THE FIRST BLOODTRANSFUSION 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.
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.
TRANSFUSION ATTEMPTS• In 1667 Jean-Baptiste Denys, French physician, performed transfusion with sheeps and calfs blood.• In 1818 James Blundell, successfully performed transfusion for postpartum hemorrhage, using patients husbands blood.• In1905 George Washington Crile, co- founder of Cleveland Clinic, was the ﬁrst surgeon who used direct blood transfusion in surgery.
BLOOD GROUPING• In 1901, Karl Landsteiner discovered human blood groups. Blood transfusion had become a lot safer since then.
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 Bogdanovs death Soviet established the worlds ﬁrst blood bank in 1930s by Sergei Sergeevich Yudin at Nikolay Sklifosovskiy Institute.
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.
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
IRRADIATION • Inactivate donor’s T-cells • Reduced GVHD risk • Reduce shelf life to 28 days • Increased K+ leak
SINGLE DONOR PRODUCT • Reduce donor exposure • Single HLA antigen
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*
PATIENT WHO SHOULD NOT BE TRANSFUSED• Nutritional anemia• Autoimmune hemolytic anemia• Patient with high peripheral blast count
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
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
CRYOPRECIPITATE• Use for replacing factor VIII, factor XIII, von Willebrand factor, ﬁbrinogen
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
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
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
TRANSFUSION COMPATIBILITYBlood 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
PLATELET REFRACTORINESS• Corrected count increment (CCI) < 3,000/mcL• Corrected count increment = (Pre - Post) x Body surface area Transfused platelet
PLATELET REFRACTORINESS• Immune • Non-immune• Alloimmunization • Infection, fever• Autoimmune • Hypersplenism• Drug-related antibody • DIC• ABO incompatibility • BMT patient • Ampho B • etc.
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
IMMEDIATE HEMOLYTICTRANSFUSION REACTION c k ! FXII generate bradykinin Sho histamine serotonin a CC5 5b C5 CC3 3b C3a anaphylotoxic activity
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
DELAYED HEMOLYTIC TRANSFUSION REACTION• Occur 1 wk after transfusion• Anamnestic immune response• Extravascular hemolysis• Usually subtle symptoms• Antibody gradually decrease after expose to antigen
BACTERIAL CONTAMINATION• Platelet prone to have bacterial overgrowth enterocollitca can• Yersinia grow at 6°c etc.• Antibioticshould be started if suspected bacterial contamination
ALLERGIC REACTION• Allergic to plasma protein of donor• Can give antihistamine to relieve symptoms• In IgA deﬁciency patient should avoid plasma product
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
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
TRANSFUSION RELATEDGRAFT-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
Recognize T T Engraft Reject Recipient tissue HLA antigenT T-cells Transfusion related GVHD
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
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
PROTOCOL FOR COMPLICATION EPISODE Check label and patient’s identiﬁcationDraw blood from patient Examine transfusing bloodCentrifuge for serum color Blood group Coomb test Re-crossmatch with pre- and Blood group post-transfusion samples Hemoculture Hemoculture
PROTOCOL FORCOMPLICATION EPISODE Identify defect in the system No accusing investigation Solution Prevent future event