during multiple courses of chemotherapy and do not have pre e isting HLA antibodies.

olume educed Platelets emoval of e cess donor plasma is indicated in patients who cannot tolerate the full volume or when AB incompatible single donor platelets are transfused. olume reduction may be helpful in patients with febrile transfusion reactions that persist despite leu ocyte reduction. Appro imately of the platelets are lost in this process and the e tra centrifugation step may cause some platelet activation and loss of function. Washed ed Blood Cells and Platelets Patients with severe life threatening plasma allergies uncontrolled by medications or volume reduction may re uire red blood cells or platelets to be resuspended in saline. Washed red blood cells must be transfused within 24 hours or be wasted. The recovery and function of platelets after washing are severely impaired.

Bacterial contamination was previously estimated to occur in 2 platelet concentrates and , rbc units. Bacterial testing ofplatelet

concentrates has significantly decreased this ris from platelet transfusions. Transfusion eactions A transfusion should be sto ed immediately henever a transfusion reaction is sus ected A hemolytic transfusion reaction occurs following transfusion of an incompatible blood component. Most are due to naturally occurring antibodies in the AB antigen system. An acute hemolytic transfusion reaction may cause hemoglobin induced renal failure and a consumptive coagulopathy (D C). Signs and symptoms include fever, hypotension, nausea, vomiting, tachycardia, dyspnea, chest or bac pain, flushing and severe an iety. Hemoglobinuria may be noted and, in the anestheti ed patient, may be the first sign of hemolysis. The diagnosis can be uic ly made by centrifuging a tube of blood and e amining the plasma for a reddish discoloration. A fresh sample of blood should be sent to the Blood Center for testing and all paper wor and the patient s identification chec ed. Treatment involves fluids, diuresis and transfusion support for bleeding. A fatal hemolytic transfusion reaction occurs about once in

, transfusions. Most errors are clerical or due to misidentification of a patient at the bedside. Delayed hemolytic transfusion reactions usually occur in patients who have been previously sensiti ed to an antigen through transfusion or pregnancy. They can result in symptomatic or asymptomatic hemolysis several days after a subse uent transfusion due to an anamnestic recall of the antibody. Transfusion of h positive red blood cells to an h negative woman of childbearing age can result in sensiti ation and hemolytic disease of the newborn in future pregnancies. Febrile transfusion reactions usually occur due to sensiti ation to antigens on cell components, particularly leu ocytes. Leu ocyte depletion of red blood cells by filtration may be helpful in patients for whom this is a problem. Leu ocyte reduced single donor pheresed platelets are a possible alternative to leu ocyte depletion by filtration of pooled random donor platelets and are comparable in cost. ccasionally, removal of most of the plasma (volume reduction) may be necessary to remove cyto ines in platelet preparations for patient with persistent febrile reactions. arely, a febrile episode during a transfusion, particularly with platelets, is due to bacterial contamination. enerally these reactions are

uite severe with high fever, rigors and or other systemic symptoms such as hypotension, nausea or vomiting. f a bacterially contaminated component is suspected, the transfusion should be stopped and the bag sent for gram stain and culture. The Blood Center should be notified. The patient should have blood cultures obtained and, if appropriate, antibiotic therapy begun. Transfusion Related Acute Lung In ury (TRALI) occurs when donor plasma contains an antibody, usually against the patient's HLA or leu ocyte specific antigens. Less often, the patient may have antibodies against donor leu ocytes in the component. Symptoms of dyspnea, hypotension and fever typically begin minutes to hours after transfusion and the chest ray shows diffuse non specific infiltrates.

entillatory support may be re uired for several days before resolution. Therapy is primarily supportive. The Blood Center should be notified so that the donor may be tested for antibodies against the patient. Urticarial and allergic ty e reactions are the most common, usually due to allergies to specific proteins in the donor s plasma and can be avoided with future transfusions by pretreatment with antihistamines or steroids. nly if severe (anaphyla is), are washed BC s and platelets to

remove all plasma indicated. gA deficiency should be considered in the case of anaphylactic reactions. mmune Modulation

Transfusions have been nown to induce immune tolerance following the observation made more than 2 years ago that multiply transfused idney transplant recipients had an increased graft survival rate. n addition, some studies suggest that transfusion may increase the rate of post operative bacterial infection. There is also evidence from animal studies that transfusion increases the ris of metastatic disease, although data in humans are inconclusive. Sensiti ation to foreign donor HLA antigens, or alloimmuni ation, can lead to poor platelet transfusion increments. Patients may respond to pheresed platelets from HLA matched donors or family members. HLA alloimmuni ation also decreases the li elihood of finding a compatible donor for heart or renal transplant. emoval of donor leu ocytes has been shown to decrease the immunomodulatory effects of blood transfusions but the clinical usefulness is clear only in the prevention of alloimmuni ation in patients undergoing chemotheraphy for AML. BLOOD COMPONENT MODIFICATION CM Sero negative CM sero negative patients who are, or will be, severely immunosuppressed due to transplantation should receive only CM seronegative platelets and red blood cells to prevent primary CM infection. Premature infants and low birth weight neonates should receive CM sero negative blood components regardless of serology. Leu ocyte depletion of blood is e uivalent to CM screening but is more e pensive and indicated only if CM sero negative blood is not available. rradiation (gamma)

nactivation of lymphocytes prevents transfusion induced HD due to engraftment of donor cells in an immunosuppressed patient.

Leu ocyte reduction ( leu opoor ) emoval of leu ocytes by filtration of platelets and red blood cell concentrates is indicated for febrile transfusion reactions and when CM sero negative components are indicated but not available. Leu ocyte depletion may prevent alloimmuni ation to platelets and should be used in patients who are e pected to need platelet transfusions during multiple courses of chemotherapy and do not have pre e isting HLA antibodies.

olume educed Platelets emoval of e cess donor plasma is indicated in patients who cannot tolerate the full volume or when AB incompatible single donor platelets are transfused. olume reduction may be helpful in patients with febrile transfusion reactions that persist despite leu ocyte reduction. Appro imately of the platelets are lost in this process and the e tra centrifugation step may cause some platelet activation and loss of function. Washed ed Blood Cells and Platelets Patients with severe life threatening plasma allergies uncontrolled by medications or volume reduction may re uire red blood cells or platelets to be resuspended in saline. Washed red blood cells must be transfused within 24 hours or be wasted. The recovery and function of platelets after washing are severely impaired.

ecommendations

CM

Neg 1,2

Irradiation 3

Leu ocyte

Reduced

BM Stem Cell Trans lant Candidate

4

5

Organ Trans lant Candidate

Candidates for heart and

idney trans lant

Chemo R Only

6

7

AIDS HI

Febrile R n s

Neonate

Hemato oietic or Lym ho ro-liferative Malignancy

or patients with negative or un nown CM serology. 2 Leu ocyte depletion may be used if CM sero negative blood components are not available.

All components for stem cell transplant patients re uire irradiation. All directed donations from family members or HLA matched donors re uire gamma irradiation. 4 amma irradiation is re uired pre transplant for patients who may receive non myeloablative ( mini ) transplants.

e uired to prevent alloimmuni ation pre transplant only. rradiation may be indicated in severely immunosuppressive

chemotherapy, such as is used to treat patients with acute leu emia, or with fludarabine r .

Leu ocyte reduced blood is recommended for patients who will undergo multiple cycles of chemotherapy that will re uire platelet transfusion support.

f uncontrolled by leu ocyte depletion, volume depletion of platelets prior to transfusion may decrease febrile reactions.

IMPORTANT PHONE NUMBERS

Puget Sound Blood Center Transfusion Service and Physician on Call for Consultation (206) 292-6525 Puget Sound Blood Center University District Lab (2 ) 22 24 2 ast Side Laboratory (42 ) 4 4 South Center Laboratory (42 ) HLA Matched Platelet Program (42 ) 4 Hos ital Blood Transfusion Services Seattle Children's Hospital (2 ) vergreen Hospital Medical Center (42 )

roup Health Coop Central Hospital (2 ) 2 ast Side (42 ) 4

Harborview Medical Center (2 )

Northwest Hospital (2 ) 44

verla e Medical Center (42 )

Seattle Cancer Care Alliance (2 ) 2 Swedish Medical Center irst Hill (2 ) 22 2 Ballard (2 )

Providence Campus (2 ) 2 University of Washington (2 ) 24 Medical Center

alley Medical Center (42 ) 22 4 t. 4

eterans Affairs Medical Center (2 ) 4 22 4

irginia Mason Medical Center (2 ) 2 2

Puget Sound Blood Center Printed February, 2010

ecommendations

CM

Neg 1,2

Irradiation 3

Leu ocyte

Reduced

BM Stem Cell Trans lant Candidate

4

5

Organ Trans lant Candidate

Candidates for heart and

idney trans lant

Chemo R Only

6

7

AIDS HI

Febrile R n s

Neonate

Hemato oietic or Lym ho ro-liferative Malignancy

or patients with negative or un nown CM serology. 2 Leu ocyte depletion may be used if CM sero negative blood components are not available.

All components for stem cell transplant patients re uire irradiation. All directed donations from family members or HLA matched donors re uire gamma irradiation. 4 amma irradiation is re uired pre transplant for patients who may receive non myeloablative ( mini ) transplants.

e uired to prevent alloimmuni ation pre transplant only. rradiation may be indicated in severely immunosuppressive

chemotherapy, such as is used to treat patients with acute leu emia, or with fludarabine r .

Leu ocyte reduced blood is recommended for patients who will undergo multiple cycles of chemotherapy that will re uire platelet transfusion support.

f uncontrolled by leu ocyte depletion, volume depletion of platelets prior to transfusion may decrease febrile reactions.

IMPORTANT PHONE NUMBERS

Puget Sound Blood Center Transfusion Service and Physician on Call for Consultation (206) 292-6525 Puget Sound Blood Center University District Lab (2 ) 22 24 2 ast Side Laboratory (42 ) 4 4 South Center Laboratory (42 ) HLA Matched Platelet Program (42 ) 4 Hos ital Blood Transfusion Services Seattle Children's Hospital (2 ) vergreen Hospital Medical Center (42 )

roup Health Coop Central Hospital (2 ) 2 ast Side (42 ) 4

Harborview Medical Center (2 )

Northwest Hospital (2 ) 44

verla e Medical Center (42 )

Seattle Cancer Care Alliance (2 ) 2 Swedish Medical Center irst Hill (2 ) 22 2 Ballard (2 )

Providence Campus (2 ) 2 University of Washington (2 ) 24 Medical Center

alley Medical Center (42 ) 22 4 t. 4

eterans Affairs Medical Center (2 ) 4 22 4

irginia Mason Medical Center (2 ) 2 2

Puget Sound Blood Center Printed February, 2010