SAMA EMERGENCY COURSE Assad University hospital Satarday, February 26, 2012

Alexander Bogdanov- Blood Transfusion

Whole Blood 450 ml of donated blood+50 ml of anticoagulant Significant RBC, Plasma, Protein, platelets, Leukocytes, and stable coagulation factors. Insignificant labile factors V, VIII, After 24 h platelets and leukocytes loose viability Indicated in trauma hypovolemic and actively bleeding patient No other indications

Packed Red Blood Cells (PRBC) The most common type of transfusions ml of Red blood cells Indicated in chronic anemia Indicated in active bleeding with and without hypovolemia Not indicated in platelets or leukocytes replacement

Washed RBC Washing RBC in saline Removing immunoglobline IgA Prevent Anaphylaxis and urticarial reaction

Leukocytes-Reduced RBC Removing 99.9 % of leukocytes from PRBC Special filters Indications: Prevent febrile non-hemolytic reaction Prevent alloimmunization Prevent post transfusion purpura

Irradiated RBC 2500 c Gray gamma irradiation Prevent post transfusion GVHD All immune suppressed individuals should receive only irradiated blood products FFP, and cryoprecipitate need no irradiation

Random-Donor platelets ml volume Indicated in bleeding patient with low platelets Indicated in non-bleeding patient with platelets less than Indicated in bleeding patient with platelets function abnormality Not indicated in none bleeding ITP patient Contraindicated in TTP, some DIC

HLA matched platelets Hemapheresis from HLA matched individual donor Refractoriness to platelets transfusion HLA alloimmunization Fever, Sepsis DIC Hyperspleenisim Bleeding Indicated only in HLA alloimmunization Low platelets 1h and 24 h post RDP transfusion indicates alloimmunization.

Leukapheresis from single donor A unit contain 10x 10 granulocytes Should be infused immediately after collection Indicated in septic neonates, granulocytes dysfunction, profound neutropenia and sepsis Granulocyte concentrates transfusion has conflicting trials results Granulocyte Concentrates

Fresh Frozen Plasma FFP Separating and freezing plasma within 6 h of phlebotomy 1ml FFP contain 1unit labile and stable Coagulation factors Indicated in factors deficiency when no single factor is available Indicated in liver dysfunction, massive transfusion

Cryoprecipitate 5-20 ml 80U VIII, vWF,fibrinogen, some XIII, fibronectin Indicated in fibrinogen replacement Not indicated in hemophilia A Not indicated in vW disease

TRANSFUSION is BAD IMMUNE-MEDIATED REACTIONS Acute Hemolytic Transfusion Reactions Delayed Hemolytic and Serologic Transfusion React Febrile Nonhemolytic Transfusion Reaction NONIMMUNOLOGIC REACTIONS Fluid Overload Electrolyte Toxicity Iron Overload INFECTIOUS COMPLICATIONS

Hepatitis, A, B, C, D, G ………. HIV, HTLV-I, HTLV-II, ……… CMV EBV Malaria, Syphlis, Trypanosoma, Toxolplasmosis, Bebesiosis, Brucelosis. Bacteria Gram +ve or Gram -ve

Acute Hemolytic Transfusion Reactions ABO Incompatible BloodABO Incompatible Blood IgM, ANTI A, OR B Agglutinates transfused RBCIgM, ANTI A, OR B Agglutinates transfused RBC Fever, chills, chest arm and flank pain, dyspnia, hemoglobinuria, oligouria, shock, and DICFever, chills, chest arm and flank pain, dyspnia, hemoglobinuria, oligouria, shock, and DIC +ve coombs test, and hemolysis lab+ve coombs test, and hemolysis lab Treatment is suportiveTreatment is suportive

Delayed Hemolytic and Serologic Transfusion Reactions Primery or secondary immunization against RBC alloantibodies Kell, Duffy, Kidd, RH system antigens Rapid fall in Hg after transfusion Most cases subclinical Occasional fever chills, nausea, hemoglobinurea

Febrile Nonhemolytic Transfusion Reaction Agglutinating, or cytotoxic antibodies against antigen on transfused granulocyte Common in multitransfused patient Complement activation and cytokins release Chills, fever, rigor, Hemolytic transfusion reaction should be ruled out Leukocytes reducing filters in future blood products

Allergic Reactions Urticaria Anaphylactic reaction Alloimmunization To red cells antigens – Delayed hemolytic transfusions reaction To platelets antigens – Refractoriness – Neonatal thrombocytopenia – Post transfusion purpura P1-A

Graft-Versus-Host Disease Live T lymphocytes transfused to immune suppressed patient Allo-lymphocytes with different HLA recognize self HLA as foreign HLA Fever, elevated LFT’s, diarrhea, erythema Cytopenia, No available therapy Prevention by irradiation blood products

Post transfusion Purpura Very serious side effect of transfusion Most people are positive P1-A1 antigen Negative patient may develop antigen destroy all platelets Develop in 5-10 days post transfusion Plasmapheresis Washed RBC for future transfusion

Transfusion-Related Acute Lung Injury Potent leukoagglutinins Antibody-antigen leading to leak syndrome in lung Respond quickly to supportive treatment

Emergency Transfusion What products to use From where are they to be obtained To what degree are they to be tested How will they be transported How will they be stored Triage is vital in mass casualty situations, ensuring that scarce resources are used for those with the best chance of recovery. Patients survive with low hemoglobin levels for considerable periods, Speedy treatment of hypovolemia is imperative

Sudden increase the demand for blood May create a sudden massive influx of donors Restricts or eliminates the ability to collect, test, processor distribute blood Restricts or prevent the use of the available inventory of blood components (liquid and frozen) Requires immediate replacement or re-supply of blood from another region/country

Blood Volume Loss Of: percent -- should be treated with crystalloids or colloids, not RBCs, in young, healthy patients; percent -- requires rapid volume replacement, and RBC transfusion is probably necessary; >40 percent -- is life-threatening and volume replacement, including RBC transfusion, is required

Hemoglobin and Transfusion More than 10g/dL transfusion is rarely indicated. Hemoglobin 6-10 g/dL indications for transfusion should be based on the patient’s risk of inadequate oxygenation from ongoing bleeding and/or high-risk factors. Hemoglobin < 6 g/dL transfusion is almost always indicated.

Massive transfusion Transfusion more than50 %of a patient's blood volume in 12 to 24 hours Hemostatic and metabolic complications Selection of the appropriate amounts and types of blood components to be administered Volume status Tissue oxygenation Management of bleeding and coagulation abnormalities Changes in ionized calcium, potassium, and acid- base balance

ALTERNATIVES TO TRANSFUSION Autologous blood transfusions –Preoperative –Intraoperative –Postoperative blood salvage Usage of Growth factors –Erythropoietin –G-CSF, GM-CSF –Erythropoietin, IL-11 Blood substitutes

BLOOD GROUP ANTIGENS AND ANTIBODIES The foundation of transfusion medicine No mistake is excused Compatibility test done on transfused RBC and recipient plasma Compatibility test for RBC and whole blood No compatibility test foe platelets, FFP, and cryoprecipitate Compatibility test detects unexpected RBC alloantibodies Cross match

BLOOD COMPONENTS Red blood cells White blood cells Platelets Plasma Different proteins, Coagulation factors, Albumin

Case # 2 60 Y F while taking blood Unit developed 39 fever and rigor Your next best step is Immediate discontinuation of transfusion NSAID or Paracetamol, Solo-cortef and Phenergan Call your senior resident Ignore fever Further testing

Case # 3 16 Y O M with Bleeding ulcer, HG 4.5, BP80/60, HR 140/m. Bright red blood per NG tube. Hx of multiple transfusions Blood group A +, all 10 U of PRBC were not compatible You do what of the following –Transfuse Non compatible blood –Cross match 10 more units –Call hematology –Wait until he cardiopulmonary arrest –Call surgery

Case # 4 20 Y M came to ER with severe hemolytic anemia G6PD Hg 2 Gm, Decline any transfusion for religious reason Your best management –Oxygen –Fluid –Erythropoietin –Transfusion after general anesthesia – Call hematology

How many Unit to transfuse No magic number Indication Diagnosis Medical plan

ABO ANTIGENS AND ANTIBODIES The major blood groups of this system are A, B, AB, and O The genes determine the A and B found on chromosome 9p

RH SYSTEM Second most important blood group system On chromosome 1 15 percent of people lack this antigen Exposure of these Rh-ve people to Rh-ve cells, by either transfusion or pregnancy, can result in the production of anti-D alloantibody.

OTHER BLOOD GROUP SYSTEMS AND ALLOANTIBODIES Other ABO, D, antigen on RBC Kell, Duffy, Kidd blood group Not normally present unless immunized by transfusion or pregnancy Antibody screen Washing RBC and better selection

PRETRANSFUSION TESTING Hepatitis B, C, B core Antibodies for Human T lymphocyte Virus I,II (HTLVI,II) HIV,I, II