Rational use of blood component
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Review general usage of blood components and basic transfusion medicine.
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Rational use of blood component
- 1. RATIONAL BLOOD USE.. ...and its components.
- 2. TOPIC • Historical interest • Blood process • Blood product • Indication • Special consideration • Complication
- 4. THE FIRST BLOOD TRANSFUSION ATTEMPT • In1492 "the harrowing story was told that, at the suggestion of a Jewish physician, the blood of three boys was infused into the dying pontiff ’s mouth (the concept of circulation and methods for intravenous access did not exist at that time). They were ten years old, and had been promised a ducat each. All three died." Diario della città di Roma di Stefano Infessura scribasenato. 15th cent.
- 5. BLOOD AND CIRCULATION • In 1628 William Harvey published De Motu Cordis (On the Motion of the Heart and Blood) revealed the action of the heart pumping blood around the body in a circuit.
- 6. TRANSFUSION ATTEMPTS • In 1667 Jean-Baptiste Denys, French physician, performed transfusion with sheep's and calf's blood. • In 1818 James Blundell, successfully performed transfusion for postpartum hemorrhage, using patient's husband's blood. • In1905 George Washington Crile, co- founder of Cleveland Clinic, was the first surgeon who used direct blood transfusion in surgery.
- 7. BLOOD GROUPING • In 1901, Karl Landsteiner discovered human blood groups. Blood transfusion had become a lot safer since then.
- 8. DEVELOPMENT OF BLOOD BANKING • Anticoagulant was discovered in 1910, making the way to blood banking. • First stored blood was successfully transfused in 1916 by Oswald Hope Robertson, an English-born medical scientist, during World War I. • The first academic transfusion institution was found by Alexander Bogdanov in Moscow. • After Bogdanov's death Soviet established the world's first blood bank in 1930s by Sergei Sergeevich Yudin at Nikolay Sklifosovskiy Institute.
- 10. HOW IS DONATED BLOOD PROCESSED? • Blood and blood components come from potential donors. • Wholeblood was used in first era of transfusion but blood components are now wildly used for better efficient management.
- 12. LEUKOCYTE REDUCTION • WBC less than 5 x 106/unit* • Reduced febrile reaction risk yte oc ! Le uk d! duce • Reduced CMV transmission re • ReducedHLA- alloimmunization risk
- 13. IRRADIATION • Inactivate donor’s T-cells • Reduced GVHD risk • Reduce shelf life to 28 days • Increased K+ leak
- 14. SINGLE DONOR PRODUCT • Reduce donor exposure • Single HLA antigen
- 15. BLOOD PRODUCT
- 16. WHOLE BLOOD •Volume 350 or 450 ml •Contain red cell, white cells, platelets, and plasma •Stored at 2-6°c •No functional platelets and labile factors •May indicated in neonatal blood exchange
- 17. PACKED RED BLOOD CELL •Volume ~300 ml •Hct ~75% •Contain red cells, white cells, small of plasma •Stored at 2-6°c •10ml/kg raise Hct ~10%
- 18. PACKED RED BLOOD CELL •Volume ~300 ml •Hct ~75% •Contain red cells, white cells, small of plasma •Stored at 2-6°c yte oc ! Le uk d! •10ml/kg raise Hct ~10% ce re du
- 19. PACKED RED BLOOD CELL •Volume ~300 ml •Hct ~75% •Contain red cells, white cells, small of plasma •Stored at 2-6°c yte oc ! Le uk d! •10ml/kg raise Hct ~10% ce re du
- 20. PLATELET CONCENTRATE •Volume ~50 ml • Contain platelet 5.5 x 1010 RBC 0.5 ml and white cells •Stored at 20-26°c with continuous rocking shelf •1 unit/10 kg raise platelet 20,000-50,000 ml/mcL
- 21. POOLED LEUKOCYTE- POOR PLATELET •Made of 4 unit of whole blood •Contain platelet 3 x 1011 and RBC 5 ml •Comparable to Plt. conc. 4-6 units (6 - 8 units for SDP)
- 22. POOLED LEUKOCYTE- POOR PLATELET •Made of 4 unit of whole blood •Contain platelet 3 x 1011 and yte oc ! RBC 5 ml Le uk d! duce •Comparable to Plt. conc. 4-6 re units (6 - 8 units for SDP)
- 23. POOLED LEUKOCYTE- POOR PLATELET •Made of 4 unit of whole blood •Contain platelet 3 x 1011 and yte oc ! RBC 5 ml Le uk d! duce •Comparable to Plt. conc. 4-6 re units (6 - 8 units for SDP)
- 24. FRESH FROZEN PLASMA •Volume 250 ml •Contain all coagulation factor •10-15 ml/kg raise factor ~25% •Stored at -18°c
- 25. CRYOPRECIPITATE •Volume 15 ml •Contain factor VIII, XIII, von Willebrand factor, fibrinogen •1-2 units/ 10 kg raise fibrinogen 100 mg/dL •Not require group matching
- 26. INDICATION
- 27. THRESHOLD FOR RBC TRANSFUSION • Hb < 7 g/dL in general patient • Hb < 10 g/dL in patient with ischemic heart disease • Hb < 10 g/dL in pre-operative patient or bleeding patient* • In symptomatic or frail patient*
- 28. PATIENT WHO SHOULD NOT BE TRANSFUSED • Nutritional anemia • Autoimmune hemolytic anemia • Patient with high peripheral blast count
- 29. PLATELET REQUIREMENT • In bleeding patient: keep platelet > 50,000 - 80,000/mcL • Bleeding in vital organ: keep platelet > 100,000/mcL • In chronic thrombocytopenia: keep > 10,000/mcL • In DIC keep platelet > 20,000/mcL • In APL keep platelet > 30,000 - 50,000/mcL
- 30. PLATELET CONTRAINDICATE • Thrombotic thrombocytopenic purpura • Heparin induced thrombocytopenia • Disseminated intravascular coagulation without bleeding*
- 31. FRESH FROZEN PLASMA • Ingeneral each milliliter of plasma count as 100% factor activity 100% + 0% = 50% Hemostat level = 40% • Ifcoagulogram ≤1.5 times of normal, other causes of abnormal bleeding should be sought
- 32. CRYOPRECIPITATE • Use for replacing factor VIII, factor XIII, von Willebrand factor, fibrinogen
- 34. SPACIAL CONSIDERATION • Rh negative patient • Mismatch transfusion • Platelet refractoriness • Massive transfusion
- 35. RH NEGATIVE • Rh negative is determined by absence of D antigen • Antibody occur 4 - 8 wks after expose to D antigen • Rh negative person should receive only Rh negative blood • Platelets have no Rh antigen but contaminated RBC can induce antibody
- 36. PLATELET TRANSFUSION IN RH NEGATIVE • Check if patient already have Rh antibody • Give anti-D IgG before or within 72 hr after platelet transfusion • 100 units can neutralize RBC 5 ml • 300 units can neutralize Plt. conc. 30 units or LPPC 3 units
- 37. MISMATCH TRANSFUSION • Transfuse packed red cell without foreign antigen to avoid major mismatch reaction • Transfuse plasma without offending antibody to avoid minor mismatch reaction • Platelet is considered as plasma due to high plasma content • Platelet recovery will be less than expected
- 38. TRANSFUSION COMPATIBILITY Blood group Compatible Compatible A RBC A, O Plt. & FFP A, AB B B, O B, AB AB AB, A, B, O AB O O O, A, B, AB
- 39. PLATELET REFRACTORINESS • Corrected count increment (CCI) < 3,000/mcL • Corrected count increment = (Pre - Post) x Body surface area Transfused platelet
- 40. PLATELET REFRACTORINESS • Immune • Non-immune • Alloimmunization • Infection, fever • Autoimmune • Hypersplenism • Drug-related antibody • DIC • ABO incompatibility • BMT patient • Ampho B • etc.
- 41. MASSIVE TRANSFUSION • 1 Total blood volume within 24 hr. • Keep platelet > 50,000/mcL • Keep coagulogram less than 1.5 times • Not recommend 1:1:1 transfusion protocol
- 42. TRANSFUSION PRACTICE • Correct blood component processing • Correct sample taking and labeling • Correct crossmatch technique • Correct blood component label • Correct patient identification
- 43. TRANSFUSION PRACTICE • Check if bags are in good condition • No leakage • No fibrin clot • Recordvital sign at before, start, 15 min after, 1 hr after, and 4 hr after transfusion
- 44. COMPLICATION OF BLOOD TRANSFUSION
- 45. COMPLICATION OF BLOOD TRANSFUSION • Immediate hemolytic • Febrilenonhemolytic transfusion reaction transfusion reaction • Delayed hemolytic • Transfusion-related acute transfusion reaction lung injury • Bacterial contamination • Transfusion-related graft- versus-host disease • Allergic reaction • Post transfusion purpura
- 46. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION • ABO incompatibility is the most common cause • Can be fatal even 30 ml of incompatible blood • Intravascular hemolysis • Renal failure • Shock
- 47. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION • Chill • Dark urine • Fever • Shock • Flank • DIC pain • Red serum
- 51. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION C5 C3
- 52. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION CC5 5b a CC3 3b a
- 53. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION a CC5 5b C5 CC3 3b C3a
- 54. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION a CC5 5b C5 CC3 3b C3a anaphylotoxic activity
- 55. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION FXII generate bradykinin histamine serotonin a CC5 5b C5 CC3 3b C3a anaphylotoxic activity
- 56. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION c k ! FXII generate bradykinin Sho histamine serotonin a CC5 5b C5 CC3 3b C3a anaphylotoxic activity
- 57. IMMEDIATE HEMOLYTIC TRANSFUSION REACTION • IV fluid maintain urine output 100 ml/hr • Furosemide or mannitol if needed • Maintain blood pressure • Check label • Re-crossmatch on pre- and post-transfusion samples • Prevention future event
- 58. DELAYED HEMOLYTIC TRANSFUSION REACTION • Occur 1 wk after transfusion • Anamnestic immune response • Extravascular hemolysis • Usually subtle symptoms • Antibody gradually decrease after expose to antigen
- 59. BACTERIAL CONTAMINATION • Platelet prone to have bacterial overgrowth enterocollitca can • Yersinia grow at 6°c etc. • Antibioticshould be started if suspected bacterial contamination
- 60. ALLERGIC REACTION • Allergic to plasma protein of donor • Can give antihistamine to relieve symptoms • In IgA deficiency patient should avoid plasma product
- 61. FEBRILE NONHEMOLYTIC TRANSFUSION REACTION • Fever • Caused by alloantibody to HLA antigen on Plt. or WBC • No specific treatment • Must differentiate from other causes of fever
- 62. TRANSFUSION RELATED ACUTE LUNG INJURY • TRALI • Causeby alloantibody from donor to WBC of recipient • Occur within 6 hours after transfusion • Symptoms is the same as ARDS
- 63. TRANSFUSION RELATED GRAFT-VERSUS-HOST DISEASE • Cause by engraftment of donor T-cells • Damage to epithelium and bone marrow • Fatal condition • Prevent with irradiation of blood component with T-cells
- 64. Recognize T T Engraft Reject Recipient tissue HLA antigen T T-cells Transfusion related GVHD
- 65. PATIENT IN RISK OF GVHD FROM TRANSFUSION • Bone marrow transplant patient • Intrauterine transfusion • Hx of fludarabine use (follicular lymphoma, CLL, AML) • HLA matched transfusion • Transfusion from relatives • Severe congenital immunodeficiency
- 66. PROTOCOL FOR COMPLICATION EPISODE Chill, fever, rash, flank pain, chest tightness, vital sign change, alteration of consciousness, dark urine Stop transfusion! Check vital sign, load IV fluid maintain BP and urine output Aware of renal complication
- 67. PROTOCOL FOR COMPLICATION EPISODE Check label and patient’s identification Draw blood from patient Examine transfusing blood Centrifuge for serum color Blood group Coomb test Re-crossmatch with pre- and Blood group post-transfusion samples Hemoculture Hemoculture
- 68. PROTOCOL FOR COMPLICATION EPISODE Identify defect in the system No accusing investigation Solution Prevent future event
- 69. FIN
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