asics_of_transfusion_therapy.pp

1. Basics of
Transfusion
Therapy
Resident Education
Lecture Series

2. Hemoglobin Level and Symptoms
HGB (GM%) SYMPTOMS
9-11 MINIMAL
7.5 EXERTIONAL DYSPNEA
6.0 WEAKNESS
3.0 DYSPNEA AT REST
2-2.5 HEART FAILURE
LINMAN
NEJM 279:812, 1968

3. RBC Transfusion: Indications
 Acute Blood Loss
 Symptomatic Anemia
 Suboptimal O2 Capacity
 Exchange (SS, Co)

4. RBC Transfusion: The Bathtub Principle
Kidney
Kidney
Kidney
100
30
0
100
40
0
Blood Volume Blood Volume
Blood Volume
100
30
0

5. Pre-Transfusion Testing
 BLOOD TYPING:
 ABO, D Antigens only
(Other antigens are weak immunogens)
 ANTIBODY SCREEN:
 Patient serum vs. cell panel
 CROSSMATCH
 Major: Patient Serum vs. Donor Cells

6. RBC Products
 PRBC MOST TRANSFUSIONS
 WHOLE BLOOD ACUTE BLEEDING
EXCHANGE
PLASMA NEEDED
 WASHED REMOVE PLASMA
 FROZEN RARE RBC PHENOTYPE
 IRRADIATED IMMUNODEFICIENT
 CMV NEGATIVE IMMUNODEFICIENT
SERONEGATIVE, NEONATE

7. RBC Transfusion Volume
 Usual: Up to 15cc/Kg in 3-4 hours
 Unusual: Acute Hemorrhage:
replace ongoing losses
Chronic Anemia, Heart Failure, îBP
2cc/Kg/Gm HGB
Diuretic
Exchange

8. Transfusion Volume
 10cc/Kg PRBC 2.4 GM% in HGB
10cc/kg = X cc/kg
2.4 GM% Desired HGB rise
 PRBC cc = Blood Volume x (HGBF- HGBI)
HGBT
BV=70cc/KG, 80-90cc/KG newborn

9. Hemolytic Transfusion Reactions
 Acute HTR 1/25,000
Fatal Acute HTR 1-4/1,000,000
 Delayed HTR 1/5-10,000

10. Symptoms and Signs of Acute
Hemolytic Reactions
 Severe Back Pain
 Substernal Tightness, Dyspnea
 Hypotension / Circulatory collapse
 Vomiting, diarrhea
 Icterus
 Hemoglobinuria
 Renal shutdown
 Diffuse Oozing from wounds/punctures

11. Response to Suspected Hemolytic
Reaction
 Stop Transfusion
 Hydrate
 Specimens to Blood Bank
Unit/Bag
Serum
Red cells
Urine

12. Acute Hemolysis: Diagnosis
 Do a direct antiglobulin test on post-
transfusion sample
 Obtain post-transfusion blood and urine and
inspect visually
 Recheck paperwork
 Recheck ABO type of unit and pre-and post-
transfusion specimens
 Run urinalysis - to check for hemoglobinuria

13. Cause of Acute HTR
 ABO incompatibility:source of error
10% at phlebotomy/labeling
23% in Transfusion Lab
67% transfusion administration (at the
bedside)

14. Nonhemolytic Transfusion Reactions
 Leukocyte Associated
 FNHTR
 Transfusion GVHD
 Neonatal Neutropenia
 Immunoglobulin Associated
 Urticaria/Fever
 Ig E
 TRALI
 Platelet Associated
 Post transfusion Purpura
 Neonatal Thrombocytopenia
 Metabolic/ Physical
 Citrate Toxicity
 Hypothermia
 Circulatory Overload
 Massive Transfusions
 Haemostatic Abnormalities
 Metabolic complications
 Hgb-O2 Curve Shift

15. TRANSFUSION-RELATED INFECTION

16. Risk of Transfusion-
Transmitted Infection
HIV 1 in 2,000,000
Hepatitis C 1 in 2,000,000
Hepatitis B 1 in 175,000
Hepatitis A Rare
HTLV I/II 1 in 3,000,000
Bacteria 1/3,000 (for platelets)
Malaria, T Cruzi, Babesia, Yersinia,
Syphilis, Lyme, CJD, West Nile Virus…??

17. Post Transfusion HCV
Percent Number
Incidence 5-10 150-300,000
Chronic 50 75-150,000
Cirrhosis 20 15-30,000

18. Neonatal Post Transfusion CMV
 Incidence: 25% of seronegative infants
receiving >50ml CMV
seropositive blood
 Severity 50% severe or lethal manifestations

19. Neonatal Transfusion CMV
Prevention by Filtering Blood
Seroconvert/Total
Filtered PRBC: 0/30
Unfiltered PRBC: 9/42
Gilbert, L1:98:228, 1989

20. Prevention of Post Transfusion
Infection
 Don’t Transfuse
 Minimize Transfusion
 Limited Donors (dedicated units)
 Autologous Transfusions
 Erythropoetin
 Donor Screening: HIV Ab, HIV NAT, HCV Ab,
HCV NAT, HBV Ag, Ab, HBc Ab, VDRL, West
Nile NAT, HTLVI/II Ab, CMV Ab, Bacterial
Culture (Platelets)

21. Strategies to Decrease Operative RBC
Transfusion
Hemostasis
Hemodilution
Cell salvage
DDAVP
Autologous Transfusion
Erythropoetin

22. Neutropenia: infection risk
0
10
20
30
40
50
60
0 1 2 3 4 5
PMNs (/microL)
%
patient
days
with
infection
100 100-500 500-1000 1000
Relapse
Remission
Bodey. Ann Int Med 64:328, 1966.

23. WBC Indications 2004
 PMN: Newborn Sepsis
Congenital/Acquired Neutropenia
PMN Dysfunction
Refractory Gram Negative Sepsis
 Ly: Disseminated Varicella-Zoster

24. WBC transfusion:
Logistics
 Donors Receive G-CSF +/- Decadron
 2-3 Hour Cytapheresis
 1010 Cells by Standards
 Donors pretested for ID markers
 Cells decay rapidly: limited value at
> 6 hours post-collection
 Quantitative impact limited

25. Fresh Frozen Plasma
 200-250 ml of plasma containing all
clotting factors, AT III, Protein C & S.
 Compatibility Important
 Can Give: A plasma to A or O patient
B plasma to B or O patient
O plasma to O patient
AB plasma to anyone

26. Indications: FFP
 Replacement of Coagulation Factors
 Abnormal Bleeding with coagulopathy
 Multiple factor deficiency:
 Liver disease
 DIC
 Reversal of Warfarin
 Dilutional
 Isolated factor deficiency-no concentrate
 Factor XI, XIII
 Replacement of regulatory proteins
 TTP, Hereditary angioedema
 Not indicated for: volume expansion, reversal of
Heparin, correction of INR < 1.5

27. Guidelines: FFP Use
 Usual dosing: Adult 10ml/Kg
Peds 10-15ml/Kg
 15-20% rise in factor levels
 Usually does not correct laboratory
coagulation status to “normal”

29. Cryoprecipitate
 10-15 ml per unit (bag)
 Fibrinogen 250 mg
 Factor VIII 80-120 units
 Von Willebrand Factor 40-70% of FFP
 Factor XIII 20-30% of FFP
 Fibronectin 20-40 mg

30. Cryoprecipitate: Dosing
 1-2 Units / 10 Kg
 Expect 60-100 mg/dl rise in fibrinogen
 Goal: Fibrinogen 70-100 mg/dl

33. Platelets: Risk of Spontaneous
Hemorrhage
Count Site
> 40,000 Minimal
20-40,000 GI Mucosa
5-20 Skin, Mucus Membranes
< 5 CNS, Lung

35. 0
10
20
30
40
0 50 100 150 200 250 300
Platelets (/microL)
Bleeding
time
(min)
ITP
AA
WAS
ASA
U
r
e
m
i
a
vWD
Harker. NEJM 287:155, 1972.

36. Prophylactic Platelet TX Guidelines
Platelet Count/μl Recommendation
0-5,000 Always
5-10,000 If Febrile of Minor Bleeding
11-20,000 If coagulopathy or minor
procedure
>20,000 If Major Bleed or invasive
procedure

37. Transfused Platelets/Survival
 6 units = 1 single donor unit (SDP);
available as ¼, ½ and full SDP
 Dose: child 1 unit/5-6 kg
adult 1 unit/8-10 kg
 Lifespan: 7-10 Days Native
2-3 Days Transfused
 Factors shortening Lifespan:
 Fever, Sepsis
 HLA, Platelet Specific Abs
 DIC
 Product Age?

38. TRAP Trial
Effect of Leukodepletion on Alloimmunization
No Rx
pooled
Filter
Pooled
UV-B
Pooled
Filter
SDP
Number 131 137 130 132
LCYTX-AB 45% 18% 21% 17%
LYCTX-AB
refractory
13% 3% 5% 4%

40. When in Doubt: Call the Transfusion
Service!
266-2119

42. From ABP
Certifying Exam Content Outline
 2. Transfusion and collection of blood
 Understand the risk of transmitting infectious
diseases during blood transfusion(s)
 Recognize that erythrocyte transfusions may be
associated with hemolytic, febrile, and urticarial
reactions
 Understand the role of erythrocyte transfusions
in the management of anemia

43. Credits
 Bruce Camitta MD
M W Lankiewicz MD