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Blood Components Therapy

Blood Components Therapy. Brian Poirier, M.D. University of California, Davis Medical Center. Topics. Whole Blood Packed Red Blood Cells Plasma Platelets Special Transfusions/Modifications. Modern Hemotherapy.

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Blood Components Therapy

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  1. Blood Components Therapy Brian Poirier, M.D. University of California, Davis Medical Center

  2. Topics Whole Blood Packed Red Blood Cells Plasma Platelets Special Transfusions/Modifications

  3. Modern Hemotherapy Administer that component of blood that the patient needs to prevent morbidity or mortality. The need may be due to lack of production, increased destruction or blood loss.

  4. Whole Blood Donation

  5. Transfusion criteria for whole blood (Hct ~ 40% if available) • Overt bleeding with clinical signs of hypovolemia • Exchange transfusion of a neonate (if RBCs reconstituted with FFP not available)

  6. Bristol, England, 1941

  7. Packed Red Blood Cells

  8. Transfuse red blood cells …to increase oxygen-carrying capacity in anemic patients Do NOT transfuse red blood cells For volume expansion In place of a hematinic To enhance wound healing To improve general “well-being”

  9. RBC concentrates to raise Hgb level of average-size adult 1g/dL

  10. RBC transfusion trigger: 7 vs. 9.5 or 10 g/dL 7 g/dL is as effective as 10 g/dL in adults* 9.5 g/dL or 10 g/dL in PICU patients without cardiovascular disease (similar morbidity and mortality)** *Hebert PC et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:409-17. **Lacroix J et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007;365:1609-19.

  11. Properties of Stored RBC’s • Supernatant • Citrate • Potassium • free hemoglobin • pH low • RBC • 2,3 DPG low • spherocytic change

  12. UCDMC Massive Transfusion Guideline (MTG) Pack 6 units of pRBC 3 FFP Jumbo (or 6 regular)* 1 Plateletpheresis *Kept thawed at 4°C for up to 5 days

  13. Washed Red Cells All Plasma and 85% of White Blood Cells are removed by washing.

  14. Indications for Washed Red Cells Urticarial transfusion reaction to several consecutive red cells transfusions. Anaphylactoid reaction to packed red cell transfusion (suspect IgA antibodies in an IgA deficient patient).

  15. Frozen, Thawed Deglyceralized Red Cells White cells and plasma are removed from the product

  16. Indication for Frozen, Thawed Deglyceralized Red Cells Predeposition of autologous blood for elective surgery to occur >42 days after donation. Patient with rare or multiple antibodies that need antigenically rare blood from the local blood bank or the “rare donor file”. Patients with HLA antibodies where febrile reaction occurred with transfusion of washed red cells. History of anaphylaxis to packed red cells or washed red cells.

  17. Irradiated Blood Products Recommended dose is between 1,500 and 5,000 cGy. 3,000 rads destroy the spindle apparatus of the lymphocytes so that they cannot divide. No functional impairments develop in the cells including phagocytosis by granulocytes. Leukemic patients, all lymphoma patients, immature infants, children with neuroblastoma receive irradiated products

  18. Indications for Irradiated Blood Products

  19. Autologous Blood Encourage physicians to use this product. The patient cannot develop diseases from it. If multiple units will be needed the patient will be placed on iron therapy. Criteria for transfusion remain the same.

  20. Fresh Frozen Plasma

  21. Male Donors

  22. Plasma Contains all the coagulation factors, albumin and fibrinogen. FFP (and FP24): Stored at -18°C for up to 1 year. Once thawed, must be used within 24 hours, or may be stored at 1-6°C for 5 days (as thawed plasma).

  23. Plasma: usual dose to increase clotting factor levels is 15-20 mL/kg body weight

  24. Indications for Plasma (Adapted from NIH Consensus conference) Prolonged PT and/or PTT (³ 1.5x ULN or INR >2) or coagulation factor assay £ 25% with active bleeding or impending surgery Bleeding with coagulopathy and specific concentrate unavailable Plasma exchange for TTP/HUS Emergency reversal of Coumadin (Warfarin) effect

  25. Plasma Transfusion Do NOT transfuse plasma For volume expansion As a nutritional supplement Prophylactically following cardiopulmonary bypass

  26. Plasma for TTP ADAMTS13 is present in similar amounts in FFP, Cryo-poor plasma, and Plasma 24h and storage at 1-6°C for up to 5 days does not significantly diminish its activity, e.g., for TTP. Scott EA et al. Comparison and stability of ADAMTS13 activity in therapeutic plasma products. Transfusion 2007;47:120-5.

  27. Properties of Stored Plasma • Citrate Anticoagulant • Coagulation Factors • Degradation of V and VII with prolonged storage (4°C), 10 & 7 days respectively

  28. Cryoprecipitate

  29. Cryoprecipitate unit (bag) Volume: 10-25 mLIncreased levels of:- Factor VIII (³ 100 U)- Fibrinogen (200-300 mg)- Von Willebrand’s factor- Factor XIII - ADAMTS13 Usual dose – 10 bags/adult N.B. – once thawed, keep at room temp

  30. Indications for Cryoprecipitate No longer recommended for mild hemophilia A. It is better to use heat treated factor VIII since HIV is destroyed by heat. D.I.C Von Willebrand’s disease Massive intra-abdominal clotting in liver lacerations Fibrin glue (cryoprecipitate is mixed with thrombin and applied directly to blood vessels)

  31. Platelets

  32. PLATELET AGITATION AT ROOM TEMPARATURE

  33. Platelets A platelet pack contains 5.5 x 1010 platelets and can raise the platelet count 10,000 mm3 maximally. A plateletpheresis contains 3 x 1011 platelets and can raise the platelet count 30,000 mm3.

  34. Properties of Stored Platelets Citrate Cytokines/Vasoactive Substances

  35. Indications for Platelets Prevention or arrest of bleeding in thrombocytopenic patients Maintain a platelet count 10,000 – 20,000 mm3 in medical cases Maintain a platelet count 50,000 – 100,000 mm3 in surgical cases GI bleeder who has taken aspirin

  36. Indications for Platelets Non-bleeding patient with count of <10,000/mm3 or 1x109/L Platelet count < 50,000/mm3 or 5x109/L and - Bleeding due to thrombocytopenia and/or - Surgical/invasive procedure imminent Documented abnormal platelet function with bleeding or surgical/invasive procedure imminent

  37. Platelet transfusion Do NOT transfuse platelets To patients with immune thrombocytopenic purpura (unless there is life-threatening bleeding) Prophylactically following cardiopulmonary bypass

  38. ABO Compatible Blood Components Blood Compatible Compatible TypeRBCs FFPs A A, O A, AB B B, O B, AB AB AB, A, B, O AB O O A, B, AB, O

  39. Editorial: Platelet ABO matters. RM Kaufman Transfusion 2009;49:5-7. ¯ PLT recovery is not the only problem with ABO-incompatible PLTs In ABO minor-incompatible PLTs, anti-A/B is passively transfused and, rarely, causes acute hemolysis PLT ABO incompatibility – major or minor – should be avoided whenever possible

  40. ABO Compatibility Study Julmy F, Amman RA, Taleghani BM, et al. Transfusion efficacy of ABO major-mismatched platelets (PLTs) in children is inferior to that of ABO-identical PLTs. Transfusion 2009;49: 21-33.

  41. Julmy F et al. (cont.) ABO major-mismatched PLTs, (e.g., A1 to O or B), result in lower 1 hr post counts (21% vs. 32%) ABO major-mismatched PLTs more often unsuccessful Platelets expressing A1 on their surface are cleared in O or B recipients A2 PLTs, expressing no detectable A, were as successful as ABO identical PLTs

  42. Julmy et al. (cont.) Conclusions In children, ABO major-mismatched PLT transfusions result in inferior efficacy, except for A2 PLTs ABO minor-mismatched PLTs showed comparable efficacy to identical PLTs

  43. Other Products andSpecial Considerations

  44. Granulocyte Transfusions

  45. Granulocyte Transfusions Severely neutropenic patients (Absolute Neutrophil count <500/mm3) with sepsis (especially if Gram negative bacteria) - Unresponsive to 24-48 hrs. of appropriate antibiotics - Reasonable chance of marrow recovery soon - Progressive cellulitis Neonatal sepsis with transient granulocytopenia

  46. Leukocyte-Depleted Components: Advantages • Sensitization to wbc • Febrile reactions (and some TRALI) • Risk of cell-associated viruses, e.g., CMV (and bacteria)  Response to platelet transfusions

  47. No benefit of leukocyte reduction for HIV-infected patients Collier AC et al. Leukocyte-reduced red blood cell transfusions in patients with anemia and human immunodeficiency virus infection. The Viral Activation Transfusion Study: A randomized controlled trial. JAMA 2001; 285:1592-1601. “Specifically, there was no difference in survival…in HIV-1 related serious events, nor…in the rate of transfusion reactions.”

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