transfusion medicine - vetgirllaboratory gel-test dms laboratories 2 darts mill road flemington, nj...
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Transfusion Medicine Justine A. Lee, DVM, DACVECC, DABT Garret Pachtinger, VMD, DACVECC CEO, VetGirl COO, VetGirl [email protected] [email protected]
Copyright 2014 © VetGirl, LLC
Introduction
Justine A. Lee, DVM, DACVECC, DABT
CEO, VetGirl
Dr. Lee’s financial disclosure
Introduction
Garret Pachtinger, VMD, DACVECC
COO, VetGirl
Sponsorship
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Why transfuse?
! Underlying causes of anemia: ! Blood loss ! Hemolysis ! Decreased production
! Why is anemia significant? ! Decreased O2 delivery to tissues (DO2)
Oxygen content: CaO2
CaO2 = [1.34 X Hg X SaO2] + 0.003 X PaO2
! Does your IMHA patient need blood or oxygen? ! SaO2 = 100% ! PaO2 = 100% ! HCT = 12%
Transfusion trigger
Transfusion trigger*
! HCT ! Human: 25% vs. Veterinary: 20%
! Chronicity
! Normovolemia
! Rate of ongoing losses
Clinical signs
! Clinical signs? ! Tachycardiac ! Tachypneic ! Hypotension unresponsive to IVF ! Hypovolemic shock ! Pulse quality ! Pallor
Feline In-house blood donors ! Healthy ! Indoor only! ! No exposure to other cats! ! >10# ! Large/lean ! 1-7 yo ! UTD ! FELV/FIV ! Blood type
! CBC ! CHEM ! UA ! T4 ! Fecal ! Toxoplasma gondii ! Mycoplasma
(Haemobartonella) ! Bartonella spp ! Heartworm ! Blood type ! FIP?
Canine In-house blood donors ! > 1 year ! Healthy ! > 25 kg ! UTD ! No concurrent meds ! Preventative meds
! Good temperament ! Physical exam ! CBC ! Chemistry ! UA ! Tick titers ! E. canis/equi ! B.canis/gibsonii ! Heartworm ! Blood type
Download the ACVIM Consensus free!
Canine blood typing
! 13 different blood types
! Dog Erythrocyte Antigen (DEA) 1.1, 1.2, 3,4,5,7
! DEA 1.1, 1.2, and 7: most antigenic
! DEA 1.1 more immunogenic than 1.2 ! Very antigenic ! Positive: has antigen on RBC surface ! Negative: antigen missing on surface
Universal Donor
! True universal donor: (-) for all but DEA 4+
! Most universal donors: DEA 1.1, 1.2, 7 (-)
! New blood type �Dal� ! Dal may be missing in an unknown proportion of
Dalmatians
Canine blood typing
Percentage %
Blood types Positive Negative DEA 1.1 1.1 (A1) 33-45 55-67
1.2 (A2) 7-20 35-60 DEA 3B 5-10 90-95 DEA 4C 87-98 2-12 DEA 5D 12-22 78-88 DEA 7Tr 8-45 55-92
DEA 1.1 negative
! DEA 1.1 (-) can be given to (-) or (+)
! Universal donor
! Use when medical conditions preclude testing
! Hypovolemic or hemorrhagic shock ! IMHA ! autoagglutination
DEA 1.1 positive
! Highly antigenic
! Can still use as blood donors
! Use for 1.1 + dogs ONLY!
! �Waste� + units for + dogs
Feline blood type groups ! A, B, AB, �Mik� ! Type A more common
! Type B strong anti-A antibodies # fatal transfusion reaction! *B students don�t like A students*
! Type A weak anti-B antibodies # shortened half life of RBC (2 days vs. 29-39 days)
Feline blood typing Percentage%
Percentage%
Type A Type B Type A Type B Abyssinian 86 14 Himalayan 93 7
Birman & Somali
84 16 Japanese Bobtail
84 16
British Shorthair
60 40 Maine Coon 98 2
Burmese 100 0 Nor. Forest 93 7
Cornish Rex 66 34 Persian 84 14
Devon Rex 59 41 Scottish Fold
82 18
DSHA XX XX Siamese/ Tonkinese
100 0
Percentage (%) Percentage (%)
Domestic shorthair* Type A Type B Purebred cats Type A Type B
USA Northeast 99.7 0.3 Abyssinian 84 16
North Central
99.6 0.4 Am. shorthair
100 0
Southeast 98.5 1.5 Birman* 82 18
Southwest 97.5 2.5 British shorthair*
64 36
West Coast 95.3 4.7 Burmese 100 0
Blood compatibility
! Pre-transfusion testing ! Prior to infusion of donor products
! Testing of donor
! Selection of appropriate donor units ! Blood type ! Blood crossmatching
Blood typing cards
! In-practice blood typing kit ! Based on agglutination reaction that occurs when rbc which
contain DEA 1.1 antigen on their surface interact with a murine monoclonal antibody specific to DEA 1.1
! Laboratory gel-test DMS Laboratories 2 Darts Mill Road Flemington, NJ 08822 1-800-567-4367
Blood Typing: Canine
DEA 1.1 -
DEA 1.1 +
DEA 1.2 +
DEA 1.1 +
Type A
Type AB
Type B
Feline blood typing
Blood crossmatching ! Detects serological incompatibility by identifying
antibodies in donor or recipient plasma against recipient or donor RBCs.
! Major* vs. minor crossmatch ! MAJOR: patient plasma with donor RBC ! MINOR: donor plasma with patient RBC
* More important to determining survival of transfused RBCs
Crossmatching
! Autocontrol (recipient RBC + plasma): rules out autoagglutination
! Any hemolysis or agglutination in major or minor = incompatibility
! Minor BCM – should be compatible in dogs but is of lesser significance in that canine donor plasma should not contain significant antibodies.
Crossmatching
! Dogs lack significant naturally occurring alloantibodies # can be safely transfused without a BCM prior to the 1st transfusion!
! 4-7 days to develop antibodies!
Crossmatching
! Since cats have naturally occurring alloantibodies and may experience a severe reaction to their first transfusion, a BCM should be performed prior if blood typing is not available.
Crossmatching Technique
So what now?
! Consider using blood typing cards for patients receiving acute transfusions (i.e., hemoabdomen, trauma)
! Consider CM when multiple transfusions will be given over one week (i.e., IMHA)
! Consider blood typing cards for FFP use
PRESERVING BLOOD
Anticoagulant preservatives
! Goal: ! Maintain rbc viability ! Lengthen survival of rbcs post-transfusion ! Am Assoc Blood Bank (AABB) standards: 75% of RBC
must survive > 24 hours to be acceptable and successful.
! Longer storage: viability decreases
Anticoagulant preservatives
! CPDA-1 (Citrate-Phosphate-Dextrose-Adenine) ! RBC 2,3-DPG & ATP better maintained ! Good anticoagulant-preservative solution ! WB: stored 28 days ! Canine pRBC: 21 days ! Ratio: 1 ml CPDA-1 to 7-9 ml blood
Anticoagulant preservatives ! CPD (Citrate-Phosphate-Dextrose)
! pRBC: 21 days ! Ratio: 1 ml CPD1 to 7-9 ml blood
! ACD (Acid-Citrate-Dextrose) ! pRBC: 21 days (dogs and cats) ! Ratio: 1 ml ACD to 7-9 ml blood
Anticoagulant preservatives ! Heparin
! Not generally recommended! ! 625 U/50 mls whole blood
! Additive Solutions (i.e., Adsol, Nutricel, Optisol) ! Protein-free solution added to red blood cells
after plasma removed from unit of WB ! pRBC: 28 days (canine)
Goals of fluid therapy ! Increase oxygen delivery ! Increase & maintain organ tissue perfusion ! Maintain blood pressure ! Maintain euvolemic state ! Correct electrolyte or acid-base imbalances ! Treat for hypoproteinemia
Blood products
! Packed red blood cells (pRBC) ! Provides: RBC
! HCT = 80% ! Minimal COP! ! 10-20 ml/kg will raise PCV 10-20% ! Treatment for anemia ! No clotting factors ! Can reconstitute with 0.9% NaCl ! Store at 1-6 C for 28-35 days
! Equation:
ml blood = PCV(target) – PCV(recipient) 80 ml/kg x BW (kg) PCV (donor)
! 10-20 ml/kg ! pRBCs ! FFP ! FP
Dose: pRBCs
Blood products ! FFP
! Separated from whole blood and frozen at -20 to -30 within 6-8 hours of collection
! Provides: plasma, albumin, all coagulation factors (labile, Vit K dept), alpha-macroglobulins
! COP = 20
! Storage: 1 year frozen at -20°C or below
! 10-20 ml/kg
Blood products
! FFP ! Dose: 6-20 ml/kg for coagulopathies
! Dose for albumin: 45 ml/kg increases albumin by 1 g/dl
! 30 kg retriever: 1.3 liters (5-6 units)
! Minimal albumin!!!
Blood products
! FFP ! Dose: 6-20 ml/kg for coagulopathies
! Dose for albumin: 45 ml/kg increases albumin by 1 g/dl
! 30 kg retriever: 1.3 liters (5-6 units)
! Minimal albumin!!!
Blood products ! Frozen plasma (FP)
! Provides: plasma, albumin, stable coagulation factors (Vitamin K dept: II, VII, IX, X)
! COP = 20
! 10-20 ml/kg
! Collected > 6-8 hours from whole blood
! Storage: 5 years frozen at -20C (1 year as FFP, 4 years as FP)
! �Waste� on Vit K deficiency patients!
Blood products ! Fresh Whole blood (FWB)
! Provides: RBC, plasma proteins, COP 20, all clotting factors, WBC
! Platelets (limited)
! HCT: 40%
! 20 ml/kg will raise PCV 10%
! Shelf life: < 8 hours
! Preparation: Use immediately!
Blood products
! Stored Whole blood (SWB) ! Provides: RBC, WBC, Plasma proteins
! Platelets only viable for 2 hours after refrigeration
! Labile coag factors (V, VIII) viable for 24 hrs
! HCT = 40%
! Defined: > 8 hours old and up to 30 days (if using CPDA-1 collection bags)
Blood products
! Platelet rich plasma and plasma concentrates ! Provides: Platelets, few RBC and WBC
! Some plasma
! Shelf life: 5 days at 22°C
! Intermittent agitation necessary
! Administer following collection and preparation (sit undisturbed for 30 min after harvesting)
! Lyophilized platelets ! Davidow et al, JVECC 2012
! Fresh platelets vs. lyophilized platelets ! No significant change in platelet count with either
product
Platelet Concentrates
Blood products
! Cryoprecipitate (CRYO) ! Provides: concentration of VIII, vWF, XI, XIII,
fibrinogen, fibronectin
! Prepared from FFP, which is thawed at 0-6C # precipitate: cryo
! 12 months frozen at -20C
! Dose: 1 unit/10 kg
HBOCs: Oxyglobin
! Oxyglobin ! Ultrapurified ! Bovine ! Stroma free ! LRS base ! Used for treatment of anemia ! 10-30 ml/kg (not to exceed 10 ml/kg/hr) ! 10 ml/kg in dogs will raise Hg 2 g/dl = PCV 6%
HBOCs: Oxyglobin ! HBOCs
! COP 40 ! Fluid overload ! Pigmentation
changes
! $$ ! Good storage ! Interferes with
colometric testing
Protocol for transfusions: ! Evaluate the unit
! Use a filter
! Pick which catheter you give it through
! Pre-treat? ! Diphenhydramine 0.5 mg/kg SQ or IM ! DexSP 0.1 mg/kg IV
Protocol for transfusions: ! Rate dependent on status
! Heart disease: < 4 ml/kg/hr
! If stable and normovolemic: ! 0.25-0.5 ml/kg for 30 minutes ! If no reaction, increase to 0.5 ml/kg (prbc or
WB) or 2-6 ml/kg (FFP)
Protocol for transfusions: ! Monitor for transfusion reaction
! TPR q 1-5 minutes initially, then q. 15 minutes until finished.
! If reaction: ! Treat ! Slow down the transfusion ! Discontinue
AUTOTRANSFUSIONS
Autotransfusions
! When can we autotransfuse?
! VetGirl’s rule: From the chest! ! Dirty, dirty abdomen
! Is the blood sterile? ! Is the blood free of neoplasia? ! Is it end-stage disease?
TRANSFUSION REACTIONS
Autotransfusions
! Sterile collection of blood (60 mls syringes) ! Filter ! Give back IV via filter ! No need to add preservative
! Hypocalcemia
Transfusion reactions
! Immune-mediated ! Hemolytic
! Acute (pre-existing alloantibodies or prior sensitization)
! Hemolytic reactions: Fever, tachycardia, weakness, muscle tremors, vomiting, collapse, hemoglobinemia, hemoglobinuria
! Due to: mismatched transfusion ! Nonhemolytic reactions: urticaria, pruritus, pyrexia, vomiting
! Due to: antibodies to WBC, plt, plasma protein ! Transient
! Delayed (4-21 days post-transfusion)
Transfusion reactions ! Nonimmune-mediated
! Trauma to the rbc: ! Overheating (protein denaturation, increased
bacterial growth) ! Freezing of rbc ! Mixing rbc with non-isotonic solutions ! Warming and then rechilling ! Collecting or infusing blood through small needles or
catheters
Transfusion reactions ! Nonimmune-mediated
! Bacterial pyrogens and sepsis (improperly collected and stored blood)
! Dark brown to black supernatant plasma: digested hemoglobin from bacterial growth
! Citrate intoxication: hypocalcemia
Risks of blood transfusion medicine ! Veterinary medicine reactions: 3%
! Risks: ! Disease transmission (FIP, Leishmania) ! Elyte and acid-base disturbances (hypocalcemia) ! ALI ! Microembolic disease ! Coagulopathy ! Immunosuppressive effects*
! 6X more nosocomial infection ! More sensitive marker of injury severity?
! Hemolytic transfusion reactions (HTR) ! Allergic/anaphylactic reactions (ATR) ! Febrile, nonhemolytic reactions (FNHTR)
! Transfusion-transmitted infections (TTI) ! Transfusion-related acute lung injury (TRALI) ! Transfusion-associated circulatory overlaod
(TACO)
Transfusion Reactions
! AlloAB against RBC antigen
! Hemolytic serum
! Hemoglobinuria
! Elevation in body temp
! Vomiting
Hemolytic Transfusion Reactions
! Histamine release ! Treat with diphenydramine ! Vomiting, facial swelling, hives, elevated
body temperature
Allergic/Anaphylactic Reactions
! Increase in at least 2� in body temperature during transfusion
! No signs of hemolysis
! Usually due to cellular components (WBCs, platelets, other) ! Leukoreduction
! Usually resolves without intervention ! Slow transfusion rate
Febrile, Non-hemolytic Reactions
! Transfusion-transmitted infections ! Reports in the veterinary literature
! Transfusion-related acute lung injury ! Pulmonary edema/pulmonary vasculitis
! During or within 6 hrs transfusion ! Massive transfusion
! 1 blood vol < 24 hrs, ½ blood vol < 3 hrs, 150% blood vol ! Immune-mediated ! Diuretics not indicated ! No reported cases in veterinary literature
! Transfusion-associated cardiovascular overload ! Hydrostatic pulmonary edema (treat with diuretics)
TTI, TRALI, TACO
CASE EXAMPLES
�Buffy,� 4 yo FS Cocker, 10 kgs
Presenting complaint: ! O noticed the following clinical signs:
! Orange urine ! Lethargy ! Vomited once this week ! Anorexia for 2 days
Buffy�s initial exam
! T: 104.8° F (40.4° C) ! HR: 180 ! Panting ! Bounding pulses ! Pallor ! Icterus ! 2/6 heart murmur ! 10 kgs
Buffy�s Big 4/SAG ! Tells you all you need to know in < 1 minute!
! PCV 15%/TS 7 g/dL
! Icteric & hemolyzed serum
! BUN 5-15 mg/dL
! Blood glucose 170 mg/dL
Goal #1: Perfusion, perfusion, perfusion
! Start with crystalloids first ! Cheap $ ! Life-saving ! 20-30 ml/kg IV balanced crystalloid over 20
minutes ! Perfusion – keep on IVF!
Goal #1: Perfusion, perfusion, perfusion
! Check perfusion values ! If still unstable, re-bolus as needed:
! 10-20 ml/kg IV crystalloids/20 minutes ! 5 ml/kg HES IV/20 minutes
Back to Buffy – does she need fluids?
! T: 104.8° F (40.4° C) ! HR: 180 ! Panting ! Bounding pulses ! Pallor ! Icterus ! 2/6 heart murmur ! 10 kgs
Back to Buffy – does she need fluids?
! 10 kgs, HR 180, pallor
! Bolus 200 mls of crystalloid over 20-30 minutes
! Recheck HR, pulse quality
! HR 160 bpm, bounding pulses
Back to Buffy – does she need fluids?
! Rebolus 100-200 mls of crystalloid again!
! Recheck HR, pulse quality
! HR 150 bpm still. Next?
! Bolus 50 mls of HES over 30 minutes!
! HR 120 bpm
Oxygen content = CaO2
! CaO2= Hgb X 1.34 X SaO2 + (0.003 X paO2)
! i.e. IMHA with a PCV of 9% ! Does it need RBC or O2?
! Does Buffy need blood or oxygen?
Give Buffy a blood transfusion! ! Pros vs. cons of giving antigenic RBC
! Deliver oxygen! ! Stimulate immune system?
! What type should I give? ! Universal donor (A-/DEA 1.1)
! Choices:
! PRBC ! FRESH whole blood ! FFP? ! Oxyglobin
PRBC
! What�s in it? RBC only! Perfect!
! Unable to blood type
! 10-20 ml/kg over 1-4 hours, depending on how stable.
Fresh whole blood ! Readily available at your clinic!
! Provides: RBC, plasma proteins, all clotting factors, WBC, some platelets, PCV 40%
! Shelf life: < 8 hours
! Preparation: Use immediately!
! 20 ml/kg will raise PCV 10%
Fresh Frozen Plasma (FFP)
! What�s in it: Plasma, albumin, all coagulation factors (Vit K dependent factors, labile coagulation factors), and alpha-macroglobulins
! Does Buffy need it? NO!
! 10-20 ml/kg
Where do we go from here?
References:
! Canine and Feline Blood Donor Screening for Infectious Disease Wardrop KJ, Reine NJ, Birkenheuer B, et al. J Vet Intern Med 19[1]:135-142 Jan-Feb'05 ACVIM Consensus Statement
! Clinical Use of Blood Products in Cats: A Retrospective Study (1997-2000). Castellanos I, Couto CG, Gray TL. J Vet Intern Med 2004;18[4]:529-532.
! Red blood cell transfusions in cats: 126 cases (1999). Klaser DA, Reine NJ, Hohenhaus AE. J Am Vet Med Assoc 2005;226(6):920-923.
! Whole Blood Transfusions In 91 Cats: A Clinical Evaluation
J Feline Med Surg 6[3]:139-148 Jun'04 Retrospective Study 27 Refs C. Weingart, U. Giger, B. Kohn *
! Massive transfusions in dogs: 15 cases (1997-2001) Jutkowitz LA, Rozanski EA, Moreau JA, et al. J Am Vet Med Assoc 2002;220(11): 1664-9.
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