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- 1. RATIONAL BLOOD USE.. ...and itscomponents.
- 2. TOPIC • Historical interest • Blood process • Blood product • Indication • S pecial consideration • Complication
- 4. THEFIRST BLOOD TRANSFUSION ATTEMPT • In 1492 "the harrowingstory wastold that,at the suggestion of aJewish physician,the blood of three boyswas infused into the dying pontiff’smouth (the concept of circulation and methodsfor intravenousaccess did not exist at that time).They were ten yearsold, andhad been promised aducat each.All three died." Diario della città di Roma di Stefano Infessura scribasenato.15th cent.
- 5. BLOOD AND CIRCULATION • In 1628William 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 acircuit.
- 6. TRANSFUSION ATTEMPTS • In 1667 Jean-Baptiste Denys,French physician,performed transfusion with sheep'sand calf'sblood. • In 1818 Ja mes Blundell,successfully performed transfusionfor postpartum hemorrhage,usingpatient'shusband'sblood. • In 1905 GeorgeWashington Crile,co- founder of Cleveland Clinic,wasthe first surgeon who used direct blood transfusion in surgery.
- 7. BLOOD GROUPING • In 1901,Karl Landsteiner discovered human blood groups. Blood transfusion had become alot safer since then.
- 8. DEVELOPMENT OFBLOOD BANKING • Anticoagulant was discovered in 1910,making the way to blood banking. • First stored blood wassuccessfully transfused in 1916 by Oswald Hope Robertson, an English-born medical scientist,duringWorldWar 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 ISDONATED BLOOD PROCESSED? • Blood and blood componentscome from potential donors. • Whole blood was used in first era of transfusion but blood componentsare now wildly used for better efficient management.
- 12. LEUKOCYTEREDUCTION • WBC less than 5 x 106/unit* • Reduced febrile reaction risk • Reduced CMV transmission • Reduced HLA- alloimmunization risk
- 13. IRRADIATION • Inactivate donor’sT-cells • Reduced GVHD risk • Reduce shelf life to 28 days • Increased K+ leak
- 14. SINGLEDONORPRODUCT • Reduce donor exposure • S ingle 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 • 10ml/kg raise Hct ~10%
- 19. 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%
- 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 kgraise 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 RBC 5 ml • Comparable to Plt.conc.4-6 units (6 - 8 units for SDP)
- 23. 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)
- 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 factorVIII,XIII, vonWillebrand factor, fibrinogen • 1-2 units/ 10 kgraise fibrinogen 100 mg/dL • Not require group matching
- 26. INDICATION
- 27. THRESHOLD FORRBC 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. P ATIENT WHO SHOULD NOT BETRANSFUSED • 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 • InAPL 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 • In general each milliliter of plasma count as100% factor activity • If coagulogram ≤1.5 times of normal,other causes of abnormal bleeding should be sought 100% + 0% = 50% Hemostat level = 40%
- 32. CRYOPRECIPITATE • Use for replacing factorVIII,factor XIII,vonWillebrand factor, fibrinogen
- 34. SP ACIAL 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. PLATELETTRANSFUSION IN RH NEGATIVE • Check if patient already have Rh antibody • Give anti-D IgG before or within 72 hr after platelet transfusion • 100 unitscan neutralize RBC 5 ml • 300 unitscan neutralize Plt.conc.30 unitsor LPPC 3 units
- 37. MISMATCHTRANSFUSION • 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 asplasma due to high plasma content • Platelet recovery will be less than expected
- 38. TRANSFUSION COMP ATIBILITY Blood group Compatible Compatible A A, O 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. MASSIVETRANSFUSION • 1Total 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. • Correct blood component processing • Correct sample takingand labeling • Correct crossmatch technique • Correct blood component label • Correct patient identification TRANSFUSION PRACTICE
- 43. TRANSFUSION PRACTICE • Check if bagsare in good condition • No leakage • No fibrin clot • Record vital sign at before,start,15 min after,1 hr after, and 4 hr after transfusion
- 45. COMPLICATION OF BLOOD TRANSFUSION • Immediate hemolytic transfusion reaction • Delayedhemolytic transfusion reaction • Bacterial contamination • Allergic reaction • Febrile nonhemolytic transfusion reaction • Transfusion-related acute lung injury • Transfusion-related graft- versus-host disease • P ost transfusion purpura
- 46. IMMEDIATEHEMOLYTIC TRANSFUSION REACTION • ABO incompatibility is the most common cause • Can be fatal even 30 ml of incompatible blood • Intravascular hemolysis • Renal failure • Shock
- 47. IMMEDIATEHEMOLYTIC TRANSFUSION REACTION • Chill • Dark urine • Fever • Shock • Flank • DIC pain • Red serum
- 55. IMMEDIATEHEMOLYTIC TRANSFUSION REACTION FXII generate bradykinin histamine serotonin anaphylotoxic activity
- 56. IMMEDIATEHEMOLYTIC TRANSFUSION REACTION FXII generate bradykinin histamine serotonin anaphylotoxic activity
- 57. IMMEDIATEHEMOLYTIC 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. • Occur 1 wk after transfusion • Anamnestic immune response • Extravascular hemolysis • Usually subtle symptoms • Antibody gradually decrease after expose to antigen DELAYED HEMOLYTIC TRANSFUSION REACTION
- 59. BACTERIAL CONTAMINATION • Platelet prone to have bacterial overgrowth • Y ersinia enterocollitca can grow at 6°c etc. • Antibiotic should be started if suspectedbacterial 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. FEBRILENONHEMOLYTIC TRANSFUSION REACTION • Fever • Caused by alloantibody to HLA antigen on Plt.or WBC • No specific treatment • Must differentiate from other causesof fever
- 62. TRANSFUSION RELATED ACUTE LUNG INJURY • TRALI • Cause by alloantibody from donor to WBC of recipient • Occur within 6 hours after transfusion • S ymptoms is the same as ARDS
- 63. TRANSFUSIONRELATED GRAFT-VERSUS-HOST DISEASE • Cause by engraftment of donorT-cells • Damage to epithelium and bone marrow • Fatal condition • Prevent with irradiation of blood component withT-cells
- 65. P ATIENT IN RISKOFGVHD FROMTRANSFUSION • Bone marrow transplant patient • Intrauterine transfusion • Hx of fludarabine use (follicular lymphoma,CLL,AML) • HLA matched transfusion • Transfusion from relatives • S evere congenital immunodeficiency
- 66. PROTOCOLFOR 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 BPand urine output Aware of renal complication
- 67. PROTOCOLFOR COMPLICATION EPISODE Check label and patient’sidentification Draw blood from patient Examine transfusing blood Centrifuge for serum color Coomb test Blood group Hemoculture Blood group Re-crossmatch with pre- and post-transfusionsamples Hemoculture
- 68. PROTOCOLFOR COMPLICATION EPISODE Identify defect in the system Prevent future event Solution No accusing investigation
- 69. FIN