Presentation on theme: "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."— Presentation transcript:
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 The procedure can be done for treatment or transfusion purposes.
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 º C, with glycerol etc: Years
Blood Preservation Effects of storage –Red cells: ATP, 2-3 DPG, osmotic fragility and oxygen affinity –Plasma : Hb, K, NH 3 : pH: –Platelets: Lost in 2 days –Coagulation factors: Eg: FV: adequate levels for about 5 days FVIII: Below 80% of original level after 1-2 days FXI: Less than 20% of original level after 7 days
Blood Preservation Platelets: –liquid phase : 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
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
White cell reduction White blood cell filtered or, Washed red cells or, Frozen red cells are white cell reduced red blood cell components.
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 ?
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
Important: Symptoms related to anemia may differ from one patient to another for a given Hb level; The trigger for red cell transfusion may differ from one patient to another!!!!!
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%
Indications for transfusion of blood or its components White cells reduced RBC’s : < 5x10 6 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
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 !!
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
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
Indications for transfusion of blood or its components Platelets: Thrombocytopenia due to decreased platelet production Platelet count/mm3 Bleeding /surgery Indication for plt transfusion > , No No < YesYes NoNo (if there is bleeding/fever/DIC/plt dysfunction) Yes < Yes or NoYes
Some special conditions about platelet transfusion 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
Types of platelet concentrates Random donor plt concentrate (single unit) –5,5 x plts – /mm 3 plt increase after transfusion Pooled plt concentrate (eg:6 random units) Apheresis plts –>3x10 11 plts – /mm 3 increase after transfusion WBC reduction of platelets is indicated in the same situations like red cells.
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
Indications for transfusion of blood or its components/products Cryoprecipitate –Includes FVIII, vWF, FXIII, fibrinogen and fibronectin – units of FVIII, ≥150 mg fibrinogen and % 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
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 ml/hr) Drugs ?
Transfusion Reactions Immunologic reactions Non-immune reactions or Acute reactions Late reactions
Hemolytic reactions Reasons: Mismatched transfusion Transfusion of hemolysed blood »During storage or warming etc May be acute or late
Acute hemolytic reaction Frequency up to 1/ / Tx mortal 40% symptomatic ABO mismatch IgM antibodies (anti-A or anti-B),complement binding and intravascular hemolysis Early onset ( first 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
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)
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
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
Allergic reactions Cause: Antibodies against donor plasma proteins Pruritus,urticaria,edema,anaphylaxis,broncho spasm 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.
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
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
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
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/ – 1/ Red cells: <1/ Stop transfusion, take cultures, treat with IV fluids and antibiotics, take support measures and follow against shock, renal failure,DIC
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
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)
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