BLOOD COMPONENTS TRANSFUSION INDICATIONS
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BLOOD COMPONENTSBLOOD COMPONENTSTRANSFUSION INDICATIONS TRANSFUSION INDICATIONS
Dr. Meral SÖNMEZOĞLUDr. Meral SÖNMEZOĞLUYeditepe University HospitalYeditepe University Hospital
Transfusion CenterTransfusion Center
Differential CentrifugationFirst Centrifugation
Whole Blood Main Bag
Satellite Bag 1
Satellite Bag 2
RBC’sPlatelet-rich Plasma
First
Closed System
Differential CentrifugationSecond Centrifugation
Platelet-rich Plasma
RBC’s PlateletConcentrate
RBC’s
Plasma
Second
Whole Blood
Whole Blood Whole Blood (WB) (WB) is blood taken from a is blood taken from a suitable donor using a sterile andsuitable donor using a sterile and pyrogen free anticoagulant and pyrogen free anticoagulant and container. container.
WW B B is a sourceis a source material for component material for component preparation, which is its major use. preparation, which is its major use.
WBWB for transfusion is used without for transfusion is used without further processingfurther processing..
WWBB for transfusion should not contain for transfusion should not contain irregular antibodies ofirregular antibodies of clinical clinical significance.significance.
Whole Blood
Storage 4° for up to 35 days
Indications 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 Red Cells is obtained by removal of a major part of the plasma frommajor part of the plasma from WB. WB.
Red Cells also contains the greater part of Red Cells also contains the greater part of the whole blood leucocytesthe whole blood leucocytes (about 2.5 to (about 2.5 to 3.0 × 109 cells) and a varying content of 3.0 × 109 cells) and a varying content of plateletsplatelets depending on the method of depending on the method of centrifugation.centrifugation.
For the preparation, plasma is removed from For the preparation, plasma is removed from Whole Blood afterWhole Blood after centrifugationcentrifugation
RBC Concentrate
Storage 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
Normovolemic Anemia
As hematocrit falls Blood viscosity decreases Cardiac output increases (Stroke volume,
pulse) Delivery of O2 O2 extraction Consumption of O2 remains constant
Limits of Compensation
At very low hemoglobin levels (approximately 4 g/dL)
O2 delivery does not meet demand
Anerobic metabolism lactic acidosis cardiac arrest
Indications for RBC transfusions
1940s 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 patients1980s Development of invasive monitoring techniques
lead to a better understanding of oxygen delivery and consumption
Lower hemoglobin levels could be tolerated
Hemoglobin and Hematocrit Levels in Healthy Adults
Hemoglobin (g/dL)
Hematocrit (%)
Mean -2SD Mean -2SD
Female 14.0 12.0 41 36
Male 15.5 13.5 47 41Hematology: Basic Principles and Practice. Elsevier 2005
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
Transfusion Trigger:Multicenter, Randomized Control Study of ICU
Patients30-day mortality P
Restrictive 18.7% 0.11
Liberal 23.3%
Less acutely ill
30-day mortality P
Restrictive 8.7% 0.03
Liberal 16.1%
Cardiac disease patient
30-day mortality P
Restrictive 20.5% 0.69
Liberal 22.9%
Herbert PC et al. N Engl J Med. 1999;340: 409-417
Restrictive vs Liberal Transfusion in Other Conditions
No differencePediatric ICU patients 7.0 g/dL vs 9.5 g/dL Lacroix J, et al. N Engl J Med. 2007:356;1609-1619Moderate to severe head injury 7.0 g/dL vs 10.0 g/dL McIntyre LA et al. Neutrocrit Care 2006;5:4-9
Possible differenceCardiovascular disease 7.0 g/dL vs 10.0 g/dL 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.
Platelets
Storage Up to 5 days at 20-24°
Indications 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 For the preparation, plasma is removed from Whole Whole Blood afterBlood after centrifugationcentrifugation
It must contain, on average, not less than 70 IU Factor It must contain, on average, not less than 70 IU Factor VIII per 100 VIII per 100 ml ml and at least similar quantities of the other and at least similar quantities of the other labile coagulation factorslabile coagulation factors and naturally occurring and naturally occurring inhibitors.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
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 TransfusionsPreparations
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 TransfusionsAdministration
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 TransfusionsPreparations
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 TransfusionsAdministration
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 TestingSerological Testing
3 tests:3 tests: ABO/RhABO/Rh Antibody detection/identificationAntibody detection/identification Crossmatch Crossmatch
ABO/Rh TypingABO/Rh Typing
In the ABO typing, the forward and reverse In the ABO typing, the forward and reverse MUST matchMUST match
In the Rh typing, the control must be In the Rh typing, the control must be negativenegative
Both of these will indicate what type of Both of these will indicate what type of blood should be givenblood should be given
Antibody screen and/or IDAntibody screen and/or ID The antibody screen will detect the presence of The antibody screen will detect the presence of
any unexpected antibodies in patient serumany unexpected antibodies in patient serum If antibodies are detected, identification should be If antibodies are detected, identification should be
performed using panel cells (with an autocontrol)performed using panel cells (with an autocontrol) ISIS 37° (LISS)37° (LISS) AHGAHG
If an antibody is present, units negative for the If an antibody is present, units negative for the antigen must be given (remember the antigen must be given (remember the calculation?)calculation?)
Proceed to the crossmatch…Proceed to the crossmatch…
CrossmatchingCrossmatching
PurposePurpose:: Prevent transfusion reactionsPrevent transfusion reactions Increase Increase in vivoin vivo survival of red cells survival of red cells Double checks for ABO errorsDouble checks for ABO errors Another method of detecting antibodiesAnother method of detecting antibodies
CrossmatchCrossmatch
Two types of crossmatchesTwo types of crossmatches Major – routinely performed in labsMajor – routinely performed in labs Minor – not required Minor – not required ((by AABB since 1976by AABB since 1976))
Major vs Minor CrossmatchMajor vs Minor Crossmatch
Why is the minor Why is the minor crossmatch crossmatch
unnecessary?unnecessary? Donated units are Donated units are
tested for antibodiestested for antibodies Most blood is Most blood is
transfused as transfused as packed cells, having packed cells, having little antibodieslittle antibodies
Crossmatch Crossmatch
Donor RBCs (washed)
Patient serum
No agglutination ~ compatible
Agglutination ~ incompatible
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
TRANSFUSION REACTIONSTRANSFUSION REACTIONS
Transfusion Reactions are…Transfusion Reactions are…
Adverse reactions associated with the
transfusion of blood and its components
Transfusion reactionsTransfusion reactions
Non-threatening to fatalNon-threatening to fatal Hemolytic or non-hemolytic – may or may Hemolytic or non-hemolytic – may or may
not cause RBC destructionnot cause RBC destruction Acute to delayedAcute to delayed
Acute – rapid onsetAcute – rapid onset Delayed – days to weeks Delayed – days to weeks
Reactions may involve antigen-antibody Reactions may involve antigen-antibody interactionsinteractions
May involve infectious agentsMay involve infectious agents
Transfusion Fatalities Reported to the FDA (FY 2004 to 2006)
Number and %
TRALI 86 (39%) Other (Non ABO Hemolytic Reactions) 67 (31%) Bacterial Contamination 20 (9%) ABO Hemolytic 15 (7%) Uncertain 31 (14%) Total 219
Disease TransmissionDisease Transmission
HepatitisHepatitis HIVHIV HTLVHTLV CytomegalovirusCytomegalovirus MalariaMalaria BabesiosisBabesiosis SyphilisSyphilis
Infectious Risk of TransfusionInfectious Risk of Transfusion
Klein HG et al. Transfusion 2007;47:2338-2347
SHOT 2011SHOT 2011Serious Hazards of Transfusion (SHOT) Steering Group. The 2011 Annual SHOT Report (2012)
1996-2011 SHOT (n=9925)