Blood transfusion


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Blood transfusion

  1. 1. BLOOD TRANSFUSION Prof. M.C.Bansal MBBS., MS., FICOG., MICOG. Founder Principal & Controller, Jhalawar Medical College & Hospital Jjalawar. MGMC & Hospital , sitapura ., Jaipur.
  2. 2. History of Transfusions• Blood transfused in humans since mid- 1600’s• 1828 – First successful transfusion• 1900 – Landsteiner described ABO groups• 1916 – First use of blood storage• 1939 – Levine described the Rh factor
  3. 3. First blood transfusion• Lower (1665)
  4. 4. First human blood transfusion Philip (1825)
  5. 5. Discovery of ABO typeLandsteiner (1900))
  6. 6. Blood TransfusionSuccessful blood transfusion is relatively recent • Crossmatching • Anticoagulation • Plastic storage container
  7. 7. Cross matching1. Matching blood components between a Pt & a Dis a direct compatibility test.2. The red cells & Plasma are cross matched thruMajor and Minor cross match, defined as to anamount of Antibody react with Antigen A. Major‘:the patients serum & the donors RBCs.–large amount of Antibody has greater impactB. Minor’: the patients RBCs & the donors serum.–Small amount of Antibody has little impact
  9. 9. WHAT IS ANTIGENS ?An antigens is a substance that causing the formation of antibodies WHAT IS ANTIBODYS ? Antibodies is a protein substance develop in the body in response to the presence of an antigen that has entered the body
  10. 10. Life Saving &Life Threatening Process
  11. 11. Transfusion Overview• Integral part of medical treatment• Most often used in Hematology/Oncology, but other specialties as well (surgery,gyn, ICU, etc)• Objectives – Blood components – Indications for transfusion – Safe delivery – Complications
  12. 12. PURPOSE OFBLOOD TRANSFUSION THERAPY * REPLACEMENT * THERAPEUTIC1.To restore intravascular volume withwhole blood or albumin.2. To restore the oxygen capacity ofblood by replacing red blood cells.3. To replace clotting factor andcorrection of anemia
  13. 13. Blood Transfusion Type of Transfusion:  Whole Blood;  Blood Component; RBC PLT FFP Leukocyte concentrate  Plasma Substitutes;Use of whole blood is considered to be a waste of resources
  14. 14. DEFINITIONSBLOOD PRODUCT = Any therapeutic substance prepared from human bloodWHOLE BLOOD = Unseparated blood collected into an approved container containing an anticoagulant preservative solutionBLOOD COMPONENT = 1. A constituent of blood , separated from whole blood such as• Red cell concentrate• Plasma• Platelet concentrates2. Plasma or platelets collected by apheresis3. Cryoprecipitate prepared from fresh frozen plasma
  15. 15. Differential Centrifugation First Centrifugation Closed SystemWhole Blood Satellite Bag Satellite BagMain Bag 1 2 First Platelet-rich RBC’s Plasma
  16. 16. Differential Centrifugation Second CentrifugationRBC’s Platelet-rich Plasma Second Platelet Plasma RBC’s Concentrate
  17. 17. Whole Blood• Storage – 4 for up to 35 days• Indications – Massive Blood Loss/Trauma/Exchange Transfusion• Considerations – Use filter as platelets and coagulation factors will not be active after 3-5 days – Donor and recipient must be ABO identical
  18. 18. Blood Components THE PRBC Storage -2–6OC Unit of issue - 1 donation ( unit or pack ) Administration- ABO & Rh compatible- Never add medication to a unit- Complete transfusion within 4 hrs of commencement M 1 e m
  19. 19. Indications - Acute blood loss with > 20% loss of blood volume Trauma Surgery - Trigger – 10gm% - 8gm% Rate of development of anemia, General condition and type of surgery Radiotherapy
  20. 20. Dosage & Administration Dosage - 1 unit/10 kg body wt Adult dose is 4-8 units Administration - Preferably ABO & Rh group specific
  21. 21. Platelets• The platelets are separated from the plasma by centrifugation.• Platelets are supplied either as single donor units or as a combination of multiple donors.• One unit of platelets will increase the platelet count of a 70 kg adult by 5 to 10,000/mm³.• Platelet viability is optimal at 22° C but storage is limited to 4-5 days.• Platelets have both the ABO and HLA antigens. ABO compatibility is ideal but not required. (incompatibility will shorten the life span of the platelet)
  22. 22. Platelets• Storage – Up to 5 days at 20-24• Indications – Thrombocytopenia, Plt <15,000 – Bleeding and Plt <50,000 – Invasive procedure and Plt <50,000• Considerations – Contain Leukocytes and cytokines – 1 unit/10 kg of body weight increases Plt count by 50,000 – Donor and Recipient must be ABO identical
  23. 23. Platelets • Thrombocytopenia (< 50,000) • Platelet dysfunction • Each unit increase 5,000 PLTs after 1 H
  24. 24. Guidelines for Platelet Tx. Mild - 50,000-1,00,000/µl Tx - usually not required Moderate - 20,000-50,000/µl Tx-if symptomatic or has to undergo surgery/trauma Severe - < 20,000/µl Risk of bleeding - high Prophylactic Tx
  25. 25. Plasma and FFP• Contents—Coagulation Factors (1 unit/ml)• Storage – FFP--12 months at –18 degrees or colder• Indications – Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange transfusion, massive transfusion• Considerations – Plasma should be recipient RBC ABO compatible – In children, should also be Rh compatible – Account for time to thaw – Usual dose is 20 cc/kg to raise coagulation factors approx 20%
  26. 26. Fresh Frozen Plasma (FFP)• Coagulation factor deficiencies• 1 ml increases 1% clotting factors• Being used as soon as possible• Albumin, hetastarch, crystallio ds are equally effective volume expander but safer than FFP• After use of 5 U of RBCs, matching 2 U of FFP
  27. 27. Dosage & Administration for FFP Dosage - 10-15 ml/Kg(Approx 2-3 bags for an adult) Administration - Thawed at +37o C before transfusion ABO compatible Group AB plasma can be used for all patient
  28. 28. Plasma SubstitutesDextran• Most widely used• Low/Middle M.W. (40,000-70,000)• Massive transfusion could impair coagulation• Occasional ALLERGIC reactionHydroxyethyl Starch Formulation (HES)• More stable• Containing essential electrolytes• No allergic reaction --Volume Expander
  29. 29. Granulocyte Transfusions• Prepared at the time for immediate transfusion (no storage available)• Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, and recovery of BM is expected• Donor is given G-CSF and steroids or Hetastarch• Complications – Severe allergic reactions – Can irradiate granulocytes for GVHD prevention
  30. 30. Cryoprecipitate• Description – Precipitate formed/collected when FFP is thawed at 4• Storage – After collection, refrozen and stored up to 1 year at -18• Indication – Fibrinogen deficiency or dysfibrinogenemia – vonWillebrands Disease – Factor VIII or XIII deficiency – DIC (not used alone)(Disseminated intravascular coagulation)• Considerations – ABO compatible preferred (but not limiting) – Usual dose is 1 unit/5-10 kg of recipient body weight
  31. 31. Leukocyte Reduction Filters• Used for prevention of transfusion reactions• Filter used with RBC’s, Platelets, FFP, Cryoprecipitate• Other plasma proteins (albumin, colloid expanders, factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusions• May reduce RBC’s by 5-10%• Does not prevent Graft Verses Host Disease (GVHD)
  32. 32. RBC Transfusions Preparations• Type – Typing of RBC’s for ABO and Rh are determined for both donor and recipient• Screen – Screen RBC’s for atypical antibodies – Approx 1-2% of patients have antibodies• Crossmatch – Donor cells and recipient serum are mixed and evaluated for agglutination
  33. 33. RBC Transfusions Administration• Dose – Usual dose of 10 cc/kg infused over 2-4 hours – Maximum dose 15-20 cc/kg can be given to hemodynamically stable patient• Procedure – May need Premedication (Tylenol ) – Filter use—routinely leukodepleted – Monitoring—VS q 15 minutes, clinical status – Do NOT mix with medications• Complications – Rapid infusion may result in Pulmonary edema – Transfusion Reaction
  34. 34. Platelet Transfusions Preparations• ABO antigens are present on platelets – ABO compatible platelets are ideal – This is not limiting if Platelets indicated and type specific not available• Rh antigens are not present on platelets – Note: a few RBC’s in Platelet unit may sensitize the Rh- patient
  35. 35. Platelet Transfusions Administration• Dose – May be given as single units or as apheresis units – Usual dose is approx 4 units/m2—in children using 1-2 apheresis units is ideal – 1 apheresis unit contains 6-8 Plt units (packs) from a single donor• Procedure – Should be administered over 20-40 minutes – Filter use – Premedicate if hx of Transfusion Reaction• Complications—Transfusion Reaction
  36. 36. Choice of blood group for transfusionPatient blood first choice second choice1. O + O+ 0-2. O- O- -3. A+ A+ A-,O+,O-4. A- A- O-5. B+ B+ B-,O-,O+6. B- B- O-7. AB+ AB+ AB+,A+,A-,B+,B-,O-,O+8. AB- AB- A-,B-,O-,
  37. 37. • Although blood transfusions can be life-saving, they are not without risks. The most serious risks are transfusion reactions and infections.
  38. 38. Transfusion Complications• Acute Transfusion Reactions (ATR’s)• Chronic Transfusion Reactions• Transfusion related infections
  39. 39. Acute Transfusion Reactions• Hemolytic Reactions (AHTR)• Febrile Reactions (FNHTR)• Allergic Reactions• TRALI(Transfusion related acute lung injury)• Coagulopathy with Massive transfusions• Bacteremia
  40. 40. Frequency of Transfusion Reactions Adverse Effect Frequency Comments Acute Hemolytic Rxn 1 in 25,000 Red cells only Anaphylactic hypotensive 1 in 150,000 Including IgA Febrile Nonhemolytic 1 in 200 Common Allergic 1 in 1,000 Common Delayed Hemolytic 1 in 2,500 Red cells only RBC alloimmunization 1 in 100 Red cells only WBC/Plt 1 in 10 WBC and Plt only alloimmunization
  41. 41. Acute Hemolytic Transfusion Reactions (AHTR)• Occurs when incompatible RBC’s are transfused into a recipient who has pre-formed antibodies (usually ABO or Rh)• Antibodies activate the complement system, causing intravascular hemolysis• Symptoms occur within minutes of starting the transfusion• This hemolytic reaction can occur with as little as 1-2 cc of RBC’s• Labeling error is most common problem• Can be fatal
  42. 42. Symptoms of AHTR• High fever/chills• Hypotension• Back/abdominal pain• Oliguria• Dyspnea• Dark urine• Pallor
  43. 43. What to do? If an AHTR occurs• STOP TRANSFUSION• ABC’s• Maintain IV access and run IVF (NS or LR)• Monitor and maintain BP/pulse• Give diuretic• Obtain blood and urine for transfusion reaction workup• Send remaining blood back to Blood Bank
  44. 44. Blood Bank Work-up of AHTR• Check paperwork to assure no errors• Check plasma for hemoglobin• Repeat crossmatch• Repeat Blood group typing• Blood culture
  45. 45. Labs found with AHTR• Hemoglobinemia• Hemoglobinuria• Hyperbilirubinemia• Abnormal DIC panel
  46. 46. Febrile Nonhemolytic Transfusion Reactions (FNHTR)• Definition--Rise in patient temperature >1 C (associated with transfusion without other fever precipitating factors)• Occurs with approx 1% of PRBC transfusions and approx 20% of Plt transfusions• FNHTR caused by alloantibodies directed against HLA antigens• Need to evaluate for AHTR and infection
  47. 47. Allergic Nonhemolytic Transfusion Reactions• Etiology – May be due to plasma proteins or blood preservative/anticoagulant – Best characterized with IgA given to an IgA deficient patients with anti-IgA antibodies• Presents with urticaria and wheezing• Treatment – Mild reactions—Can be continued after Benadryl – Severe reactions—Must STOP transfusion and may require steroids or epinephrine• Prevention—Premedication (Antihistamines)
  48. 48. TRALI Transfusion Related Acute Lung Injury• Clinical syndrome similar to ARDS• Occurs 1-6 hours after receiving plasma- containing blood products• Caused by WBC antibodies present in donor blood that result in pulmonary leukostasis• Treatment is supportive• High mortality
  49. 49. Monitoring in AHTR• Monitor patient clinical status and vital signs• Monitor renal status (BUN, creatinine)• Monitor coagulation status (DIC panel– PT/PTT, fibrinogen, D- dimer/FDP, Plt, Antithrombin-III)• Monitor for signs of hemolysis (LDH, bili, haptoglobin)
  50. 50. Bacterial Contamination• More common and more severe with platelet transfusion (platelets are stored at room temperature)• Organisms – Platelets—Gram (+) organisms, ie Staph/Strep – RBC’s—Yersinia, enterobacter• Risk increases as blood products age (use fresh products for immunocompromised)
  51. 51. Chronic Transfusion Reactions• Alloimmunization• Transfusion Associated Graft Verses Host Disease (GVHD)• Iron Overload• Transfusion Transmitted Infection
  52. 52. Transfusion Associated Infections• Hepatitis C• Hepatitis B• HIV• CMV – CMV can be diminished by leukoreduction, which is indicated for immunocompromised patients
  53. 53. ABO System & Pregnancyhemolytic diseases of the newborn may be due toABO incompatibilityABO incompatibility is a common and generally mildtype of haemolytic disease in babies. The termhaemolytic disease means that red blood cells arebroken down more quickly than usual which cancause jaundice, anaemia and in very severe cases cancause death. During pregnancy, this breakdown of redblood cells in the baby may occur if the mother andbaby’s blood types are incompatible and if thesedifferent blood types come into direct contact witheach other and antibodies are formed.
  54. 54. Significant problems with ABO incompatibilityoccur mostly with babies whose mothershave O blood type and where the baby iseither A or B blood type. Premature babiesare much more likely to experience severeproblems from ABO incompatibility, whilehealthy full term babies are generally onlymildly affected. Unlike haemolytic diseasethat can result in subsequent babies when amother has a negative blood group, ABOincompatibility can occur in first-born babiesand does not become more severe in furtherpregnancies
  55. 55. After birth there are two options for testingfor ABO incompatibility:The cord blood of all babies whose mothershave an O blood group and the father eithertype A or B blood is tested The theory behindthis approach is that if the baby is type A or Band they test positive in direct antiglobulintests (DAT), the baby can then be followedclosely for jaundice.The alternate approach is to screen any babywho becomes significantly jaundiced(particularly within the first 24 hours
  56. 56. Rh FACTOR• This can induce varying degrees of anemia in the foetus, with hiperbilirubinemia, organ malfunction, etc. Bilirubin deposition in the cerebral basal ganglia (kernicterus)can lead to severe mental damage. Severe cases of this disease were mortal.• Prevention started in the 60s and nowadays Rh negative pregnant women receive immunoglobulin doses at several moments during pregnancy and after childbirth if the baby is Rh positive. Besides, women in fertile age are never transfused Rh positive blood. Thus, HDN due to Rh antibodies has practically disappeared in developed countries.
  57. 57. Rhesus Isoimmunization Rhesus Iso immunization is an immunologic disease that occurs in pregnancy resulting in a serious complication affecting the fetus / or the neonate ranging from … mild neonatal jaundice … to intra uterine loss or neonatal death
  58. 58. Rhesus Isoimmunization This immunologic disease occur when a Rh – negative patient carrying a Rh – positive fetus ….. had a feto – maternal blood transfusion ….. the mother immunological system is stimulated to produce antibodies to the Rh antigen on the fetal blood cell ….. This antibodies cross the placenta and destroy fetal red blood cells leads to fetal anemia …. Usually the 1st fetus will not be affected if this is the 1st time that the mother has been exposed to the rhesus positive antigen
  59. 59. Managementof rhesus negative pregnant womenManagement of non sensitized PregnancyManagement of sensitized Pregnancy
  60. 60. Prophylactic Management of non sensitized Pregnancy During antenatal period Prophylactic (500 IU / 100 mcg ) Anti D are recommended to be given to all negative non sensitized mothers married to Rh positive husband at 28weeks and 34 weeks to protect and overcome any asymptomatic or un noticed antenatal feto maternal blood transfusion
  61. 61. Management of Sensitized PregnancyIntra uterine therapy Intra peritoneal blood transfusion Through the umbilical vein “ Cordocentesis 80 % of packed cell “ o “ rhesus negative Blood Cross matched against maternal blood group Free of infection Fresh
  62. 62. ThAnk You!Hope you learned something!