SAMA EMERGENCY COURSE Assad University hospital Satarday , February 26, 2012

1. Transfusion Medicine NabeelRajeh, M.D. SAMA EMERGENCY COURSE Assad University hospital Satarday , February 26, 2012

2. Alexander Bogdanov- Blood Transfusion

4. Whole Blood • 450 ml of donated blood+50 ml of anticoagulant • Significant RBC, Plasma, Protein, platelets, Leukocytes, and stable coagulation factors. • Insignificant labile factors V, VIII, • After 24 h platelets and leukocytes loose viability • Indicated in trauma hypovolemic and actively bleeding patient • No other indications

5. Packed Red Blood Cells (PRBC) • The most common type of transfusions • 250-350 ml of Red blood cells • Indicated in chronic anemia • Indicated in active bleeding with and without hypovolemia • Not indicated in platelets or leukocytes replacement

6. Washed RBC • Washing RBC in saline • Removing immunoglobline IgA • Prevent Anaphylaxis and urticarial reaction

7. Leukocytes-Reduced RBC • Removing 99.9 % of leukocytes from PRBC • Special filters • Indications: • Prevent febrile non-hemolytic reaction • Prevent alloimmunization • Prevent post transfusion purpura

8. Irradiated RBC • 2500 c Gray gamma irradiation • Prevent post transfusion GVHD • All immune suppressed individuals should receive only irradiated blood products • FFP, and cryoprecipitate need no irradiation

9. Random-Donor platelets • 50-70 ml volume • Indicated in bleeding patient with low platelets • Indicated in non-bleeding patient with platelets less than 10 000 • Indicated in bleeding patient with platelets function abnormality • Not indicated in none bleeding ITP patient • Contraindicated in TTP, some DIC

10. HLA matched platelets • Hemapheresis from HLA matched individual donor • Refractoriness to platelets transfusion • HLA alloimmunization • Fever, Sepsis • DIC • Hyperspleenisim • Bleeding • Indicated only in HLA alloimmunization • Low platelets 1h and 24 h post RDP transfusion indicates alloimmunization.

11. Granulocyte Concentrates • Leukapheresis from single donor • A unit contain 10x 10 granulocytes • Should be infused immediately after collection • Indicated in septic neonates, granulocytes dysfunction, profound neutropenia and sepsis • Granulocyte concentrates transfusion has conflicting trials results

12. Fresh Frozen Plasma FFP • Separating and freezing plasma within 6 h of phlebotomy • 1ml FFP contain 1unit labile and stable Coagulation factors • Indicated in factors deficiency when no single factor is available • Indicated in liver dysfunction, massive transfusion

13. Cryoprecipitate • 5-20 ml • 80U VIII, vWF,fibrinogen, some XIII, fibronectin • Indicated in fibrinogen replacement • Not indicated in hemophilia A • Not indicated in vW disease

14. TRANSFUSION is BAD • IMMUNE-MEDIATED REACTIONS • Acute Hemolytic Transfusion Reactions • Delayed Hemolytic and Serologic Transfusion React • Febrile Nonhemolytic Transfusion Reaction • NONIMMUNOLOGIC REACTIONS • Fluid Overload • Electrolyte Toxicity • Iron Overload • INFECTIOUS COMPLICATIONS

15. INFECTIOUS COMPLICATIONS • Hepatitis, A, B, C, D, G ………. • HIV, HTLV-I, HTLV-II, ……… • CMV • EBV • Malaria, Syphlis, Trypanosoma, Toxolplasmosis, Bebesiosis, Brucelosis. • Bacteria Gram +ve or Gram -ve

16. Acute Hemolytic Transfusion Reactions • ABO Incompatible Blood • IgM, ANTI A, OR B Agglutinates transfused RBC • Fever, chills, chest arm and flank pain, dyspnia, hemoglobinuria, oligouria, shock, and DIC • +ve coombs test, and hemolysis lab • Treatment is suportive

17. Delayed Hemolytic and Serologic Transfusion Reactions • Primery or secondary immunization against RBC alloantibodies • Kell, Duffy, Kidd, RH system antigens • Rapid fall in Hg after transfusion • Most cases subclinical • Occasional fever chills, nausea, hemoglobinurea

18. Febrile Nonhemolytic Transfusion Reaction • Agglutinating, or cytotoxic antibodies against antigen on transfused granulocyte • Common in multitransfused patient • Complement activation and cytokins release • Chills, fever, rigor, • Hemolytic transfusion reaction should be ruled out • Leukocytes reducing filters in future blood products

19. Allergic Reactions • Urticaria • Anaphylactic reaction • Alloimmunization • To red cells antigens • Delayed hemolytic transfusions reaction • To platelets antigens • Refractoriness • Neonatal thrombocytopenia • Post transfusion purpura P1-A

21. Graft-Versus-Host Disease • Live T lymphocytes transfused to immune suppressed patient • Allo-lymphocytes with different HLA recognize self HLA as foreign HLA • Fever, elevated LFT’s, diarrhea, erythema • Cytopenia, • No available therapy • Prevention by irradiation blood products

22. Post transfusion Purpura • Very serious side effect of transfusion • Most people are positive P1-A1 antigen • Negative patient may develop antigen destroy all platelets • Develop in 5-10 days post transfusion • Plasmapheresis • Washed RBC for future transfusion

23. Transfusion-Related Acute Lung Injury • Potent leukoagglutinins • Antibody-antigen leading to leak syndrome in lung • Respond quickly to supportive treatment

24. Emergency Transfusion • What products to use • From where are they to be obtained • To what degree are they to be tested • How will they be transported • How will they be stored • Triage is vital in mass casualty situations, ensuring that scarce resources are used for those with the best chance of recovery. • Patients survive with low hemoglobin levels for considerable periods, • Speedy treatment of hypovolemia is imperative

25. Sudden increase the demand for blood • May create a sudden massive influx of donors • Restricts or eliminates the ability to collect, test, processor distribute blood • Restricts or prevent the use of the available inventory of blood components (liquid and frozen) • Requires immediate replacement or re-supply of blood from another region/country

26. Blood Volume Loss Of: • 15 - 30 percent -- should be treated with crystalloids or colloids, not RBCs, in young, healthy patients; • 30 - 40 percent -- requires rapid volume replacement, and RBC transfusion is probably necessary; • >40 percent -- is life-threatening and volume replacement, including RBC transfusion, is required

28. Hemoglobin and Transfusion • More than 10g/dL transfusion is rarely indicated. • Hemoglobin 6-10 g/dL indications for transfusion should be based on the patient’s risk of inadequate oxygenation from ongoing bleeding and/or high-risk factors. • Hemoglobin < 6 g/dL transfusion is almost always indicated.

29. Massive transfusion • Transfusion more than50 %of a patient's blood volume in 12 to 24 hours • Hemostatic and metabolic complications • Selection of the appropriate amounts and types of blood components to be administered • Volume status • Tissue oxygenation • Management of bleeding and coagulation abnormalities • Changes in ionized calcium, potassium, and acid-base balance

30. ALTERNATIVES TO TRANSFUSION • Autologous blood transfusions • Preoperative • Intraoperative • Postoperative blood salvage • Usage of Growth factors • Erythropoietin • G-CSF, GM-CSF • Erythropoietin, IL-11 • Blood substitutes

31. Thank you Nabeel Rajeh, MD

34. BLOOD GROUP ANTIGENS AND ANTIBODIES • The foundation of transfusion medicine • No mistake is excused • Compatibility test done on transfused RBC and recipient plasma • Compatibility test for RBC and whole blood • No compatibility test foe platelets, FFP , and cryoprecipitate • Compatibility test detects unexpected RBC alloantibodies • Cross match

35. BLOOD COMPONENTS • Red blood cells • White blood cells • Platelets • Plasma • Different proteins, Coagulation factors, Albumin

36. Case # 2 • 60 Y F while taking blood Unit developed 39 fever and rigor • Your next best step is • Immediate discontinuation of transfusion • NSAID or Paracetamol, • Solo-cortef and Phenergan • Call your senior resident • Ignore fever • Further testing

37. Case # 3 • 16 Y O M with Bleeding ulcer, HG 4.5, BP80/60, HR 140/m. Bright red blood per NG tube. Hx of multiple transfusions • Blood group A +, all 10 U of PRBC were not compatible • You do what of the following • Transfuse Non compatible blood • Cross match 10 more units • Call hematology • Wait until he cardiopulmonary arrest • Call surgery

38. Case # 4 • 20 Y M came to ER with severe hemolytic anemia G6PD • Hg 2 Gm, Decline any transfusion for religious reason • Your best management • Oxygen • Fluid • Erythropoietin • Transfusion after general anesthesia • Call hematology

39. How many Unit to transfuse • No magic number • Indication • Diagnosis • Medical plan

40. ABO ANTIGENS AND ANTIBODIES • The major blood groups of this system are A, B, AB, and O • The genes determine the A and B found on chromosome 9p

41. RH SYSTEM • Second most important blood group system • On chromosome 1 • 15 percent of people lack this antigen • Exposure of these Rh-ve people to Rh-ve cells, by either transfusion or pregnancy, can result in the production of anti-D alloantibody.

42. OTHER BLOOD GROUP SYSTEMS AND ALLOANTIBODIES • Other ABO, D, antigen on RBC • Kell, Duffy, Kidd blood group • Not normally present unless immunized by transfusion or pregnancy • Antibody screen • Washing RBC and better selection

43. PRETRANSFUSION TESTING • Hepatitis B, C, B core • Antibodies for Human T lymphocyte Virus I,II (HTLVI,II) • HIV,I, II