Hematology

1. TRANSFUSION
THERAPY
PRESENTER: DR HASSAN (IMR1)
MODERATOR : DR BINIYAM
( CONSULTANT INTERNIST,
HEMATOLOGIST)

2. Outline
• Blood group antigens and antibodies
• Blood components
• Donor selection
• Pretransfusion testing
• Indication of transfusion
• Complications of transfusion

3. HUMAN BLOOD GROUP ANTIGENS AND ANTIBODIES
• A blood group antigen is a sugar or protein
present on the surface of the RBC
• Antigens systems important in transfusion
medicine comprise:
• ✓Red blood cell (RBC) antigens
• ✓Platelet antigens
• ✓Neutrophil antigens, and
• RH system

5. Donor
selection
 General physical
examination
• General Appearance : should appear to be in
good health.
• Age :18-65 years.
• Weight : 45-55 Kg - 350 ml blood,55 Kg &
above - 450 ml.
• Temp : < 37.5 C
• Pulse : 60 to 100 beats/min & regular pulse
• Blood Pressure : SBP :100-160 mm of Hg,
DBP :60-90 mm of Hg
• Skin : free of any skin lesion or infections

6. • Medical History
• History of malaria : accepted after 3 months.
• History of being HIV, HBsAg / HCV antibody positive: permanently deferred.
• Not accepted During period of pregnancy and till 12 months after full term delivery and
also during lactation.
• Surgery Procedures
• Major : one year after the recovery.
• Minor : 6 months
• ➢Laboratory examination :
• Hemoglobin : not less than 12.5mg/dl.

7. Pretransfusion Testing

8. Indications for Transfusion
• Whole Blood
• collected in bag containing anticoagulants; CPDA
• provides both oxygen-carrying capacity and volume expansion.
• Stored at 4°C to maintain erythrocyte viability.
• It is the ideal component for patients who have sustained acute
hemorrhage of ≥25% total blood volume loss.

10. Red blood cells concentrates
• Increases oxygen-carrying capacity in the anemic patient.
• stored in additive solution up to 35–42 days at 4°C.
• A single PRBC unit will raise the Hgb by 1 g/dL and Hct by
3% in adults.

14. Platelets
• Platelets are stored in additive solution up
to 3–7 days at 20–24°C and under
permanent motion.
• From 100ml to 700ml containing >/= 2*1011
platelets
• can be transfused therapeutically (i.e. to
treat active bleeding or in preparation for an
invasive procedure that would cause
bleeding), or prophylactically (i.e. to
prevent spontaneous bleeding).
• One unit of whole blood yields 50‐60 mL of
plasma with 55 x 103 /ul platelets and
≥
raise serum platelet by 5- 10 x 103/ul

15. Prophylactic
indications
• Most afebrile patients with platelet counts
below 10,000/microL due to bone marrow
suppression.
• We use higher thresholds (ie, 20,000 to
30,000/microL) in patients who are febrile
or septic.
• Patients with acute promyelocytic
leukemia (APL) have a coexisting
coagulopathy (30,000 to 50,000/microL).
• The threshold for prophylactic transfusion
can also vary depending on the patient and
on the clinical scenario.

16. Refractoriness to platelet transfusion
• Failure to observe a post-transfusion platelet increment of
at least 10,000/microL is considered suspicious for
refractoriness.

19. Fresh frozen plasma
• contains stable coagulation factors and plasma proteins: fibrinogen,
antithrombin, albumin, as well as proteins C and S.
• Plasma from fresh whole blood is rapidly frozen at less than 30°C within
8 hrs of collection
• Volume – 200 to 250 ml, Each unit of FFP increase the clotting protein by
2.5 – 5%
• Stored at < -30°C for up to 1 year.
• Should be thawed at +30°C - +37°C before use.
• FFP is an acellular component and does not transmit intracellular
infections.

20. Indications for FFP include:-
• correction of coagulopathies, including the rapid reversal of warfarin
• supplying deficient plasma proteins
• Cardiopulmonary by pass surgery with bleeding
• treatment of auto-antibody-mediated thrombotic thrombocytopenic
purpura (TTP).
• For extremely high INRs, you will likely need to give more than 4 units
• considered for lowering the INR only when the patient's INR is 1.6
≥
• To have a significant change on clotting status, you need to get at least
10% increase in clotting factor levels

21. Complications of transfusion
• Adverse reactions to transfused blood components occur despite
multiple tests, inspections, and checks.
• Fortunately, the most common reactions are not life threatening.
• When an adverse reaction is suspected, the transfusion should be stopped and
reported to the blood bank for investigation.
• Methods to reduce complications
• Avoid unnecessary transfusion
• Appropriate patient sample & product labeling, processing …
• Appropriate pre-transfusion tests
• Using processed products: Leukodepled, washed, irradiated …

22. • Complications can be classified as
• Immunologic - Non immunologic
• Acute (< 24 hrs) – Delayed (>24 hrs)
• Hemolytic – Non hemolytic
• When an adverse reaction is suspected, the transfusion should be
stopped and reported to the blood bank for investigation.

23. ACUTE HEMOLYTIC REACTIONS
• Rapid destruction of donor erythrocytes by preformed recipient
antibodies or the reverse.
• Results intravascular hemolysis.
• Due to:
1.ABO incompatibility (common)
• By anti-A and anti-B antibodies
• Most often due to procedural error
2.Antibodies against other RBC antigens: Rh, Kell, Duffy

24. • Clinical presentation
• Classic triad of fever, chest and/or pain and hemoglobinuria.
• Hypotension, tachypnea, tachycardia and discomfort at the infusion site.
• So, monitoring vital signs before, during & after transfusion is important.
• DIC with oozing of blood from puncture sites may be the presentation in
comatose pts.
• Tissue factor released from the lysed erythrocytes may initiate DIC.
• Lab evidences for hemolysis - haptoglobin, LDH & indirect bilirubin levels

25. • Management
• Whenever FEVER occurs after a red cell transfusion, AHTR must be ruled out.
• Check lab evidences for hemolysis - haptoglobin, LDH, and indirect bilirubin levels.
• Stop transfusion but keep the IV line attached.
• Assess ABC/Vital signs and manage as needed
• Induce diuresis with IV fluids and furosemide or mannitol.
• Fluid/saline (100 to 200 mL/hour) to keep a UOP above 100 to 200 mL/hr
• Send patient post transfusion blood sample & bag to blood bank (should not be discarded) for repeat
typing and cross-matching of this unit
• Obtain a sample for DAT, plasma free hemoglobin, and repeat type and X-match.
• Assess, manage accordingly & monitor for
• Hyperkalemia, renal function , coagulopathy (PT/PTT/ INR, fibrinogen, plt)
• Prevention – avoid errors (labeling, correct pt, lab errors)

26. DELAYED HEMOLYTIC REACTIONS
• Seen generally within 2 to 10 days after transfusion.
• Hemolysis is extravascular, gradual, and less severe.
• Dx: labs (↓HCT, ↑unconjugated bilirubin)
• Rx: not needed unless brisk hemolysis, if so, additional RBC transfusions may
be necessary.
• Prevention: not completely preventable (because antibodies are
undetectable before transfusion), avoid products containing the implicated
red cell antigen.

27. FEBRILE NONHEMOLYTIC REACTIONS
• The most common transfusion reaction.
• Occurs within one to six hours after transfusion of red cells or platelets.
• Mxm: patient antibodies (Class l HLA) against donor leukocyte or cytokines (released by
leukocytes) in the stored blood can mediate these reactions.
• So leukoreduction may prevent it
• Risky - Multi transfused and multiparous patients
• Manifests with fever (≥ 1°C rise in temp), chills and sometimes mild dyspnea.
• Dx: diagnosis of exclusion, exclude other causes of fever; whenever there is fever r/o hemolytic
reaction
• Management: Stop transfusion and r/o hemolytic reaction, antipyretics
• Prevention - Leukoreduction

28. URTICARIAL (ALLERGIC) REACTIONS
• Mxm: recipient IgE antibodies against donor plasma proteins >> &
platelets.
• C/F:
• Dx: clinical
• Mx: Temporarily stop the transfusion and administer antihistamines
• The transfusion may be completed after the signs and/or symptoms
resolve.
• Prevention: premedicate with antihistamines if prior history, washed component
to remove plasma

29. ANAPHYLACTIC REACTIONS
• Mxm: Presents after transfusion of only a few milliliters of the blood
component within a few sec to few min.
• Patients who are IgA-deficient( <1% of the population) may be sensitized to
this Ig class; so, rare (1:20,000 to 50,000 ).
• Patients who have anaphylactic or repeated allergic reactions to blood
components should be tested for IgA deficiency
• Diagnosis: clinical
• Coughing, difficulty breathing/respiratory arrest (bronchospasm)
• Nausea and vomiting,
• Loss of consciousness, hypotension/shock.

30. • Treatment
• Stop transfusion immediately
• ABC – maintain airway & oxygenation (intubation maybe needed), IV
fluid/ vasopressors if necessary
• Epinephrine -0.3-0.5 mL of a 1:1000 solution IM
• Glucocorticoids in severe cases.
• Hydrocortisone 500100 QID
• Nebulization (albuterol)

31. POSTTRANSFUSION PURPURA
• Mxm: patient antibodies against both donor and recipient platelet antigens, mainly human
platelet antigen 1a (HPA-1a)
• Presents as thrombocytopenia 7–10 days after platelet transfusion
• Risky: mainly in women because they may be sensitized by antigens during prior pregnancy or
transfusion.
• C/F:
• Dx: CF, presence of a circulating alloantibody to a common platelet antigen, and that the patient's
own platelets lack this antigen.
• Rx: neutralizing offending antibodies by IVIG (400 to 500 mg/kg/d for five days) or plasmapheresis
to remove them.
• Additional platelet transfusions can worsen the thrombocytopenia& should be avoided.
• Prevention: washed blood products and/or transfusion of HPA-1a negative plts

32. TRANSFUSION RELATED ACUTE LUNG INJURY
• TRALI is a new episode of acute lung injury (ALI) that occurs during
or within 6 hours of transfusion.
• The most common cause of transfusion related fatalities.
• Mxm: high titer anti-HLA antibodies in donor plasma bind and activates
recipient leukocytes  aggregate in the pulmonary vasculature and release
mediators that damage endothelium & increase capillary permeability
(cytokines, reactive oxygen species, oxidases, and proteases)
• Dx: Testing the donor's plasma for anti-HLA antibodies can support
this diagnosis.

33. • C/F: symptoms of hypoxia and signs of non cardiogenic pulmonary edema
• Fever , Hypotension ,Cyanosis
• In an intubated patient
• Desaturation or increased oxygen requirements.
• Pink frothy secretions from the ETT
• Dx: clinical - using the criteria outlined by the NHLBI’s working group on TRALI as
well as the Canadian Consensus Conference on TRALI.
• CXR (bilateral Pulmonary infiltrates)
• Considered TRALI whenever a patient becomes hypoxic during or shortly after
transfusion of any blood product .

35. Treatment
• Primarily supportive
• Oxygen, ~70-90% pts need mechanical ventilation.
• Corticosteroids – no supportive evidence
• TRALI generally has a good prognosis with mortality ranging from 5-10%.
• Prevention
• Deferral of multiparous female donors and donors implicated in a TRALI reaction
•

36. • Graft-versus-host disease (TA-GVHD)
• donor T lymphocytes against host HLA antigens
• C/F: @ 8–10 days, and death @ 3–4 weeks post transfusion.
• characterized by marrow aplasia and pancytopenia, fever, a characteristic
cutaneous eruption, diarrhea, and liver function abnormalities.
• Rx: is highly resistant to treatment with immunosuppressive therapies,
including glucocorticoids, cyclosporine.
• Prevention: irradiation of cellular components (minimum of 2500 cGy)
before transfusion to patients at risk, avoid units from family members.

37. NONIMMUNOLOGIC REACTIONS
Transfusion Associated Volume Overload (TACO)
• Blood components are excellent volume expanders – so risk of TACO.
• Begin near the end of the transfusion, or within six hours.
• Risky: the elderly and compromised cardiac function pts.
• C/F: dyspnea (PaO2 <90% on room air), orthopnea, tachycardia
• Dyspnea with, bilateral infiltrates on chest x-ray

38. • Treatment
• Oxygen, NIPPV if severe respiratory compromise
• Diuretics
• Phlebotomy in 250 mL increments, with or without reinfusion of the removed red
cells, if symptoms persist or diuresis cannot be promoted.
• Prevention
• Decrease rate & volume of transfusion
• 2.0 - 2.5 mL/kg/hour, 1 ml/kg/hour if more risky pts
• Two units per day unless obligatory
• Diuretic

40. Electrolyte Disturbance
• Hyperkalemia
• Mxm: RBC leakage during storage
• Risky: neonates and renal failure patients
• Use fresh or washed RBCs
• Hypocalcemia
• Mxm: chelation by citrate (anticoagulant)
• Risk: multiple rapid transfusions.
• C/F : circumoral numbness and/or tingling sensation of the fingers/toes

41. • Metabolic alkalosis
• citrate is quickly metabolized to bicarbonate
• Iron Overload (hemosiderosis)
• Mxm: chronic transfusions
• Each unit of RBCs contains 200–250 mg of iron.
• Symptoms & signs develop when the total-body Fe load becomes 20 g or more = after
100 units of RBCs transfusion
• Rx: iron chelators: deferoxamine and deferasirox
• Prevention: using non blood alternatives (e.g., erythropoietin) and judicious
transfusion

42. INFECTIOUS COMPLICATIONS
• Transfusion transmitted infections
• Bacterial contamination (during collection & processing)
• Bacterial contamination (during transfusion)

43. Bacterial contamination
• Contamination source: skin , asymptomatic bacteremic donor,
collection packs or blood processing.
• The highest-risk blood products are platelets, because they are stored
at room temperature
• Some bacteria can grow at 1– 6°C
• Gram-negative bacteria: Yersinia, Pseudomonas, Serratia, Acinetobacter, and
Escherichia species

44. • Clinical manifestations
• None, mild or septic
• Fever 38.5°C, rigors, hypotension and tachycardia.
• Nausea, vomiting, diarrhea and dyspnea
• May progress quickly to shock, DIC, and renal failure with oliguria.
• Sudden and fulminant onset distinguish it from FNHTR
• Dx: culture (aerobic and anaerobic) from both the pt & the blood product.
• Definitive – if the same organism from both the blood product & the recipient.
• Draw pt blood from arm opposite to transfusion site.
• Treatment - Stop the transfusion immediately and keep IV access open.
• Resuscitate as needed.
• Empiric broad-spectrum antibiotics.

46. References

47. •THANK YOU