overview of transfusion medicine
TRANSCRIPT
Transfusion MedicineJanejira Kittivorapart, MD.
Department of Transfusion Medicine
Faculty of Medicine Siriraj Hospital
Mahidol University
Blood Transfusion
Patients
Blood Bank
Physicians
OUTLINE
Type, indication and composition of blood products
Blood utilization
Processes of blood transfusion
Special requests
Platelet refractoriness
Transfusion reactions & their managements
Preparation of Blood Components
Whole Blood
Plasma
FFP
CRYO
Buffy coat
WBC Platelet
LPB
Whole Blood
Platelets & Plasma
Platelet FFP
Cryoprecipitate CRP
Packed red cells
Type of component Composition/storage Indications
Whole Blood Volume 500 mlHct > 33%Shelf life at 2 – 6°CCPDA-1 35 days
Hypovolemic anemia:- Active bleeding, surgery
Packed red cells (PRC) Volume 250 – 300 mlHct < 80%Shelf life at 2-6°C CPDA-1 35 days
• Loss of RBC mass• Symptomatic anemia
Red cells in additive solution (Adsol blood) Volume 300 – 350 ml
Hct 55-65%Shelf life 42 days Contatained mannitol but not Sodium citrate
• Same as PRC• Emergency situations• Autologous donation
Type of Component Composition/storage Indications
Leukocyte poor blood (LPB, LPRC)Prepared by centrifugation
Volume 250-300 mlHct ≤ 80%WBC ≤ 12 x 108 cells/bagShelf life same as WB, PRC
•↓ Febrile nonhemolytic transfusion reaction
•↓ Alloimmunization to WBC antigens (i.e. HLA)
•↓Transmission of CMV
Proved only WBC < 5x106
Leukocyte depleted blood Prepared by filtration
Volume 250-300 mlHct ≤ 80%WBC ≤ 5 x 106 cells/bagShelf life same as WB, PRC
Type of Component Composition/storage Indications
Platelet concentrate Platelets 5.5x1010/unitShelf life 5 days 22 ± 2°C Soft continuous agitation
Therapeutic• Thrombocytopenic
bleeding• Platelet dysfunction with
bleeding
Prophylaxis• Spontaneous hemorrhage> 10,000/µl> 20,000/µl- DIC, sepsis, fever• Pre-operative
Pooled 4 donors(pooled-buffy coat)
Shelf life 5 days 22 ± 2°C Soft continuous agitation
Single donor platelet Platelets 3x1011/unitShelf life 5 days 22 ± 2°C Soft continuous agitation
AS Plasma … mlPRC Plasma …. ml
Type of Component Composition/storage Indications
Fresh frozen plasma (FFP)
Volume 150-300 mlAll coagulation factors Shelf life at ≤ - 18°C 1 yrThawed FFP at 37°C, shelf life 24 hNo Refrozen
• Abnormal PT, APTT• Multiple coagulation factors deficiencies :- liver disease, massive transfusion, DIC, warfarin reversal (bleeding)• Hemophilia B • Plasma exchange in TTP
Cryoprecipitate Volume 5-10 mlFactor VIII:C ≥ 80 IU/bag Fibrinogen 150 mg/bagFactor XIII vWFShelf life at ≤ - 18°C 1 yrThawed and pooled CRYO kept at 20-24°C for 4 h
• Source of FVIII in hemophilia A, vWD• Source of fibrinogenDIC, hypofibrinogenemia• Source of vWF
• Fibrin glue (CRYO: fibrinogenHuman thrombin)
DosageBlood
/ComponentDose What to be expected?
RBCs 10 ml/kg/doseChronic anemia: 1-2 u/dosePed, Hb<5 g/dl: 2x Hb ml/kg(i.e. Hb 4 g/dl 8 ml/kg/dose)
↑ Hb 1 g/dl per one unit transfused
Platelet conc. 10 kg/unit Infant: 5-10 ml/kg
• Absolute Platelet Increment
1 u->↑ plts 5,000-7,000/uL• CCI
FFP 10-20 ml/kg(500-1000 ml in a 50 kg patient)
PTR within 1.5 x of normal(clotting factor 50% of normal)
Cryoprecipitate 5-10 kg/bag (5-10 units in a 50 kg patient)
Fibrinogen 100 – 150 mg/dl
IN REAL SITUATION…
Case 156 y.o. male, HBV with cirrhosis Child C• Present with UGIB • BP110/70 mmHg, HR 110/min, good consciousness• CBC: Hb 7 g/dL, Hct 22%, WBC6500/mm3 Platelet
90,000/µL • PT 48s (<13 s), aPTT 72s (28-32 s), Fibrinogen 53 mg/dL • LFT: compatible with liver cirrhosis
What is your management?
Case 2
• 69 y.o. female; BW 60 Kg• Pre-op drainage for her parotid space abscess• CBC: Hb 12 g/dl, WBC 5,600/mm3, Plt 260,000/µl• Clinician requests for platelet conc. 6 U
What is your management?
Sample Collection
เจาะเลื�อดเพื่�อขอจองเลื�อดEDTA tube 6 ml• Active patient identification• Permission• Consent form • Labeling sample –
Don’t forget to sign your name
AT BLOOD BANK
Processing
Check from previous history • Recheck name and surname, HN• Check blood group and previous antibody
Check cell and serum grouping
Antibody screening
Type & Screen
Cells and Serum Grouping
Crossmatching
Donor cells VS Patient serum
– Immediate spin – to detect antibody at room TIgM antibody :- ABO blood group
– Incubation at 37C- IgG Ab Rh blood group– Indirect antiglobulin
Test – Coombs control cells
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TRANSFUSION PRACTICE
FREQUENTLY ASKED QUESTIONS
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FAQ
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– Platelets– Cryoprecipitate
OUTLINE
Type, indication and composition of blood products
Blood utilization
Processes of blood transfusion
Special requests
Platelet refractoriness
Transfusion reactions & their managements
SPECIAL REQUESTS
1. Irradiated Blood
• Purpose: inactivated T-cell lymphocytes
Not eradicated!• Dose: 25 Gy with at least 15 Gy periphery• TA-GVHD prevention• Age - Platelet: same age as origin
- RBCs: 28 days • Hyperkalemia
TA-GVHD– Very high mortality rate (almost 100%)– Pancytopenia + GVHD – 8-10 days after transfusion– No available effective treatment
1. There must be differences in the HLA Ag expressed between donor & recipient2. Immunocompetent cells must be presented in the graft3. The host must be incapable of rejecting the immunocompetent cells
3 requirements of GVHD (Billingham)
Indications: Irradiation1. High risk groups• PBSCT/BMT – allogeneic & autologous• Received purine analogue agent • After ATG administration• Intrauterine transfusion• Compromised T-cell functions – SCID, Digeorge
syndrome, etc.
2. The donor is a blood relative of the recipient
3. The donors is selected for HLA compatability by typing or crossmatching
Case
• G1P0, GA 36 week twin pregnancy patients• One of her fetus was detected to be anemic by
ultrasonography.• The obstretician requested for intrauterine
transfusion • We prepared the prestorage group O Rh
negative red cells with irradiation and washed
2.Washed Component
• History of severe allergy or anaphylaxis after transfusion
• Usually allergic to plasma protein :- IgA deficiency, haptoglobin deficiency, etc.
• Purpose: Plasma removal • Age: Within 4 h after bag opening• In particular situation – 6 times wash
3.Rh Negative
• Incompatible Rh platelet administration• Anti-D immunoglobulin (Rhesonativ®)• Anti-D 250 µg / 15 ml of Rh D+ RBCs
(PC 30 units, SDP 3 units)• IM/SC injection• Within 72 h after exposure• Monitor at least 20 min after injection
Patient, Rh D negative
pt
pt
pt
ptpt
ptpt
pt
pt
Platelet Rh D+ Rh D- Patient
pt
pt
d d
pt
ptd
d
pt
RBCs in Platelet bag
pt
Anti-D injection
Platelet Rh D+ Rh D- Patient
pt
pt
pt
pt
Anti-D bind to D antigens
pt
d d
d
d
4.Platelet Crossmatch
• Platelet refractoriness• Immune vs Non-immune causes• Screening methods
- Fail from what expected
(1 unit ↑ platelet 5,000 – 7,000/µl)
- Corrected count increment (CCI)
CCI
CCI = Platelet count increment X BSA(m2)(x1011)
no. of platelet transfused
• Failure transfusion : 1 hour CCI < 5,500
or 24 hour CCI < 2,500
CCI Interpretation1 hour 24 hours
Not Decrease Decrease (<2,500) Consumption of Plt
Decrease (<5,500) - Suspected Plt Ab
PC: 5.5 x 1010 x unitsSDP: 3 x 1011
Alloimmune Thrombocytopenia
• Request for platelet crossmatching• ALWAYS! monitor 1-hour increment • Either Paroxysmal or Persistent• No effective treatment • Prevention: Leukodepleted blood products
OUTLINE
Type, indication and composition of blood products
Blood utilization
Processes of blood transfusion
Special requests
Platelet refractoriness
Transfusion reactions & their managements
TRANSFUSION REACTIONS
• Acute transfusion reaction .. Within 24 hours– Acute hemolytic transfusion reaction– Bacterial sepsis– Febrile non-hemolytic transfusion reaction (FNHTR)– Anaphylaxis/ allergic reactions– Transfusion related acute lung injury (TRALI)– Transfusion associated circulatory overload (TACO)
• Delayed transfusion reaction .. >24 hours– Delayed hemolytic transfusion reaction– Iron overload – Transfusion-associated graft versus host disease (TA-GvHD)
Transfusion Reactions
Symptoms/signs of Acute Transfusion Reaction
- Immediately STOP the transfusion
- Retain the IV port
Urticaria
Fever
- Premed with CPM
- Closed observation
FNHTR Bacterial contamination
Allergy
Anaphylaxis
- ABC approach- Adrenaline IM- Return product
to blood bank- Saline wash in
future Transfusion
Hemolytic reaction
- Vigorous IV infusion- Urine output monitoring- Take H/C, CBC, BUN, Cr, K,
DIC profile- Prophylaxis antibiotic- Return product and the giving
set to blood bank
FNHTR- Febrile non-hemolytic transfusion reaction
Acute dyspnea ± Hypotension
TACO TRALI
- Oxygen supplement
- Diuretics IV- I/O monitoring
- Treat as ARDS - Respiration and
ventilation support- Usually recovers
within 72-96 h
TACO - transfusion associated circulatory overload
TRALI – transfusion related acute lung injury
Hemolytic Transfusion Reactions
AHTR DHTR• Occur within 24 hours
• Intravascular hemolysis
• Usually fatality and need intensive care
• The most common cause is ABO incompatibility
• Occur many days to years after transfusion
• Majority is extravascular hemolysis
• Usually mild symptoms with some degrees of anemia
• Kidd, Duffy, Kell and MNS systems were reported
Form for Transfusion Reactions
Investigation
SUMMARY• Introducing every type of blood and components• Blood utilization • Blood transfusion• Special requests
– Irradiated products, TA-GVHD– Washed components– Rh negative– Crossmatching platelets
• Transfusion reactions & their managements
“True success is not in the learning, but in its
application to the benefit of mankind.”
HRH Prince Mahidol of Songkla
QUESTIONs
&
ANSWERs