Blood Transfusion

Teoman SOYSAL Prof. MD

Blood Donation

Healty adult donors

• 450 ml +/- 10% per whole blood donation

• Male: 5/year, Female : 4/year

• > 8 weeks between two donations

Apheresis:

Platelets

Plasma

White cells (or subsets)

Red cells

The procedure can be done for treatment or transfusion purposes.

Blood Preservation

• Whole blood or red cells1-Liquid phase storage : 1-6º C

• 63 ml anticoagulant-preservation liquid/unitduration of preservation– ACD: 3 weeks– CPD: 3 weeks– CPD-A1: 35 days– RBC concentrate with SAG-Mannitol : 7 weeks

2- Frozen storage of red cells• -80 to - 196 º C , with glycerol etc: Years

Blood Preservation• Effects of storage

– Red cells: ATP, 2-3 DPG,

osmotic fragility and oxygen affinity

– Plasma : Hb, K, NH3 :

pH:– Platelets: Lost in 2 days– Coagulation factors:

Eg:

• FV: adequate levels for about 5 days

• FVIII: Below 80% of original level after 1-2 days

• FXI: Less than 20% of original level after 7 days

Blood Preservation

• Platelets: – liquid phase : 1 - 5 days, room temp., avoid light exposure kept on special agitator

• Plasma : Use fresh or freeze– frozen at -18 º C within 8 hrs of collection

Blood components & products• Cell containing components

– Red cells: • Whole blood( fresh or not)

• Red cells: packed red blood cells

washed red blood cells

frozen red blood cells

leukocyte – reduced red blood cells

– Platelets: Random donor platelets

Apheresis platelets ( single donor platelets)

– Granulocytes or mononuclear cells

– Peripheral blood progenitor cells

Blood components & products

• Plasma and products– Plasma : fresh / fresh-frozen plasma– Cryopresipitate– Coagulation factor concentrates– Immunglobulin preperations– Albumin– others

Deciding blood transfusion;

• Severity of symptoms• Cause of anemia• Rapidity of anemia or symptoms• Co-morbidities and the age of the patient• Can we treat the anemia without transfusion?

And • Is there enough time to wait for the response of

such a treatment ?

This is not a guide to be used in every patient

• Hemoglobin >10 g/dL : Tx rarely needed

• Hemoglobin < 6-7 g/dL: Tx mostly necessary

• Hemoglobin : 6-10 g/dL: Dependable

Important: • Symptoms related to anemia may

differ from one patient to another for a given Hb level;

• The trigger for red cell transfusion may differ from one patient to another!!!!!

Indications for transfusion of blood or its components

• Whole blood: Acute massive bleeding

1 unit increases Hb: 1g/dl, Hct: 3%

• Fresh whole blood:

– Massively bleeding patient/shock

– Exchange transfusion, open heart surg, severe renal or hepatic failure,

• Red blood cells:

– (To increase the oxygen carrying capacity in case of symptomatic anemia not

treatable by other means or due to urgency of symptoms)

– Symptomatic anemia (May be due to different causes), post-bleeding

hypovolemia

– 1 unit increases Hb: 1g/dl, Hct: 3%

Indications for transfusion of blood or its components

• White cells reduced RBC’s:< 5x106 WBC’s per unitWhite cell filters (before storage or before transfusion)

• An indication for RBC transfusion +– To prevent reactions caused by WBC antibodies

• Febrile non-hemolytic transfusion reactions

– To prevent alloimmunization– To prevent CMV transmission

Indications for transfusion of blood or its components

Washed RBC’s: • An indication for RBC transfusion +

– Any need to prevent the recipient allo-immunisation to WBC’s , plasma antigens or any contraindication to infuse complement

• PNH• IgA deficiency• Prevention of anaphylaxis

• Washed units must be transfused no later than 24 hours

Frozen RBC’s: • An indication for RBC transfusion +

– Autologous transfusion: rare blood groups, – Catastrophy etc

Washed before infusion !!

Indications for transfusion of blood or its components

Blood IrradiationTo prevent transfusion related GVHD in;• Congenital immune deficient states• Bone marrow or stem cell transplantation• Some cases of hematologic malignancies

– Hodgkin’s disease– Purin analogue or anti-CD52 treatment

• Intra-uterin transfusion• New borne exchange transfusion• Transfusions between relatives

– first or second degree• HLA matched platelets

Some of the indications for platelet transfusions• Decreased platelet production because of bone marrow

failure or infiltration :bleeding or risk of bleeding– Leukemia– MDS– Myelofibrosis– Malignant tm infiltration – Myelosupression– Aplastic anemia

• Functional platelet disease and bleeding or risk of bleeding• Dilutional thrombocytopenia (after massive transfusion)• Cardiac by-pass surgery• Increased platelet destruction or consumption

– DIC– Drug induced– sepsis– ITP

Indications for transfusion of blood or its components

• Platelets: Thrombocytopenia due to decreased platelet production

Platelet count/mm3 Bleeding /surgery Indication for plt transfusion

> 50.000, No No

< 50.000 Yes Yes

10.000-20.000 No No

(if there is bleeding/fever/DIC/plt dysfunction) Yes

< 10.000 Yes or No Yes

Some special conditions about platelet transfusion

Disease status may change

the transfusion effectiveness: • DIC• Hypersplenism• Sepsis• Allo-immunisation

Cotraindicated in Thrombotic Thrombocytopenic Purpura: Used only in high risk bleeding

Not effective/useful in ImmuneThrombocytopenic Purpura: Usedonly in high risk bleeding

Practical issues• ABO matched platelets have a

longer in-vivo life span after transfusion

• Use Rh- platelets for Rh- recipients (to prevent Rh immunisations) or use anti-Rh(D) Ig if Rh+ component used in such recipients

Types of platelet concentrates

• Random donor plt concentrate (single unit)– 5,5 x 1010 plts – 5.000-6.000/mm3 plt increase after transfusion

• Pooled plt concentrate (eg:6 random units)• Apheresis plts

– >3x1011 plts– 30.000-50.000/mm3 increase after transfusion

• WBC reduction of platelets is indicated in the same situations like red cells.

Indications for transfusion of blood or its components/products

• Fresh frozen plasma ( contains all coag. Factors)

– Congenital or acquired coag.Factor deficiency (bleeding or surgery)

– Oral anticoagulant overdose– Plasma exchange (eg:TTP)– After massive transfusion– 10-20 ml/kg : to increase deficient factor level

about 20-30% from baseline

Indications for transfusion of blood or its components/products

• Cryoprecipitate– Includes FVIII, vWF, FXIII, fibrinogen and

fibronectin– 80-120 units of FVIII, ≥150 mg fibrinogen and 20-30 % of FXIII that

is in one unit of plasma – Can be used for the purpose of replacing the

deficient state of these factors in case of bleeding or surgery

Practical Issues

• Is there a need for transfusion?• Which product should be used?• Number of units?• Re-check the blood types of the patient and donör

and be sure about the cross match• Read label, ID, inspect the product• Is irradiaton necesssary?• Temperature?• Filters?• Flow rate ? (start 5 ml/min-15 minutes , the rest 200-500ml/hr)

• Drugs ?

Transfusion Reactions

• Immunologic reactions

• Non-immune reactions

or

• Acute reactions

• Late reactions

Hemolytic reactions

• Reasons: Mismatched transfusion

Transfusion of hemolysed blood» During storage or warming etc

• May be acute or late

Acute hemolytic reaction• Frequency up to 1/25.000 • 1/600.000 Tx mortal • 40% symptomatic

• ABO mismatch • IgM antibodies (anti-A or anti-B) ,complement

binding and intravascular hemolysis• Early onset ( first 50-100 ml’s),seldom after 1-2 hrs

– pain at the infusion site, flushing, chest or back pain,dyspnea,vomiting, fever-chills, hypotension and tachicardia,bleeding, hemoglobinuria

• Complications: Acute Renal Failure, shock,DIC

Acute hemolytic reaction

• Stop transfusion, • Take measures to keep normal BP and urine

output: hydration/diuretics, • Re-check groups, re-cross, take blood cultures,• Follow signs of hemolytic anemia, antiglobulin

tests,renal function and DIC tests, • Treat accordingly (eg: dialysis/ICU etc)

Delayed hemolytic reaction• 1/2500-1/6000• Onset: 3-21 days after transfusion• Reason: Rh, Kidd etc mismatches

– Previous alloimmunization and anamnestic response

• Coombs + ( do not confuse with OIHA)

• Jaundice or absence of the expected increase in red cell values.

• Frequently undetected• Treatment : none

Febrile reactions

• 0,5- 3% of all transfusions• Cause: Antibodies against white cell/plt/plasma antigens

• Fever-chills, increased pulse rate during or after transfusion

• Antipyretics/antihistamines

• Stop transfusion if there is doupt about hemolysis

• Prophylaxis: White cell reduction

Allergic reactions

• Cause:Antibodies against donor plasma proteins

• Pruritus,urticaria,edema,anaphylaxis,bronchospasm

• IgA deficient patients are under the greatest risk

• Treat according to the type of reaction• For IgA deficient patients: use washed or

frozen red cells instead of regular red cells or whole blood.

Pulmonary hypersensitivity reaction/TRALI

• 1/5000 frequency• Cause : Leukocyte incompatibility and

agglutination of white cells inside the pulmonary vascular area leading to complement activation and endothelial damage- pulmonary edema.

• Fever-chills,tachycardia,chest pain, hemoptysis,

BP fall within 4 hrs of transfusion• Respiratory support may be necessary

Transfusion Related Graft- versus -Host Disease

• Cause: Immune deficient recipient transfused with viable lymphocytes which are engrafted and start allo-reaction against mismatched HLA and other antigens of the recipient.

• High fatality with skin,liver and gut symptoms, pancytopenia and infections

• Prophylaxis: Blood irradiation• Treatment: immunosupressive drugs• Mortality high

Circulatory overload

• Old aged or premature/ new borne or patients with cardiopulmonary compromise are under risk.

• Clinics: Acute heart failure

• Treatment: As acute myocardial failure

• Prophylaxis: Slow infusion rate, low volume of transfusion

Bacterial Contamination

• Bacterial contamination may cause a reaction with symptoms resembling Acute Hemolytic Reaction without LAB findings of hemolysis.

• May be fatal: – Mortality: Plt constr: 1/17.000 – 1/65.000

Red cells: <1/700.000

• Stop transfusion, take cultures, treat with IV fluids and antibiotics , take support measures and follow against shock, renal failure,DIC

Air embolism

• May cause acute respiratory and circulatory failure

• Clump the tubing

• Change the posture of the patient: – Left side / Trandelenburg (left side ,head-

down, legs upside)– Swan -Ganz catheter

• Patients with bone marrow failure , transfused chronically are under the risk of transfusion hemosiderosis.

• Massive transfusion may cause:– Citrate toxicity: Hypocalcemia– Hyperkalemia– Bleeding ( due to thrombocytopenia and /or

factor deficiency)

Transfusion transmitted pathogens

• Hepatitis ( C,B,A ,D etc )

• HIV

• HTLV

• CMV

• E-Barr

• HHV

• Creutzfeldt-Jakob or

• variant CJD (therotical)

• Parvovirus

• Malaria

• Lyme ? (not enough evidence)

• Chagas

• Babesiosis

• Sy

• Toxoplasmosis

• West Nil virus