Overview of transfusion medicine

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Overview of transfusion medicine

  1. 1. Transfusion Medicine Janejira Kittivorapart, MD. Department of Transfusion Medicine Faculty of Medicine Siriraj Hospital Mahidol University
  2. 2. Blood Transfusion Patients Blood Bank Physicians
  3. 3. OUTLINE Type, indication and composition of blood products Blood utilization Processes of blood transfusion Special requests Platelet refractoriness Transfusion reactions & their managements
  4. 4. Preparation of Blood Components Whole Blood Plasma FFP CRYO Buffy coat WBC Platelet LPB Whole Blood Platelets & Plasma Platelet FFP Cryopreci pitate CRP Packed red cells
  5. 5. Type of component Composition/storage Indications Whole Blood Volume 500 ml Hct > 33% Shelf life at 2 – 6 C CPDA-1 35 days Hypovolemic anemia :- Active bleeding, surgery Packed red cells (PRC) Volume 250 – 300 ml Hct < 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
  6. 6. Type of Component Composition/storage Indications Leukocyte poor blood (LPB, LPRC) Prepared by centrifugation Volume 250-300 ml Hct ≤ 80% WBC ≤ 12 x 108 cells/bag Shelf 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 ml Hct ≤ 80% WBC ≤ 5 x 106 cells/bag Shelf life same as WB, PRC
  7. 7. Type of Component Composition/storage Indications Platelet concentrate Platelets 5.5x1010/unit Shelf 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/unit Shelf life 5 days 22 2 C Soft continuous agitation
  8. 8. AS Plasma … ml PRC Plasma …. ml Type of Component Composition/storage Indications Fresh frozen plasma (FFP) Volume 150-300 ml All coagulation factors Shelf life at ≤ - 18 C 1 yr Thawed FFP at 37 C, shelf life 24 h No 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 ml Factor VIII:C ≥ 80 IU/bag Fibrinogen 150 mg/bag Factor XIII vWF Shelf life at ≤ - 18 C 1 yr Thawed and pooled CRYO kept at 20-24 C for 4 h • Source of FVIII in hemophilia A, vWD • Source of fibrinogen DIC, hypofibrinogenemia • Source of vWF • Fibrin glue (CRYO: fibrinogen Human thrombin)
  9. 9. Dosage Blood /Component Dose What to be expected? RBCs 10 ml/kg/dose Chronic anemia: 1-2 u/dose Ped, 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
  10. 10. IN REAL SITUATION…
  11. 11. Case 1 56 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?
  12. 12. 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?
  13. 13. Sample Collection EDTA tube 6 ml • Active patient identification • Permission • Consent form • Labeling sample – Don’t forget to sign your name
  14. 14. AT BLOOD BANK
  15. 15. 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
  16. 16. Cells and Serum Grouping
  17. 17. Crossmatching Donor cells VS Patient serum – Immediate spin – to detect antibody at room T IgM antibody :- ABO blood group – Incubation at 37 C- IgG Ab Rh blood group – Indirect antiglobulin Test – Coombs control cells
  18. 18. TRANSFUSION PRACTICE
  19. 19. FREQUENTLY ASKED QUESTIONS
  20. 20. FAQ • Normal saline • plasma antigen A A AB anti-A •
  21. 21. FAQ • Cryoprecipitate cryoprecipitate set • 30 • – Platelets – Cryoprecipitate
  22. 22. OUTLINE Type, indication and composition of blood products Blood utilization Processes of blood transfusion Special requests Platelet refractoriness Transfusion reactions & their managements
  23. 23. SPECIAL REQUESTS
  24. 24. 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
  25. 25. 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 & recipient 2. Immunocompetent cells must be presented in the graft 3. The host must be incapable of rejecting the immunocompetent cells 3 requirements of GVHD (Billingham)
  26. 26. Indications: Irradiation 1. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Patient, Rh D negative pt pt pt pt pt pt pt pt pt
  31. 31. Platelet Rh D+  Rh D- Patient pt d ptd pt RBCs in Platelet bagAnti-D injection
  32. 32. Platelet Rh D+  Rh D- Patient pt pt Anti-D bind to D antigens d d d
  33. 33. 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)
  34. 34. 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 Interpretation 1 hour 24 hours Not Decrease Decrease (<2,500) Consumption of Plt Decrease (<5,500) - Suspected Plt Ab PC: 5.5 x 1010 x units SDP: 3 x 1011
  35. 35. Alloimmune Thrombocytopenia • Request for platelet crossmatching • ALWAYS! monitor 1-hour increment • Either Paroxysmal or Persistent • No effective treatment • Prevention: Leukodepleted blood products
  36. 36. OUTLINE Type, indication and composition of blood products Blood utilization Processes of blood transfusion Special requests Platelet refractoriness Transfusion reactions & their managements
  37. 37. TRANSFUSION REACTIONS
  38. 38. • 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. Form for Transfusion Reactions Investigation
  43. 43. 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
  44. 44. “True success is not in the learning, but in its application to the benefit of mankind.” HRH Prince Mahidol of Songkla
  45. 45. QUESTIONs & ANSWERs

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