2 Blood Donation Healty adult donors 450 ml +/- 10% per whole blood donationMale: 5/year, Female : 4/year> 8 weeks between two donations
3 Apheresis:PlateletsPlasmaWhite cells (or subsets)Red cellsThe procedure can be done for treatment or transfusion purposes.
4 Blood Preservation Whole blood or red cells 1-Liquid phase storage : 1-6º C63 ml anticoagulant-preservation liquid/unitduration of preservationACD: 3 weeksCPD: 3 weeksCPD-A1: 35 daysRBC concentrate with SAG-Mannitol : 7 weeks2- Frozen storage of red cells-80 to º C , with glycerol etc: Years
5 Blood Preservation Effects of storage Red cells: ATP, 2-3 DPG, osmotic fragility and oxygen affinityPlasma : Hb, K, NH3 :pH:Platelets: Lost in 2 daysCoagulation factors:Eg:FV: adequate levels for about 5 daysFVIII: Below 80% of original level after 1-2 daysFXI: Less than 20% of original level after 7 days
6 Blood Preservation Platelets: Plasma : Use fresh or freeze liquid phase :1 - 5 days,room temp.,avoid light exposurekept on special agitatorPlasma : Use fresh or freezefrozen at -18 º C within 8 hrs of collection
7 Blood components & products Cell containing componentsRed cells:Whole blood( fresh or not)Red cells: packed red blood cellswashed red blood cellsfrozen red blood cellsleukocyte – reduced red blood cellsPlatelets: Random donor plateletsApheresis platelets ( single donor platelets)Granulocytes or mononuclear cellsPeripheral blood progenitor cells
9 White cell reduction White blood cell filtered or, Washed red cells or,Frozen red cellsare white cell reduced red blood cell components.
10 Deciding blood transfusion; Severity of symptomsCause of anemiaRapidity of anemia or symptomsCo-morbidities and the age of the patientCan we treat the anemia without transfusion?AndIs there enough time to wait for the response of such a treatment ?
11 This is not a guide to be used in every patient Hemoglobin >10 g/dL : Tx rarely neededHemoglobin < 6-7 g/dL: Tx mostly necessaryHemoglobin : 6-10 g/dL: Dependable
12 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!!!!!
13 Indications for transfusion of blood or its components Whole blood: Acute massive bleeding1 unit increases Hb: 1g/dl, Hct: 3%Fresh whole blood:Massively bleeding patient/shockExchange 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
14 Indications for transfusion of blood or its components White cells reduced RBC’s:< 5x106 WBC’s per unitWhite cell filters(before storage or before transfusion)An indication for RBC transfusion +To prevent reactions caused by WBC antibodiesFebrile non-hemolytic transfusion reactionsTo prevent alloimmunizationTo prevent CMV transmission
15 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 complementPNHIgA deficiencyPrevention of anaphylaxisWashed units must be transfused no later than 24 hoursFrozen RBC’s:Autologous transfusion: rare blood groups,Catastrophy etcWashed before infusion !!
16 Indications for transfusion of blood or its components Blood IrradiationTo prevent transfusion related GVHD in;Congenital immune deficient statesBone marrow or stem cell transplantationSome cases of hematologic malignanciesHodgkin’s diseasePurin analogue or anti-CD52 treatmentIntra-uterin transfusionNew borne exchange transfusionTransfusions between relativesfirst or second degreeHLA matched platelets
17 Some of the indications for platelet transfusions Decreased platelet production because of bone marrow failure or infiltration :bleeding or risk of bleedingLeukemiaMDSMyelofibrosisMalignant tm infiltrationMyelosupressionAplastic anemiaFunctional platelet disease and bleeding or risk of bleedingDilutional thrombocytopenia (after massive transfusion)Cardiac by-pass surgeryIncreased platelet destruction or consumptionDICDrug inducedsepsisITP
18 Indications for transfusion of blood or its components Platelets:Thrombocytopenia due to decreased platelet productionPlatelet count/mm Bleeding /surgery Indication for plt transfusion> , No No< Yes YesNo No(if there is bleeding/fever/DIC/plt dysfunction) Yes< Yes or No Yes
19 Some special conditions about platelet transfusion Disease status may changethe transfusion effectiveness:DICHypersplenismSepsisAllo-immunisationCotraindicated in ThromboticThrombocytopenic Purpura: Usedonly in high risk bleedingNot effective/useful in ImmunePractical issuesABO matched platelets have a longer in-vivo life span after transfusionUse Rh- platelets for Rh- recipients (to prevent Rh immunisations) or use anti-Rh(D) Ig if Rh+ component used in such recipients
20 Types of platelet concentrates Random donor plt concentrate (single unit)5,5 x 1010 plts/mm3 plt increase after transfusionPooled plt concentrate (eg:6 random units)Apheresis plts>3x1011 plts/mm3 increase after transfusionWBC reduction of platelets is indicated in the same situations like red cells.
21 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 overdosePlasma exchange (eg:TTP)After massive transfusion10-20 ml/kg : to increase deficient factor level about 20-30% from baseline
22 Indications for transfusion of blood or its components/products CryoprecipitateIncludes FVIII, vWF, FXIII, fibrinogen and fibronectinunits of FVIII,≥150 mg fibrinogen and % of FXIII that is in one unit of plasmaCan be used for the purpose of replacing the deficient state of these factors in case of bleeding or surgery
23 Practical IssuesIs 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 matchRead label, ID, inspect the productIs irradiaton necesssary?Temperature?Filters?Flow rate ? (start 5 ml/min-15 minutes , the rest ml/hr)Drugs ?
25 Hemolytic reactions Reasons: Mismatched transfusion Transfusion of hemolysed bloodDuring storage or warming etcMay be acute or late
26 Acute hemolytic reaction Frequency up to 1/25.0001/ Tx mortal40% symptomaticABO mismatchIgM antibodies (anti-A or anti-B) ,complement binding and intravascular hemolysisEarly onset ( first ml’s),seldom after 1-2 hrspain at the infusion site, flushing, chest or back pain,dyspnea,vomiting, fever-chills, hypotension and tachicardia,bleeding, hemoglobinuriaComplications: Acute Renal Failure, shock,DIC
27 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)
28 Delayed hemolytic reaction 1/2500-1/6000Onset: 3-21 days after transfusionReason: Rh, Kidd etc mismatchesPrevious alloimmunization and anamnestic responseCoombs + ( do not confuse with OIHA)Jaundice or absence of the expected increase in red cell values.Frequently undetectedTreatment : none
29 Febrile reactions 0,5- 3% of all transfusions Cause: Antibodies against white cell/plt/plasma antigensFever-chills, increased pulse rate during or after transfusionAntipyretics/antihistaminesStop transfusion if there is doupt about hemolysisProphylaxis: White cell reduction
30 Allergic reactions Cause:Antibodies against donor plasma proteins Pruritus,urticaria,edema,anaphylaxis,bronchospasmIgA deficient patients are under the greatest riskTreat according to the type of reactionFor IgA deficient patients: use washed or frozen red cells instead of regular red cells or whole blood.
31 Pulmonary hypersensitivity reaction/TRALI 1/5000 frequencyCause : 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 transfusionRespiratory support may be necessary
32 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 infectionsProphylaxis: Blood irradiationTreatment: immunosupressive drugsMortality high
35 Circulatory overloadOld aged or premature/ new borne or patients with cardiopulmonary compromise are under risk.Clinics: Acute heart failureTreatment: As acute myocardial failureProphylaxis: Slow infusion rate, low volume of transfusion
36 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/ – 1/65.000Red cells: <1/Stop transfusion, take cultures, treat with IV fluids and antibiotics , take support measures and follow against shock, renal failure,DIC
37 Air embolism May cause acute respiratory and circulatory failure Clump the tubingChange the posture of the patient:Left side / Trandelenburg (left side ,head- down, legs upside)Swan -Ganz catheter
38 Massive transfusion may cause: Patients with bone marrow failure , transfused chronically are under the risk of transfusion hemosiderosis.Massive transfusion may cause:Citrate toxicity: HypocalcemiaHyperkalemiaBleeding ( due to thrombocytopenia and /or factor deficiency)