1. Basics of Transfusion Therapy
Resident Education Lecture Series

2. Hemoglobin Level and Symptoms
HGB (GM%) SYMPTOMS
MINIMAL
EXERTIONAL DYSPNEA
WEAKNESS
DYSPNEA AT REST
HEART FAILURE
LINMAN
NEJM 279:812, 1968

3. RBC Transfusion: Indications
Acute Blood Loss
Symptomatic Anemia
Suboptimal O2 Capacity
Exchange (SS, Co)

4. RBC Transfusion: The Bathtub Principle
Kidney
Kidney
Kidney
100 30
100 30
100 40
Blood Volume
Blood Volume
Blood Volume

5. Pre-Transfusion Testing
BLOOD TYPING:
ABO, D Antigens only
(Other antigens are weak immunogens)
ANTIBODY SCREEN:
Patient serum vs. cell panel
CROSSMATCH
Major: Patient Serum vs. Donor Cells

6. RBC Products PRBC MOST TRANSFUSIONS WHOLE BLOOD ACUTE BLEEDING
EXCHANGE
PLASMA NEEDED
WASHED REMOVE PLASMA
FROZEN RARE RBC PHENOTYPE
IRRADIATED IMMUNODEFICIENT
CMV NEGATIVE IMMUNODEFICIENT
SERONEGATIVE, NEONATE

7. RBC Transfusion Volume
Usual: Up to 15cc/Kg in 3-4 hours
Unusual: Acute Hemorrhage:
replace ongoing losses
Chronic Anemia, Heart Failure, îBP
2cc/Kg/Gm HGB
Diuretic
Exchange

8. Transfusion Volume 10cc/Kg PRBC 2.4 GM% in HGB 10cc/kg = X cc/kg
2.4 GM% Desired HGB rise
PRBC cc = Blood Volume x (HGBF- HGBI)
HGBT
BV=70cc/KG, 80-90cc/KG newborn

9. Hemolytic Transfusion Reactions
Acute HTR /25,000
Fatal Acute HTR 1-4/1,000,000
Delayed HTR 1/5-10,000

10. Symptoms and Signs of Acute Hemolytic Reactions
Severe Back Pain
Substernal Tightness, Dyspnea
Hypotension / Circulatory collapse
Vomiting, diarrhea
Icterus
Hemoglobinuria
Renal shutdown
Diffuse Oozing from wounds/punctures

11. Response to Suspected Hemolytic Reaction
Stop Transfusion
Hydrate
Specimens to Blood Bank
Unit/Bag
Serum
Red cells
Urine

12. Acute Hemolysis: Diagnosis
Do a direct antiglobulin test on post-transfusion sample
Obtain post-transfusion blood and urine and inspect visually
Recheck paperwork
Recheck ABO type of unit and pre-and post-transfusion specimens
Run urinalysis - to check for hemoglobinuria

13. Cause of Acute HTR ABO incompatibility:source of error
10% at phlebotomy/labeling
23% in Transfusion Lab
67% transfusion administration (at the bedside)

14. Nonhemolytic Transfusion Reactions
Leukocyte Associated
FNHTR
Transfusion GVHD
Neonatal Neutropenia
Immunoglobulin Associated
Urticaria/Fever
Ig E
TRALI
Platelet Associated
Post transfusion Purpura
Neonatal Thrombocytopenia
Metabolic/ Physical
Citrate Toxicity
Hypothermia
Circulatory Overload
Massive Transfusions
Haemostatic Abnormalities
Metabolic complications
Hgb-O2 Curve Shift

15. TRANSFUSION-RELATED INFECTION

16. Risk of Transfusion- Transmitted Infection
HIV 1 in 2,000,000
Hepatitis C 1 in 2,000,000
Hepatitis B 1 in 175,000
Hepatitis A Rare
HTLV I/II 1 in 3,000,000
Bacteria 1/3,000 (for platelets)
Malaria, T Cruzi, Babesia, Yersinia, Syphilis, Lyme, CJD, West Nile Virus…??

17. Post Transfusion HCV Percent Number Incidence 5-10 150-300,000
Chronic ,000
Cirrhosis ,000

18. Neonatal Post Transfusion CMV
Incidence: 25% of seronegative infants
receiving >50ml CMV
seropositive blood
Severity 50% severe or lethal manifestations

19. Neonatal Transfusion CMV Prevention by Filtering Blood
Seroconvert/Total
Filtered PRBC: 0/30
Unfiltered PRBC: 9/42
Gilbert, L1:98:228, 1989

20. Prevention of Post Transfusion Infection
Don’t Transfuse
Minimize Transfusion
Limited Donors (dedicated units)
Autologous Transfusions
Erythropoetin
Donor Screening: HIV Ab, HIV NAT, HCV Ab, HCV NAT, HBV Ag, Ab, HBc Ab, VDRL, West Nile NAT, HTLVI/II Ab, CMV Ab, Bacterial Culture (Platelets)

21. Strategies to Decrease Operative RBC Transfusion
Hemostasis
Hemodilution
Cell salvage
DDAVP
Autologous Transfusion
Erythropoetin

22. Neutropenia: infection risk
100
1000
Relapse
Remission
Bodey. Ann Int Med 64:328, 1966.

23. WBC Indications 2004 PMN: Newborn Sepsis
Congenital/Acquired Neutropenia
PMN Dysfunction
Refractory Gram Negative Sepsis
Ly: Disseminated Varicella-Zoster

24. WBC transfusion: Logistics
Donors Receive G-CSF +/- Decadron
2-3 Hour Cytapheresis
1010 Cells by Standards
Donors pretested for ID markers
Cells decay rapidly: limited value at > 6 hours post-collection
Quantitative impact limited

25. Fresh Frozen Plasma
ml of plasma containing all clotting factors, AT III, Protein C & S.
Compatibility Important
Can Give: A plasma to A or O patient
B plasma to B or O patient
O plasma to O patient
AB plasma to anyone

26. Indications: FFP Replacement of Coagulation Factors
Abnormal Bleeding with coagulopathy
Multiple factor deficiency:
Liver disease
DIC
Reversal of Warfarin
Dilutional
Isolated factor deficiency-no concentrate
Factor XI, XIII
Replacement of regulatory proteins
TTP, Hereditary angioedema
Not indicated for: volume expansion, reversal of Heparin, correction of INR < 1.5

27. Guidelines: FFP Use Usual dosing: Adult 10ml/Kg Peds 10-15ml/Kg
15-20% rise in factor levels
Usually does not correct laboratory coagulation status to “normal”

29. Cryoprecipitate 10-15 ml per unit (bag) Fibrinogen 250 mg
Factor VIII units
Von Willebrand Factor 40-70% of FFP
Factor XIII 20-30% of FFP
Fibronectin mg

30. Cryoprecipitate: Dosing
1-2 Units / 10 Kg
Expect mg/dl rise in fibrinogen
Goal: Fibrinogen mg/dl

33. Platelets: Risk of Spontaneous Hemorrhage
Count Site
> 40, Minimal
20-40, GI Mucosa
Skin, Mucus Membranes
< CNS, Lung

35. Platelets (/microL) Bleeding time (min)10 20 30 40 50
100
150
200
250
300
Platelets (/microL)
Bleeding time (min)
ITP AA
WAS
ASA
Uremia
vWD
Harker. NEJM 287:155, 1972.

36. Prophylactic Platelet TX Guidelines
Platelet Count/μl Recommendation
0-5,000 Always
5-10,000 If Febrile of Minor Bleeding
11-20,000 If coagulopathy or minor procedure
>20,000 If Major Bleed or invasive procedure

37. Transfused Platelets/Survival
6 units = 1 single donor unit (SDP); available as ¼, ½ and full SDP
Dose: child 1 unit/5-6 kg
adult 1 unit/8-10 kg
Lifespan: 7-10 Days Native
2-3 Days Transfused
Factors shortening Lifespan:
Fever, Sepsis
HLA, Platelet Specific Abs
DIC
Product Age?

38. TRAP Trial Effect of Leukodepletion on Alloimmunization
No Rx
pooled
Filter
Pooled
UV-B
SDP
Number
131
137
130
132
LCYTX-AB
45%
18%
21%
17%
LYCTX-AB
refractory
13% 3% 5% 4%

40. When in Doubt: Call the Transfusion Service!

42. From ABP Certifying Exam Content Outline
2. Transfusion and collection of blood
Understand the risk of transmitting infectious diseases during blood transfusion(s)
Recognize that erythrocyte transfusions may be associated with hemolytic, febrile, and urticarial reactions
Understand the role of erythrocyte transfusions in the management of anemia

43. Credits
Bruce Camitta MD M W Lankiewicz MD