BLOOD COMPONENTS TRANSFUSION INDICATIONS Dr. Meral SÖNMEZOĞLU Yeditepe University Hospital Transfusion Center

BLOOD DONATION

Differential Centrifugation First Centrifugation Closed System Whole Blood Main Bag Satellite Bag 1 Satellite Bag 2 First Platelet-rich Plasma RBC’s

Differential Centrifugation Second Centrifugation Platelet-rich Plasma RBC’s Second Platelet Concentrate Plasma RBC’s

Whole Blood Whole Blood (WB) is blood taken from a suitable donor using a sterile and pyrogen free anticoagulant and container. W B is a source material for component preparation, which is its major use. WB for transfusion is used without further processing. WB for transfusion should not contain irregular antibodies of clinical significance.

Whole Blood Storage Indications Considerations 4° for up to 35 days 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

RBC Concentrate Red Cells is obtained by removal of a major part of the plasma from WB. Red Cells also contains the greater part of the whole blood leucocytes (about 2.5 to 3.0 × 109 cells) and a varying content of platelets depending on the method of centrifugation. For the preparation, plasma is removed from Whole Blood after centrifugation

RBC Concentrate Storage Indications Considerations 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

Function of RBCs Oxygen Transport Delivery of oxygen from lungs to tissues Oxygen transport is dependent on Hematocrit Cardiac output Oxygen extraction 11

Normovolemic Anemia As hematocrit falls Blood viscosity decreases Cardiac output increases (Stroke volume,  pulse) Delivery of O2  O2 extraction  Consumption of O2 remains constant 12

Limits of Compensation At very low hemoglobin levels (approximately 4 g/dL) O2 delivery does not meet demand Anerobic metabolism  lactic acidosis  cardiac arrest 13

Indications for RBC transfusions Recommended that surgery patients have a hemoglobin of 8 to 10 g/dL Led to a general rule of hemoglobin > 10 g/dL of surgery patients 1980s Development of invasive monitoring techniques lead to a better understanding of oxygen delivery and consumption Lower hemoglobin levels could be tolerated 14

Hemoglobin and Hematocrit Levels in Healthy Adults Hemoglobin (g/dL) Hematocrit (%) Mean -2SD Female 14.0 12.0 41 36 Male 15.5 13.5 47 Hematology: Basic Principles and Practice. Elsevier 2005 15

Transfusion Trigger: Multicenter, Randomized Control Study of ICU Patients Transfusion Strategy Hb Trigger Maintenance Level Conservative 7.0 g/dL 7.0 to 9.0 g/dL Liberal 10.0 g/dL 10.0 to 12.0 g/dL Herbert PC et al. N Engl J Med. 1999;340: 409-417 16

Cardiac disease patient Transfusion Trigger: Multicenter, Randomized Control Study of ICU Patients 30-day mortality P Restrictive 18.7% 0.11 Liberal 23.3% Less acutely ill 8.7% 0.03 16.1% Cardiac disease patient 20.5% 0.69 22.9% Herbert PC et al. N Engl J Med. 1999;340: 409-417 17

Restrictive vs Liberal Transfusion in Other Conditions No difference Pediatric ICU patients 7.0 g/dL vs 9.5 g/dL Lacroix J, et al. N Engl J Med. 2007:356;1609-1619 Moderate to severe head injury 7.0 g/dL vs 10.0 g/dL McIntyre LA et al. Neutrocrit Care 2006;5:4-9 Possible difference Cardiovascular disease Liberal transfusions may be better in patients with acute myocardial infarction and unstable angina Hebert PC et al. Crit Care Med. 2001;29:227-234. 18

Platelets Storage Indications Considerations Up to 5 days at 20-24° 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

Platelets

Plasma and FFP For the preparation, plasma is removed from Whole Blood after centrifugation It must contain, on average, not less than 70 IU Factor VIII per 100 ml and at least similar quantities of the other labile coagulation factors and naturally occurring inhibitors.

Plasma and FFP Contents—Coagulation Factors (1 unit/ml) Storage FFP—36 months at –35 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%

Cryoprecipitate Description Storage Indication Considerations 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

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

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)

RBC Transfusions Preparations 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

RBC Transfusions Administration 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

Platelet Transfusions Preparations 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

Platelet Transfusions Administration 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

Serological Testing 3 tests: ABO/Rh Antibody detection/identification Crossmatch

ABO/Rh Typing In the ABO typing, the forward and reverse MUST match In the Rh typing, the control must be negative Both of these will indicate what type of blood should be given

Blood Grouping using gel cards 2

Antibody screen and/or ID The antibody screen will detect the presence of any unexpected antibodies in patient serum If antibodies are detected, identification should be performed using panel cells (with an autocontrol) IS 37° (LISS) AHG If an antibody is present, units negative for the antigen must be given (remember the calculation?) Proceed to the crossmatch…

Crossmatching Purpose: Prevent transfusion reactions Increase in vivo survival of red cells Double checks for ABO errors Another method of detecting antibodies

Crossmatch Two types of crossmatches Major – routinely performed in labs Minor – not required (by AABB since 1976)

Major vs Minor Crossmatch Why is the minor crossmatch unnecessary? Donated units are tested for antibodies Most blood is transfused as packed cells, having little antibodies Major: Patient serum crossmatched with donor red cells. Minor: Donor serum crossmatched with patient red cells. Antibody screen testing on donor samples has replaced the minor crossmatch.

Crossmatch No agglutination ~ compatible Agglutination ~ incompatible Donor RBCs (washed) Patient serum

Conclusions Although RBCs are much safer than 20 years ago, transfusion practices have become more restrictive The transfusion threshold at most institutions is a hemoglobin of 7 to 8 g/dL for most patients Higher thresholds are used for specific patients 39

TRANSFUSION REACTIONS

Transfusion Reactions are… Adverse reactions associated with the transfusion of blood and its components

Transfusion reactions Non-threatening to fatal Hemolytic or non-hemolytic – may or may not cause RBC destruction Acute to delayed Acute – rapid onset Delayed – days to weeks Reactions may involve antigen-antibody interactions May involve infectious agents

Transfusion Fatalities Reported to the FDA (FY 2004 to 2006) 43

Disease Transmission Hepatitis HIV HTLV Cytomegalovirus Malaria Babesiosis Syphilis

Infectious Risk of Transfusion Klein HG et al. Transfusion 2007;47:2338-2347

SHOT 2011 Serious Hazards of Transfusion (SHOT) Steering Group. The 2011 Annual SHOT Report (2012)

1996-2011 SHOT (n=9925)

SHOT 2011 Serious Hazards of Transfusion (SHOT) Steering Group. The 2011 Annual SHOT Report (2012)

Enfeksiyon Riski (Türkiye) 2010’da , 1.014.516 (56.4%) bağış Türk Kızılay’ı tarafından toplandı. 2005 de 20%. 42% si ilk kez bağışçı olmayandan Serolojik test pozitifliği 2010; Sifiliz: 0,10% HIV : 0,17% HCV: 0,25% HBsAg:0,93%

Enfeksiyon Riski HBsAg (Türkiye)

TRANSFÜZYON Evliliğe benzer İyi düşünmeden yapılmamalıdır Gerekmedikçe yapılmamalıdır Gereğinden fazla yapılmamalıdır En güvenlisi hiç yapılmamalıdır