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Blood Transfusion

Blood Transfusion. Teoman SOYSAL Prof. MD. Blood Donation. Healty adult donors 450 ml +/- 10% per whole blood donation Male: 5/year, Female : 4/year > 8 weeks between two donations. Apheresis: Platelets Plasma White cells (or subsets) Red cells.

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Blood Transfusion

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  1. Blood Transfusion Teoman SOYSAL Prof. MD

  2. Blood Donation Healty adult donors • 450 ml +/- 10% per whole blood donation • Male: 5/year, Female : 4/year • > 8 weeks between two donations

  3. Apheresis: Platelets Plasma White cells (or subsets) Red cells The procedure can be done for treatment or transfusion purposes.

  4. Blood Preservation • Whole blood or red cells 1-Liquid phase storage : 1-6º C • 63 ml anticoagulant-preservation liquid/unit duration of preservation • ACD: 3 weeks • CPD: 3 weeks • CPD-A1: 35 days • RBC concentrate with SAG-Mannitol : 7 weeks 2- Frozen storage of red cells • -80 to - 196 º C , with glycerol etc: Years

  5. Blood Preservation • Effects of storage • Red cells: ATP, 2-3 DPG, osmotic fragility and oxygen affinity • Plasma : Hb, K, NH3 : pH: • Platelets: Lost in 2 days • Coagulation factors: Eg: • FV: adequate levels for about 5 days • FVIII: Below80% of original level after 1-2 days • FXI: Less than 20% of original level after 7 days

  6. Blood Preservation • Platelets: • liquid phase : 1 - 5 days, room temp., avoid light exposure kept on special agitator • Plasma : Use fresh or freeze • frozen at -18 º C within 8 hrs of collection

  7. Blood components & products • Cell containing components • Red cells: • Whole blood( fresh or not) • Red cells: packed red blood cells washed red blood cells frozen red blood cells leukocyte – reduced red blood cells • Platelets: Random donor platelets Apheresis platelets ( single donor platelets) • Granulocytes or mononuclear cells • Peripheral blood progenitor cells

  8. Blood components & products • Plasma and products • Plasma : fresh / fresh-frozen plasma • Cryopresipitate • Coagulation factor concentrates • Immunglobulin preperations • Albumin • others

  9. Deciding blood transfusion; • Severity of symptoms • Cause of anemia • Rapidity of anemia or symptoms • Co-morbidities and the age of the patient • Can we treat the anemia without transfusion? And • Is there enough time to wait for the response of such a treatment ?

  10. This is not a guide to be used in every patient • Hemoglobin >10 g/dL : Tx rarely needed • Hemoglobin < 6-7 g/dL: Tx mostly necessary • Hemoglobin : 6-10 g/dL: Dependable

  11. Important: • Symptomsrelatedtoanemiamaydifferfromonepatienttoanotherfor a givenHblevel; • Thetriggerforredcelltransfusionmaydifferfromonepatienttoanother!!!!!

  12. Indications for transfusion of blood or its components • Whole blood: Acute massive bleeding 1 unit increases Hb: 1g/dl, Hct: 3% • Fresh whole blood: • Massively bleeding patient/shock • Exchange transfusion, open heart surg, severe renal or hepatic failure, • Red blood cells: • (To increase the oxygen carrying capacity in case of symptomatic anemia not treatable by other means or due to urgency of symptoms) • Symptomatic anemia (May be due to different causes), post-bleeding hypovolemia • 1 unit increases Hb: 1g/dl, Hct: 3%

  13. Indications for transfusion of blood or its components • White cells reduced RBC’s: < 5x106 WBC’s per unit White cell filters (before storage or before transfusion) • An indication for RBC transfusion + • To prevent reactions caused by WBC antibodies • Febrile non-hemolytic transfusion reactions • To prevent alloimmunization • To prevent CMV transmission

  14. Indications for transfusion of blood or its components Washed RBC’s: • An indication for RBC transfusion + • Any need to prevent the recipient allo-immunisation to WBC’s , plasma antigens or any contraindication to infuse complement • PNH • IgA deficiency • Prevention of anaphylaxis • Washed units must be transfused no later than 24 hours Frozen RBC’s: • An indication for RBC transfusion + • Autologous transfusion: rare blood groups, • Catastrophy etc Washed before infusion !!

  15. Indications for transfusion of blood or its components Blood Irradiation To prevent transfusion related GVHD in; • Congenital immune deficient states • Bone marrow or stem cell transplantation • Some cases of hematologic malignancies • Hodgkin’s disease • Purin analogue or anti-CD52 treatment • Intra-uterin transfusion • New borne exchange transfusion • Transfusions between relatives • first or second degree • HLA matched platelets

  16. Some of the indications for platelet transfusions • Decreased platelet production because of bone marrow failure or infiltration :bleeding or risk of bleeding • Leukemia • MDS • Myelofibrosis • Malignant tm infiltration • Myelosupression • Aplastic anemia • Functional platelet disease and bleeding or risk of bleeding • Dilutional thrombocytopenia (after massive transfusion) • Cardiac by-pass surgery • Increased platelet destruction or consumption • DIC • Drug induced • sepsis • ITP

  17. Indications for transfusion of blood or its components • Platelets: Thrombocytopenia due to decreased platelet production Platelet count/mm3 Bleeding /surgery Indication for plt transfusion > 50.000, No No < 50.000 Yes Yes 10.000-20.000 No No (if there is bleeding/fever/DIC/plt dysfunction) Yes < 10.000 Yes or No Yes

  18. Disease status may change the transfusion effectiveness: DIC Hypersplenism Sepsis Allo-immunisation Cotraindicated in Thrombotic Thrombocytopenic Purpura: Used only in high risk bleeding Not effective/useful in Immune Thrombocytopenic Purpura: Used only in high risk bleeding Practical issues ABO matched platelets have a longer in-vivo life span after transfusion Use Rh- platelets for Rh- recipients (to prevent Rh immunisations) or use anti-Rh(D) Ig if Rh+ component used in such recipients Some special conditions about platelet transfusion

  19. Types of platelet concentrates • Random donor plt concentrate (single unit) • 5,5 x 1010 plts • 5.000-6.000/mm3 plt increase after transfusion • Pooled plt concentrate (eg:6 random units) • Apheresis plts • >3x1011 plts • 30.000-50.000/mm3 increase after transfusion • WBC reduction of platelets is indicated in the same situations like red cells.

  20. Indications for transfusion of blood or its components/products • Fresh frozen plasma( contains all coag. Factors) • Congenital or acquired coag.Factor deficiency (bleeding or surgery) • Oral anticoagulant overdose • Plasma exchange (eg:TTP) • After massive transfusion • 10-20 ml/kg : to increase deficient factor level about 20-30% from baseline

  21. Indications for transfusion of blood or its components/products • Cryoprecipitate • Includes FVIII, vWF, FXIII, fibrinogen and fibronectin • 80-120 units of FVIII, ≥150 mg fibrinogen and 20-30 % of FXIII that is in one unit of plasma • Can be used for the purpose of replacing the deficient state of these factors in case of bleeding or surgery

  22. Practical Issues • Is there a need for transfusion? • Which product should be used? • Number of units? • Re-check the blood types of the patient and donör and be sure about the cross match • Read label, ID, inspect the product • Is irradiaton necesssary? • Temperature? • Filters? • Flow rate ? (start 5 ml/min-15 minutes , the rest 200-500ml/hr) • Drugs ?

  23. Transfusion Reactions • Immunologic reactions • Non-immune reactions or • Acute reactions • Late reactions

  24. Hemolytic reactions • Reasons: Mismatched transfusion Transfusion of hemolysed blood • During storage or warming etc • May be acute or late

  25. Acute hemolytic reaction • Frequency up to 1/25.000 • 1/600.000 Tx mortal • 40% symptomatic • ABO mismatch • IgM antibodies (anti-A or anti-B) ,complement binding and intravascular hemolysis • Early onset ( first 50-100 ml’s),seldom after 1-2 hrs • pain at the infusion site, flushing, chest or back pain,dyspnea,vomiting, fever-chills, hypotension and tachicardia,bleeding, hemoglobinuria • Complications: Acute Renal Failure, shock,DIC

  26. Acute hemolytic reaction • Stop transfusion, • Take measures to keep normal BP and urine output: hydration/diuretics, • Re-check groups, re-cross, take blood cultures, • Follow signs of hemolytic anemia, antiglobulin tests,renal function and DIC tests, • Treat accordingly (eg: dialysis/ICU etc)

  27. Delayed hemolytic reaction • 1/2500-1/6000 • Onset: 3-21 days after transfusion • Reason: Rh, Kidd etc mismatches • Previous alloimmunization and anamnestic response • Coombs + ( do not confuse with OIHA) • Jaundice or absence of the expected increase in red cell values. • Frequently undetected • Treatment : none

  28. Febrile reactions • 0,5- 3% of all transfusions • Cause: Antibodies against white cell/plt/plasma antigens • Fever-chills, increased pulse rate during or after transfusion • Antipyretics/antihistamines • Stop transfusion if there is doupt about hemolysis • Prophylaxis: White cell reduction

  29. Allergic reactions • Cause:Antibodies against donor plasma proteins • Pruritus,urticaria,edema,anaphylaxis,bronchospasm • IgA deficient patients are under the greatest risk • Treat according to the type of reaction • For IgA deficient patients: use washed or frozen red cells instead of regular red cells or whole blood.

  30. Pulmonary hypersensitivity reaction/TRALI • 1/5000 frequency • Cause : Leukocyte incompatibility and agglutination of white cells inside the pulmonary vascular area leading to complement activation and endothelial damage- pulmonary edema. • Fever-chills,tachycardia,chest pain, hemoptysis, BP fall within 4 hrs of transfusion • Respiratory support may be necessary

  31. Transfusion Related Graft- versus -Host Disease • Cause: Immune deficient recipient transfused with viable lymphocytes which are engrafted and start allo-reaction against mismatched HLA and other antigens of the recipient. • High fatality with skin,liver and gut symptoms, pancytopenia and infections • Prophylaxis: Blood irradiation • Treatment: immunosupressive drugs • Mortality high

  32. Circulatory overload • Old aged or premature/ new borne or patients with cardiopulmonary compromise are under risk. • Clinics: Acute heart failure • Treatment: As acute myocardial failure • Prophylaxis: Slow infusion rate, low volume of transfusion

  33. Bacterial Contamination • Bacterial contamination may cause a reaction with symptoms resembling Acute Hemolytic Reaction without LAB findings of hemolysis. • May be fatal: • Mortality:Plt constr: 1/17.000 – 1/65.000 Red cells: <1/700.000 • Stop transfusion, take cultures, treat with IV fluids and antibiotics , take support measures and follow against shock, renal failure,DIC

  34. Air embolism • May cause acute respiratory and circulatory failure • Clump the tubing • Change the posture of the patient: • Left side / Trandelenburg (left side ,head- down, legs upside) • Swan -Ganz catheter

  35. Patients with bone marrow failure , transfused chronically are under the risk of transfusion hemosiderosis. • Massive transfusion may cause: • Citrate toxicity: Hypocalcemia • Hyperkalemia • Bleeding ( due to thrombocytopenia and /or factor deficiency)

  36. Transfusion transmitted pathogens • Hepatitis ( C,B,A ,D etc ) • HIV • HTLV • CMV • E-Barr • HHV • Creutzfeldt-Jakob or • variant CJD (therotical) • Parvovirus • Malaria • Lyme ? (not enough evidence) • Chagas • Babesiosis • Sy • Toxoplasmosis • West Nil virus

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