Basics of Transfusion Therapy Laura Cooling MD, MS Associate Medical Director Transfusion Medicine

Blood Collection Most components results of single whole blood donations 500 mL blood + anticoagulant min Blood processed into components –packed RBC, FFP, platelets, cryo –Manufactured Components: IVIgG, albumin, factor concentrates, etc….

Anticoagulants-Preservative Anticoagulant: Sodium citrate –prevent coagulation through chelation Ca++ Carbohydrate: Dextrose –RBC utilize glycolytic pathway Buffer: Na Phosphate –Counter lactic acid acumulation Adenine: Support ATP production Mannitol: Stabilize RBC membrane

ABO TYPES Fucose  1-2Galactose-R H-Antigen GalNAc  1-3Gal-R Fuc  1 2 A-Antigen Gal  1-3Gal-R Fuc  1 2 B-Antigen

DISTRIBUTION AND COMPATIBILITY OF ABO TYPES AND BLOOD COMPONENTS (holds true for solid organ transplant as well)

% Donors Compatible/Component

RBC Transfusion Replace oxygen carrying capacity Acute blood loss with symptomatic anemia Chronic anemia hypoproliferative marrow symptomatic anemia Hx Cardio/cerebrovascular disease

Transfusion Trigger General guidelines but must be tailored to specific patients based on age, history and medical condition

3-4 gm Endocardial Ischemia 6-7 gm Increase Cardiac Output 10 gm Optimal Blood Viscosity Normal Adult 13 gm Blood Donation

10 gm Example: Severe Cardiovascular Disease Increase Cardiac Output Endocardial Ischemia Angina

6 gm Chronic Anemia Example: Thalassemia “Normal” Compensated Stable Vital Signs

Underlying Medical Conditions Influencing the Need for RBC Transfusion Hx myocardial infarction, angina Valvular heart disease Congestive heart failure Hx/risk cerebrovascular disease (TIA,CVA) Coagulopathy Chronic anemia-hemoglobinopathy, leukemia, chemotherapy, renal failure

Signs/Symptoms Supporting Need for RBC Transfusion Active bleeding-rate, medical vs surgical Rapid, unexplained fall in Hgb Syncope/TIA Dypsnea Postural hypotension Tachycardia Angina Oliguria (new onset)

Hgb <7 Hypoproliferative anemia Symptomatic anemia Recent/active bleeding Hx cerebro/cardiovascular ds Hgb < 8 Leukemia/Oncology Bone Marrow Transplant Symptomatic Anemia Hgb > 10 Symptomatic Anemia (ex ischemia) Admit MI, ECMO Increased Oxygen Consumption GENERAL GUIDELINES (ADULTS & CHILDREN)

O 2 Consumption 15-25% O 2 carrying capacity is normally extracted in peripheral tissues 1 gm Hgb = 1.34 mL O2 –Hgb 15 gm (45%)= 20 ml O2/dL –(4X minimal baseline need) Anemia –Hgb 7 gm (21%) = 9.4 ml (1.9x baseline) –Less excess capacity in face of  O2 demands

O 2 Consumption Extraction ratio (ER) > 0.5 (50%) –increased metabolic demand –aerobic  anaerobic metabolism –measure in invasively monitored patients –examples: sepsis, burn patients Practice: Raising Hgb often fails to lower ER in critically ill patients

Blood Viscosity Relative to H20 Hematocrit 33%60% Hct Viscosity O2 transport Relation of Blood Viscosity to O 2 Delivery

Blood Viscosity Relative to H20 Hematocrit 30% Viscosity nl donors O2 transport Blood Viscosity to O 2 Delivery in SS Disease Viscosity SS Do NOT Transfuse Patients with SS Ds Hct >35 %.

RBC Administration ABO, Rh compatible Administer within 4 hrs of leaving BB Administer with isotonic saline only Dose:1 unit raise Hgb 1 gm or Hct 3% children: ml/kg children with CHF: 5 ml/kg Rate:avg 1 unit/2 hrs (3-4 cc/min) OR 1 ml/kg/hr (ex. pts with CHF) Efficacy:1 gm Hgb or 3% Hct per unit

Contraindications RBC Transfusion Volume expansion Enhance wound healing “Patient feel better” Mistakes: Hypertransfusion in sickle cell disease DO NOT TRANSFUSE OVER >30-35%

Plasma Replace coagulation or anticoagulant factors in bleeding patients or at risk of bleeding due to invasive procedure Two Products Fresh Frozen Plasma Liquid Plasma

Inherited Factor Deficiencies DeficiencyTreatmentTrade Name Hypofibrinogenemiacryoppt Dysfibrinogenemiacryoppt FIIPlasma FVPlasma FVIIrFVIIaNovoSeven FVIIIrVIII, VIIIc FXPlasma (PCC) FXIInone FXIIIFXIII conc., cryopptCortifact Protein CPrC concentrateCeprotin Protein S(anticoagulation)

Indications for Plasma Acquired Multifactor Deficiencies Massive Transfusion DIC Liver failure Exchange transfusion (HDFN) Coumadin reversal Vitamen K deficiency –PCC (4 factor) –Vitamen K Plasma Plasma not first choice

Indications: FFP A.PT and/or PTT > 1.5 x normal range AND Active bleeding Risk of bleeding due to invasive procedure B.Pt with documented anticoagulant deficiency and at risk for thrombosis

PT (sec) % Normal Plasma Normal Range 1.5 x normal PT 1.5x normal (or INR >1.6) 30-40% Factor Concentration 30-40% 1.5 x nl

PT (sec) % Normal Plasma Normal Range 1.5 x normal Historical Therapeutic Goal: > 60% activity  3 sec normal range or INR  % 30% ≥ 2x  factor

Mildly Elevated PT/INR Mildly Elevated INR (< 3 sec, INR < 1.6) 56% – 62% of ALL plasma transfusions –Univ. Oklahoma: mean INR = 1.37 Plasma has minimal impact at INR < 1.6 –Mean decrease INR/unit = sec –FFP variability: mean INR = 1.1 (0.0 – 1.3)

Change in INR in patients with mildly elevated INR (1.1 – 1.8) by plasma volume infused Effect of FFP transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Omar et al. Transfusion 2006;46: % corrected PT/INR in normal range 15% had a 50% decrease PT/INR Mean change: PT = 0.2 sec ( ), INR = 0.07 No dose-response Results:

Efficacy FFP in Shortening Clotting Times End Stage Liver Disease (INR > 1.8) Variable response per patient Transient (1-4 hours) Significant amounts of plasma –Minimum 10 mL/kg to 30 mL/kg! Shorten but NOT correct PT/INR

Adapted from Spector NEJM 1966 Transient Increase in Factor Levels with FFP in ESLD (Plasma doses = 22-30% total blood volume, 6 units)

Fresh Frozen Plasma Whole Blood Derived or Apheresis Frozen within 8 hrs of collection 1 unit/mL coagulant and anticoagulant factors Shelf-life 1 yr frozen Thawed: outdates in 24 hrs > 24 hrs, convert to liquid plasma

Liquid Plasma Plasma frozen after 8 hrs but < 5 days of collection Has essentially same level of coagulation factors as FFP except for VIII Standing inventory per MTP –6U A –6U O –2U B –4U AB

ADMINISTRATION FFP min thaw, 24 hr outdate ABO (but not Rh) compatible Transfused within 4 hrs after leaving BB volume 250 ml/unit Dose: cc/kg Rate: 1 unit per min (10 cc/min) OR: as fast as possible and tolerated Monitor: Post-PT/PTT ONE UNIT OF FFP IN AN ADULT IS HOMEOPATHIC AND INAPPROPRIATE

PLASMA: Common Mistakes Transfusion not indicated –Prophylactic administration in a stable, non- bleeding patient (treating numbers) –Mildly elevated PT/PTT (< 3 sec normal range) Inadequate dose Slow infusion rate –actively bleeding patient Transfused too soon (VII t1/2=5-7 hrs!) –planned surgical, medical intervention

CONTRAINDICATIONS Nutritional support Oncotic/fluid support Heparin reversal Reversal direct thrombin inhibitors –Pradaxa (no reversal agent) –Rivaroxaban, apixiban (tx PCC) Isolated factor deficiencies –VIII Deficiency, von Willebrand Disease

Cryoprecipitate Prepared from FFP that is allowed to thaw overnight at 4C. It is literally the “cold” precipitate” of plasma Enriched source of Fibrinogen, VIII, vWF Contains thrombospondin, fibronectin, some IgM antibodies

Cryoprecipitate Production FFP Thaw Overnight 1- 6 C Precipitation Of Proteins “Cold Precipitate” Fibrinogen, FVIII, vWF Cryoprecipitate 7-15 mL/unit CPP Cryo By-product Cryopoor Plasma

Cryoprecipitate Each unit 7-15 cc total volume 150 mg fibrinogen –* less than FFP unit ( mg) U VIII Adult: Pool several units (avg 10) for adults

Indications for Cryoprecipitate Hypofibrinogenemia (<100 mg/dL) and bleeding/prior to surgery Dysfibrinogenemia and bleeding/prior to surgery Fibrin patch-Oto, cardiothoracic, dental Uremic bleeding Less Common Now (better alternatives) VWD, FVIII deficiency, FXIII deficiency

Common Mistakes Inadequate dose order 1 unit (10 cc) for adult Inappropriate Administration Patient with volume overload and Multifactor deficiency (long PT/PTT) Over-ordering/ Over transfusion Surgery responsible for 65% cryo waste

Cryoprecipitate Administration ABO compatible preferred but not required Infused within 4 hrs of thaw, pooling Dose:10 pooled (adult) 1 unit/5 kg (infants/children) Rate:Like FFP ( cc/20-30 min) Efficacy:Increase fibrinogen 5 mg/dl /unit 10 units=raise fibrinogen 50 mg/dl

Platelet Concentrates Whole Blood Derived (Pooled Platelets) Single Donor Apheresis (Pathology Approval) HLA (antigen negative, HLA matched) Crossmatched Platelets

Platelet Concentrates Biggest Inventory Problem stored room temperature shelf-life 5 days from collection –about 3 days after processing & testing outdate 4 hrs after pooling

Platelets: Product Use/Availability Dependent on Market Availability and Cost Whole Blood Derived Majority of UM supply 65,000 plts/yr Single Donor Apheresis Random, Crossmatched, HLA Limited availability locally UM: Requires special order, pathology approval and rigid post-transfusion monitoring

Platelets: Two Products Available Whole-Blood Derived Derived whole blood “pooled platelets” mL unit ~8 x plts/unit  5-10K plts/unit tx DOSE: adult=5 units (4.2 x ) infants=10-15cc/kg BW Single donor apheresis mL unit >3 x plts/unit equivalent to 5 units pooled platelets  K plts/unit tx DOSE: adult=1 unit infants=15 cc/kg children=10 cc/kg

Platelet Yields: SEMARC Data (2007-8) (courtesy Angelo D’Anna, SEMARC) PLT Yield WBD-RDPpHPer unitPool x 5LR* PRP x x Y Pre-pooled7.48 NA4.0 x Y Apheresis single x Y double x Y triple x Y * LR, leukoreduced

Platelets Treat/prevent bleeding in patients severe thrombocytopenia (ex. plt < 10-20K) thrombocytopenia (<50K) and bleeding Inherited platelet defects and bleeding Acquired platelet defects and bleeding

Platelets: Transfusion Guidelines Platelets < 5-10K Prophylactic to prevent bleeding

Real Risk of Bleeding < 5000/uL Fraction of bleeding days by PLT count PLT count% Days < 1000/  L38% /  L15% /  L10% 5-10K/  L9% 10-20K/  L7% The quantitative relation between platelet count and hemorrhage in patients with acute leukemia. Gaydos et al, NEJM 1962;266: PLT < 5K Early study by Gaydos, aplastic anemia patients

Increasing Move to PLT < 5000/uL Schlicter et al, NEJM 2010;362: Gmur et al, Bleeding Risk Factors PLADO Study (2000) Morning Plt < 5000/  L –33% increase bleeding Platelet count > 6000/  L Steady-state bleeding risk No correlation with platelet count Plt 6 – 100K

Platelets: Transfusion Guidelines Platelets < 5-10K Prophylactic to prevent bleeding Platelets < 20 K Prophylactic in patients at risk for bleeding due to infection, chemotherapy, coagulopathy, etc Platelet < 50K surgical hemostasis Active bleeding or prior to invasive procedure Stable, sick infant (<37 weeks)

Platelet > 100K Extracoporeal Membrane Oxygenation (ECMO) Neurosurgery +/- Opthamology/airway surgery +/- CABG surgery with microvascular bleeding despite appropriate coagulation parameters Sick infants (< 37 wks gestation, *  risk ICH) Infant, bleeding + DIC or other abnl coagulation Normal Platelet Count Inherited qualitative defect (ex. Bernaud-Soulier) Acquired defect* (ex. MoAb Anti-IIb/IIIa, plavix)

Relative Contraindications: Platelets Thrombotic thrombocytopenia purpura (TTP) Hemolytic uremic syndrome Heparin-associated thrombocytopenia During cardiopulmonary bypass Prophylactic Transfusion (absence bleeding): Immune thrombocytopenic purpura (ITP) Alloimmune thrombocytopenia (PTP) Severe HLA-alloimmunization

Platelets: Administration ABO compatible preferred but not required Transfused within 4 hrs volume 50 ml/unit=250 ml/5 pooled Dose: Adults:5 units pooled (raise plt 25-50K) Children:0.3 units/kg or cc/kg Rate: 10 cc/min (1 unit/30 min in adult)

Platelets: Common Mistakes Over-ordering –4 hr outdate from pooling!!! Prior surgical/invasive procedure –Administering too soon (ex night before) –Prophylactic administration severe splenomegaly Prophylactic: immune thrombocytopenia Lack of appropriate post-transfusion monitoring Administration within 2-4 hrs amphotericin

Platelets: Specialty Products Single donor apheresis platelets Crossmatched platelets HLA-matched platelets Pathology consult and evaluation Patients with suspected alloimmune platelet refractoriness

Platelet Refractoriness Immune (25-50%) Alloimmunization Autoantibodies Passive Immunity Drug-related Nonimmune (50-75%) Fever Infection Splenomegaly Drugs/Antibiotics Consumption Bleeding Platelet Dose Poor response to platelet by immune or nonimmune factors

Platelet Kinetics circulating life span 8-10 days Spleen 30-40% Circulation 60% 10-12% loss/day 20% endothelial integrity 80% senescence

Relationship between platelet count and physiologic platelet losses. Mueller-Eckhardt et al, Br J Hematology 1982;52:49-58 Physiologic PLT loss –Physiologic baseline –Est. 7 x 10 9 plts/day Equiv /  L Low PLT counts –% PLT loss/day  80% PLT transfusion survival Transfusion interval % PLT loss due Physiologic processes

PLT > 150K PLT  K 1 hr20-24 hr2 days8-10 days Pre-Transfusion Platelet Count: Platelet Survival and Transfusion Interval 50% 75% 65% PLT < 10K % Platelet Recovery 1 hr

Asplenia Normal Plt>200K Splenomegaly Plt<50K Normal Plt<50K 1 hr20-24 hr2 days8-10 days Effect of Splenomegaly on Platelet Survival 50% 75% 65%

Effect of Patient Size on Post-transfusion Platelet Count. Platelet recovery (1 hr): 60-65% Platelet increment: 1 x /m 2 (BSA) Body Surface Area (M 2 ) Rise in Post-transfusion Plt (x 1000/uL) 3 x platelets transfused

Transfusion Increment is a function of patient size and # platelets transfused Body Surface Area (M 2 ) Post-transfusion Plt (x 1000/uL ) No. platelets transfused (x )

Evaluating Platelet Transfusion Response Corrected Count Increment (CCI): In vivo Measurement Platelet Survival Number of Platelets Transfused Size of Patient Requires a 1-4 hour post-platelet count Positive Predictor platelet survival at 20 hrs

Corrected Count Increment Whole Blood Derived Platelet Concentrates CCI= (post-platelet count - pre-platelet count)(BSA) (3.5 [ approximate # platelets transfused x ]) CCI > 7.5 Good Response * Platelet count at 1 hour post transfusion, BSA=body surface area in M 2 Example: Patient (1.7 M 2 ) transfused with 5 units pooled platelets for platelet count=2. At 1 hr, plts=30K. CCI=(30-2)(1.7)/3.5=13.6

24 hrs Normal PPR>30% hrs PPR = 60-66% CCI > 7.5 Nonimmune Immune Hypersplenism % Platelet Recovery (PPR) Platelet Response and Kinetics Short Survival vs Refractoriness 1- 4 hr Post-transfusion

Irradiation Prevent transfusion-associated GVHD. Engraftment donor lymphocytes Mortality >80-90% Cellular components only (RBC, platelets) Symptoms: Fever Skin eruptions Diarrhea Elevated LFT Pancytopenia

INDICATIONS Intrauterine transfusion/exchange transfusion Premature neonates –(< gm and < 4 month age) Congenital immunodeficiencies Aplastic anemia Bone marrow transplant recipients Hematologic malignancy Solid tumor malignancy requiring high dose, mutiagent chemotherapy Purine analogs (fludarabine) HLA-matched platelets Directed donations from relatives ORGAN TRANSPLANTS DO NOT REQUIRE IRRADIATION

Adverse Effects of Irradiation Increased rigidity, less deformability Contributes storage lesion (RBC) –Increased K+ leak –Decrease ATP, pH –“accelerated aging” Give irradiated components only to those patients at risk

CMV-safe Prevent TA-CMV in at-risk patients Transmitted by lymphocytes cellular components only (RBC, platelets) Prevented by leukodepletion (CMV-safe) Indications: (CMV-safe) Intrauterine transfusion Premature infants/exchange transfusion Bone marrow transplant Solid organ transplant The UM supply is 100% prestorage-leukoreduced, CMV-safe

Cases

Patient with diabetes, renal insufficiency, and cardiovascular disease is admitted to the hospital with severe angina. Her Hgb on admission is 8.0 gm/dl. The attending would like to keep her Hgb > 10 gm/dl. Is RBC transfusion appropriate? How many units should the resident order? The resident is concerned about volume overload. What is the slowest rate RBC can be administered?

A 100 kg patient with severe liver disease is scheduled for shunt placement. His PT on admission is 26 sec (nl range sec). His platelet count on admission is 27,000. A pre-op order for FFP and platelets is placed for 7 am case. How many FFP should be ordered? When should FFP be administered? Will FFP completely correct the PT? When should platelets be administered?

A 65 yr old woman with ovarian cancer with renal obstruction is admitted for stent placement. Because of recent chemotherapy, her platelet count is 35,000. Does she need platelet transfusion before stent placement? When should platelets be administered? What would be the expected increase in platelet count after transfusion of 5 units pooled platelets?

Over the next 3-4 days, the patient has persistant, significant hematuria and is transfused with RBC and platelets. The blood bank is called for HLA-matched platelets because the patient is “refractory”, based on daily am plt count=35,000 (20 hr post). Is this patient refractory? Evidence of alloimmune refractoriness? What needs to be done?

Three Consecutive 1 hr post-transfusion platelet counts Based on pre-count, did the patient have an appropriate increase in platelet count? Is this immune refractoriness or decreased survival?

The patient is a 5 year old girl followed for sickle cell anemia. She is currently being seen in clinic for a pain crises. Her current CBC shows Hgb=4.0 (baseline Hgb=7.0). The patient is treated with hydration, pain medication and a RBC transfusion. Is transfusion appropriate? Does the patient require irradiated RBC? Is there a problem with giving irradiated RBC? What are the transfusion risks for these patients ?

Blood Transfusion Policies and Standard Practices Select: Clinical Resource “Blood Bank and Transfusion Services” Link on UMHS Clinical Homepage

Role of FFP in Correcting Coagulopathy Decrease in PT  Pre-Tx INR What about mildly elevated INR? ESLD, PT > 3s nl range Adapted from Youseff 2003

Practical Guide to Transfusion Medicine By M. Petrides, G. Stack, L. Cooling AABB Press Blood Transfusion Therapy: A Physician’s Handbook AABB Press

THINK PINK PINK TOP TUBE FOR BLOOD BANK SPECIMENS ONLY

Platelet Wastage by Surgery at the UM Not used after pooling Reasons for wastage 1. Outdate before transfusion 2. Ordered “just in case”, not need 3. Improper storage 4. Patient died

PLADO (Platelet Dose Trial) Slichter et al; NEJM 2010;362: Study Subjects Stem cell transplant Cancer with HD chemotherapy PLT 5 days Low Dose  1.1 x /m 2 (0.5 SDP/3 RDP) N=417 Medium Dose  2.2 x /m 2 (1 SDP/5 RDP) N=423 High Dose  4.4 x /m 2 (2 SDP/10 RDP) N=432 Primary Outcome Measure Grade 2 Bleeding or Higher ExclusionsCoagulopathy Hx refractoriness HLA PRA > 20% Recent surgery Wt > 135 kg

Platelet Dose NO Impact on Bleeding BleedingLow (LD)Medium (MD) High (HD)P > Grade 2 (all)68%67%69%NS Grade 258%59%60%NS Grade 39%7%8%NS Grade 43%2% NS Death001NS RBC Utilization % Transfused95%92% NS No. units444NS No difference in incidence or severity of bleeding No difference in the number of days with bleeding No difference in RBC utilization