transfusion medicine: types, indications and complications david harford hematology/oncology
TRANSCRIPT
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Transfusion Medicine:Types, Indications and
Complications
David Harford
Hematology/Oncology
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History of Transfusions
• Blood transfused in humans since mid-1600’s
• 1828 – First successful transfusion
• 1900 – Landsteiner described ABO groups
• 1916 – First use of blood storage
• 1939 – Levine described the Rh factor
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Transfusion Overview
• Integral part of medical treatment• Most often used in Hematology/Oncology, but
other specialties as well (surgery, ICU, etc)• Objectives
– Blood components
– Indications for transfusion
– Safe delivery
– Complications
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Blood Components
• Prepared from Whole blood collection or apheresis• Whole blood is separated by differential centrifugation
– Red Blood Cells (RBC’s)– Platelets– Plasma
• Cryoprecipitate• Others
• Others include Plasma proteins—IVIg, Coagulation Factors, albumin, Anti-D, Growth Factors, Colloid volume expanders
• Apheresis may also used to collect blood components
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Differential CentrifugationFirst Centrifugation
Whole Blood Main Bag
Satellite Bag 1
Satellite Bag 2
RBC’sPlatelet-rich Plasma
First
Closed System
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Differential CentrifugationSecond Centrifugation
Platelet-rich Plasma
RBC’s PlateletConcentrate
RBC’s
Plasma
Second
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Whole Blood
• Storage– 4° for up to 35 days
• Indications– Massive Blood Loss/Trauma/Exchange Transfusion
• Considerations– Use filter as platelets and coagulation factors will not
be active after 3-5 days
– Donor and recipient must be ABO identical
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RBC Concentrate
• Storage– 4° for up to 42 days, can be frozen
• Indications– Many indications—ie anemia, hypoxia, etc.
• Considerations– Recipient must not have antibodies to donor RBC’s
(note: patients can develop antibodies over time)– Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)– Usually transfuse over 2-4 hours (slower for chronic
anemia
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Platelets
• Storage– Up to 5 days at 20-24°
• Indications– Thrombocytopenia, Plt <15,000
– Bleeding and Plt <50,000
– Invasive procedure and Plt <50,000
• Considerations– Contain Leukocytes and cytokines
– 1 unit/10 kg of body weight increases Plt count by 50,000
– Donor and Recipient must be ABO identical
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Plasma and FFP
• Contents—Coagulation Factors (1 unit/ml)• Storage
– FFP--12 months at –18 degrees or colder
• Indications– Coagulation Factor deficiency, fibrinogen replacement, DIC, liver
disease, exchange transfusion, massive transfusion
• Considerations– Plasma should be recipient RBC ABO compatible– In children, should also be Rh compatible– Account for time to thaw– Usual dose is 20 cc/kg to raise coagulation factors approx 20%
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Cryoprecipitate
• Description– Precipitate formed/collected when FFP is thawed at 4°
• Storage– After collection, refrozen and stored up to 1 year at -18°
• Indication– Fibrinogen deficiency or dysfibrinogenemia– vonWillebrands Disease– Factor VIII or XIII deficiency– DIC (not used alone)
• Considerations– ABO compatible preferred (but not limiting)– Usual dose is 1 unit/5-10 kg of recipient body weight
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Granulocyte Transfusions
• Prepared at the time for immediate transfusion (no storage available)
• Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, and recovery of BM is expected
• Donor is given G-CSF and steroids or Hetastarch• Complications
– Severe allergic reactions– Can irradiate granulocytes for GVHD prevention
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Leukocyte Reduction Filters
• Used for prevention of transfusion reactions• Filter used with RBC’s, Platelets, FFP,
Cryoprecipitate• Other plasma proteins (albumin, colloid
expanders, factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusions
• May reduce RBC’s by 5-10%• Does not prevent Graft Verses Host Disease
(GVHD)
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RBC TransfusionsPreparations
• Type– Typing of RBC’s for ABO and Rh are determined for
both donor and recipient
• Screen– Screen RBC’s for atypical antibodies
– Approx 1-2% of patients have antibodies
• Crossmatch– Donor cells and recipient serum are mixed and
evaluated for agglutination
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RBC TransfusionsAdministration
• Dose– Usual dose of 10 cc/kg infused over 2-4 hours– Maximum dose 15-20 cc/kg can be given to hemodynamically
stable patient
• Procedure– May need Premedication (Tylenol and/or Benadryl)– Filter use—routinely leukodepleted– Monitoring—VS q 15 minutes, clinical status– Do NOT mix with medications
• Complications– Rapid infusion may result in Pulmonary edema– Transfusion Reaction
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Platelet TransfusionsPreparations
• ABO antigens are present on platelets– ABO compatible platelets are ideal
– This is not limiting if Platelets indicated and type specific not available
• Rh antigens are not present on platelets– Note: a few RBC’s in Platelet unit may sensitize the
Rh- patient
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Platelet TransfusionsAdministration
• Dose– May be given as single units or as apheresis units– Usual dose is approx 4 units/m2—in children using 1-2
apheresis units is ideal– 1 apheresis unit contains 6-8 Plt units (packs) from a single
donor
• Procedure– Should be administered over 20-40 minutes– Filter use– Premedicate if hx of Transfusion Reaction
• Complications—Transfusion Reaction
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Transfusion Complications
• Acute Transfusion Reactions (ATR’s)
• Chronic Transfusion Reactions
• Transfusion related infections
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Acute Transfusion Reactions
• Hemolytic Reactions (AHTR)
• Febrile Reactions (FNHTR)
• Allergic Reactions
• TRALI
• Coagulopathy with Massive transfusions
• Bacteremia
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Frequency of Transfusion Reactions
Adverse Effect Frequency Comments
Acute Hemolytic Rxn 1 in 25,000 Red cells only
Anaphylactic hypotensive 1 in 150,000 Including IgA
Febrile Nonhemolytic 1 in 200 Common
Allergic 1 in 1,000 Common
Delayed Hemolytic 1 in 2,500 Red cells only
RBC alloimmunization 1 in 100 Red cells only
WBC/Plt alloimmunization
1 in 10 WBC and Plt only
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Acute Hemolytic Transfusion Reactions (AHTR)
• Occurs when incompatible RBC’s are transfused into a recipient who has pre-formed antibodies (usually ABO or Rh)
• Antibodies activate the complement system, causing intravascular hemolysis
• Symptoms occur within minutes of starting the transfusion
• This hemolytic reaction can occur with as little as 1-2 cc of RBC’s
• Labeling error is most common problem
• Can be fatal
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Symptoms of AHTR
• High fever/chills
• Hypotension
• Back/abdominal pain
• Oliguria
• Dyspnea
• Dark urine
• Pallor
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What to do?If an AHTR occurs
• STOP TRANSFUSION• ABC’s• Maintain IV access and run IVF (NS or LR)• Monitor and maintain BP/pulse• Give diuretic• Obtain blood and urine for transfusion reaction
workup• Send remaining blood back to Blood Bank
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Blood Bank Work-up of AHTR
• Check paperwork to assure no errors
• Check plasma for hemoglobin
• DAT
• Repeat crossmatch
• Repeat Blood group typing
• Blood culture
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Labs found with AHTR
• Hemoglobinemia
• Hemoglobinuria
• Positive DAT
• Hyperbilirubinemia
• Abnormal DIC panel
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Monitoring in AHTR
• Monitor patient clinical status and vital signs
• Monitor renal status (BUN, creatinine)• Monitor coagulation status (DIC panel–
PT/PTT, fibrinogen, D-dimer/FDP, Plt, Antithrombin-III)
• Monitor for signs of hemolysis (LDH, bili, haptoglobin)
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Febrile Nonhemolytic Transfusion Reactions (FNHTR)
• Definition--Rise in patient temperature >1°C (associated with transfusion without other fever precipitating factors)
• Occurs with approx 1% of PRBC transfusions and approx 20% of Plt transfusions
• FNHTR caused by alloantibodies directed against HLA antigens
• Need to evaluate for AHTR and infection
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What to do?If an FNHTR occurs
• STOP TRANSFUSION• Use of Antipyretics—responds to Tylenol• Use of Corticosteroids for severe reactions• Use of Narcotics for shaking chills• Future considerations
– May prevent reaction with leukocyte filter– Use single donor platelets– Use fresh platelets– Washed RBC’s or platelets
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Washed Blood Products
• PRBC’s or platelets washed with saline• Removes all but traces of plasma (>98%)• Indicated to prevent recurrent or severe reactions• Washed RBC’s must be used within 24 hours• RBC dose may be decreased by 10-20% by
washing• Does not prevent GVHD
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Allergic Nonhemolytic Transfusion Reactions
• Etiology– May be due to plasma proteins or blood
preservative/anticoagulant– Best characterized with IgA given to an IgA deficient
patients with anti-IgA antibodies
• Presents with urticaria and wheezing• Treatment
– Mild reactions—Can be continued after Benadryl– Severe reactions—Must STOP transfusion and may require
steroids or epinephrine
• Prevention—Premedication (Antihistamines)
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TRALITransfusion Related Acute Lung Injury
• Clinical syndrome similar to ARDS• Occurs 1-6 hours after receiving plasma-
containing blood products• Caused by WBC antibodies present in
donor blood that result in pulmonary leukostasis
• Treatment is supportive• High mortality
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Massive Transfusions
• Coagulopathy may occur after transfusion of massive amounts of blood (trauma/surgery)
• Coagulopathy is caused by failure to replace plasma
• See electrolyte abnormalities– Due to citrate binding of Calcium– Also due to breakdown of stored RBC’s
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Bacterial Contamination
• More common and more severe with platelet transfusion (platelets are stored at room temperature)
• Organisms– Platelets—Gram (+) organisms, ie Staph/Strep– RBC’s—Yersinia, enterobacter
• Risk increases as blood products age (use fresh products for immunocompromised)
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Chronic Transfusion Reactions
• Alloimmunization
• Transfusion Associated Graft Verses Host Disease (GVHD)
• Iron Overload
• Transfusion Transmitted Infection
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Alloimmunization
• Can occur with erythrocytes or platelets• Erythrocytes
– Antigen disparity of minor antigens (Kell, Duffy, Kidd)
– Minor antigens D, K, E seen in Sickle patients
• Platelets– Usually due to HLA antigens
– May reduce alloimmunization by leukoreduction (since WBC’s present the HLA antigens)
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Transfusion Associated GVHD
• Mainly seen in infants, BMT patients, SCID• Etiology—Results from engraftment of
donor lymphocytes of an immunocompetent donor into an immunocompromised host
• Symptoms—Diarrhea, skin rash, pancytopenia
• Usually fatal—no treatment• Prevention—Irradiation of donor cells
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Transfusion Associated Infections
• Hepatitis C
• Hepatitis B
• HIV
• CMV– CMV can be diminished by leukoreduction,
which is indicated for immunocompromised patients
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Prevention
Leukocyte Depletion Filter
Gamma Irradiation
CMV Negative
Single Donor Platelets (Apheresis)
Febrile Transfusion Reactions X1 X
Alloimmunization X XCMV ?2 XTransfusion Related GVHD X
1 In PRBC transfusion2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood
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Summary
• Blood Components– Indications– Considerations
• Preparation and Administration of blood products
• Acute and chronic transfusion reactions
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Transfusion Reaction Summary
• AHTR can be fatal• Stop the Transfusion• Monitor for symptoms and complete evaluation• FNHTR is a diagnosis of exclusion• TRALI (ARDS-like reaction)• Chronic Transfusion reactions • Prevention methods – using filters, irradiation and
premedication
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