lec transfusion medicine

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S2 L5: Transfusion Medicineby Dr. Ma. Mystica Flodalyn T. Bautista SSSeeepppttteeemmmbbbeeerrr 111111,,, 222000111000 HIGLIGHTS OF TRANSFUSION MEDICINE

1628- EnglandoWilliam Harvey discovered blood circulationoEarliest known blood transfusion (BT) attempted

1665- Englando1st recorded successful BT (dogs other dogs)

1667o Jean- Baptiste Denis (France)oRichard Lower (England) Sucessful transfusions from lambs to humans Law prohibited BT from animals to humans due to reactions

James Blundell (England)o1818 Patient for the treatment of post partum hemorrhage Patients husband as a donor

o1825-1830

Performed 10 BT; 5/10 proved to be beneficial to his patients 1873-1880oUS physicians transfused milk (from cows, goats and humans)

1884oSaline infusion replaced milk as a blood substitute due to the

increased frequency of adverse reactions to milk

1900oKarl Landsteiner (Austrian) discovered the 1st 3 human blood

groups A, B and O (formerly A, B and C)

oHis colleagues added AB the 4th tyoe in 1902 1916oWorld War I Problem with preservation and transport of blood

oFrancis Rous and J.R. Turner Use of citrate-glucose solutionpermitted storage of blood for

several days after collection

Establishment of the first blood depot by the British during WWI 1940 (World War II)oUse of preservative solutionsoUS program for the collection of blood : Plasma for BritainAmerican Red Cross collected 13 M blood units during WW II

1947oBlood banks established in major cities across the US and blood

donation was promoted to the public as a way of fulfilling ones civic

responsibility

VOLUNTARY BLOOD DONATION

Transfusion

A multi-step process1. Recruitment 4. Processing 7. Transportation2. Collection 5. Prescribing 8. Transfusion 3. Testing 6. Issuing 9. Follow-up

Purpose1. Quickly restore blood volume post hemorrhage, burns or injuries

and combat shock

2. Treat severe anemia3. Promote hemostasis

Criteria for Blood Donation

1. Medical HistoryoAll donors are required to complete a health questionnaire and blood

safety form (Confidential interview)

2. Physical Health3. Donor Information

a. Nameb. Date and time of donationc.Addressd. Telephone numbere. Genderf. Age and/or date of birth Less than 17 yo requires written consent from parent/ guardian No upper age limit elderly donors may be accepted at the

discretion of the blood bank (BB) physician

4. Who is a potential donor?o In good health and feeling well on the day of donationoNot on prescribed medication that would cause the donor a problem

when donating or that would affect the recipient

oNormal hemoglobin (>12.5 mg/dL)oWeight: at least 50 kg for 450 mL donationsoPulse rate: regular rhtyhm, 60-100 bpmoBlood pressure Systole: 90-160 mmHg Diastole: 70-100 mmHg

Deferral

Permanent1. Cancer2.

Cardiac diseases Arryhtmia, congestife heart failure, etc.

3. Severe lung diseas Complicated asthma, bronchiectasis, etc.

4. History of viral hepatitis (+) HBs Ag Reactive for Anti- HBc Past/present evidene of Hepatitis C infection Donor involved in post transfusion hepatitis

5. History of jaundice of unknown origin, or other liver diseases6. Use of prohibited drugs (past or present)7. Sexually transmitted disease (past or present)8. Prolonged bleeding

Hemophilia A or B9. Unexplained weight loss of more than 5kg over 6 months10. Chronic alcoholism11. Prostitution12. High risk sexual behavior or continuing exposure to persons with

hepatitis, HIV, and other STDs including inmates of mental institutions

and prisons

13. Chronic eczema, dermatitis, recurring boils14. Cardiovascular and kidney diseases15. Convulsion, epilepsy or other mental diseases

3 years1. Malaria

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GienahJhoKathAynzJeGladNickieRicobe

arTeacherDadangNiaArleneVivsPaulF.

RicoF.

RenMaiRevsMavisJepayYanaMayiSergeHungTopeAgBien


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12 months1. Operation or blood transfusion2. Ear piercing, tattooing, needle puncture3. Exposure to a sexual partner or close household contact with HIV or

hepatitis

4. Rabies vaccine 9 months

1. Child birth 3 months

1. Whole blood donation2. Weaning

2 months1.Anti- acne medication (retinoids, retinoic acid)

1 month1. Vaccine: German measles

2 weeks1.Acute febrile illness (2-3 weeks)2. Vaccine: Measles, OPV, mumps

12 hours1.Alcohol intake

Other conditions for temporary deferral1.After skin lesion has completely healed2.After full recovery from febrile illness3. When TB is completely cured

No deferral

Killed vaccines1. Injectable polio vaccine2. Hepatitis B vaccine3. Influenza4. DPT (diphtheria-pertussis-tetanus)

Medications1.Antibiotics other than anti-TB drugs (if medical condition is not severe)2.Aspirin and piroxican but not for platelets3. Contraceptive pills, depoprovera4. Other drugs for symptomatic treatment

Types of Donation

Directed DonationoPotential recipient of blood or blood products designates certain

persons to donate specifically for his or her use

Autologous DonationoWhen a person donates his or her own blood for personal useoThe blood is not to be used for anyone elseo If an autologous unit is collected but not used by the patient-donor, then

it is destroyed.

Republic Act 7719: National Blood Services Act of 1994An act promoting voluntary blood donation, providing for an adequate

supply of safe blood, regulating blood banks and providing penalties for

violations thereof

oPhilippines annual blood requirement = 700 000 to 750 000 unitsoTarget = 1% of the population

Commercial blood banks are prohibited because:oBlood sources may be contaminatedoLimited means of crosschecking donors That may change names That conceal their medical history That supply blood repeatedly

Apharesis

Involves removal of whole blood from a patient or donor One of the separated components is then withdrawn and the remaining

components are re-transfused into the patient or donor

PRE-TRANSFUSION TESTING

Tests on Al l Units Collected for Transfusion

1.ABO typingoComponents to be transfused and permissible donor type

Pxtype

Wholeblood

RBC PlasmaSingle donorfull volumeplatelets

Single donorreduced

volume plt

Cryoppt

O O O Any Any Any Irrel

A A A,O A,AB A,AB Any

B B B,O B,AB B,AB Any Irrel

AB AB Any AB AB Any

2. Rh typingoRh considerations for blood and components

Px

type

Whole

blood

RBC PlasmaSingle donorfull volume

platelets

Donor plt

(Pheresed)

Cryo

ppt+ +/- +/- +/- +/- +/- Irrel

- - - +/- - - Irrel

3. CrossmatchingoTypes: Major crossmatch = Donors cells + Recipients serum Minor crossmatch = Donors serum + Recipients cells

oPurpose: Final check of ABO compatibility to prevent transfusionreaction Detect presence of antibody in patients serum that will react to

donors RBC that is not detected in antibody screen

4. Screening for blood group antibodiesoPurpose: to detect as many clinically significant antibodies as possible Clinically significant Abs~Reactive at 37C and/or in the AHG test~Known to have caused a transfusion reaction or

unacceptablyshort survival of the transfused red cell

The Formation of A, B and H Antigens

ABO genes code not for the antigen themselves

but for the production of glycosyl transferasethat add immunodominant sugars that define the blood type

Gene Transferase Sugar

H Fucosyltransferase L-fucose

A Acetylgalactosaminyltransferase N-acetylgalactosamine

B Galactosyltransferase D-galactose

D Antigen

Most clinically significant of all non-ABO antigens Highly immunogenic


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INDICATIONS FOR TRANSFUSION

STORAGEINDICATIONS

ADULT

WHOLE BLOOD

Approximate volume: 500 mL

Storage temperature: 1 - 6 CShelf life: 35- 42 daysComponents: RBCs and plasma

Length of transfusion: 2-4hrs within 4 hrs after leaving the

blood bank

Active bleeding with at least one of the following:

>15% blood volume loss Hb < 9 mg/dL Blood pressure decrease > 20%

Systolic pressure < 90 mmHg

When both oxygen-carrying capacity and volumeexpansion are required

For exchange transfusion

Hyperbilirubinemia Direct bilirubin of 20 mg/dLduring the 1st week of life

Hyperbilirubinemia with prematurity or otherconcomitant illness:oPrenatal asphyxia HypothermiaoAcidosis SepsisoProlonged hypoxemia Hemolysis

PACKED RED BLOOD CELLS

Approx volume: 225 - 250 mLStorage temperature: 1 - 6 C

Shelf life: 35- 42 daysLength of transfusion: 2-4hrs

within 4 hrs after leaving theblood bank

Hb < 8 mg/dL or Hct < 24%

Concomitant hemorrhage, COPD, CAD, sepsis,hemoglobinopathy

General anesthesiaHb < 10 mg/dL or Hct < 30%

Major operationNormovolemic patients (chronic anemia/ bleeding)

who require an increase in oxygen-carryingcapacity and red cell mass regardless of Hb level

Hypovolemia from acute blood loss

Signs of shockAnticipated blood loss of 1.5 times mid normal range within 8 hrsof transfusion (PT > 17 secs; PTT > 47 secs)

Reversal of coumadin anticoagulation

Treatment of TTPClinical coagulopathy associated with:

Massive transfusion 10 U / 24 hours Late pregnancy Abruptio placentae

Significant congenital factor deficiencyAnti thrombin III deficiencyBleeding in exchange transfusion or massive

transfusion

CRYOPRECIPITATE

Approximate volume: 15 - 20 mL

Storage temperature: -18 CShelf life: 1 year

Thawing: 20 - 24 C

Length of transfusion: 30 mins

w/in 4 hrs after leaving the BB

Preferred replacement for plasma exchange in TTP or HUSSignificant hypofibrinogenemia (Factor XIII): < 100 mg/dLHemophilia AVon Willebrands DiseaseUremic bleeding with prolonged bleeding timeBurn or traumatic shock patients who lack fibronectin


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Administration Considerations

1. PlateletsoContraindications:

a.Prophylactic transfusion in a stable patient with plateletrefractoriness of a known cause

b.Thrombotic Thrombocytopenic Purpura (TTP)c. Idiopathic Thrombocytopenic Purpura (ITP)d.Heparin-induced Thrombocytopenia

oEffect of platelet product and patient weight on platelet incrementPatient wt

(in lbs)

Single whole blood

platelet concentrate

Standard apheresis

50 17 600 70 400

100 8 800 35 200

150 5 900 23 500

200 4 400 17 600

oAdministrationa.Must not be refrigeratedb.Require immediate transfusionc.Rate of infusion (10mL/min in adults)

2. Fresh Frozen PlasmaoGeneral guidelines

a.Document PT/PTT pre and post transfusion within 4 hoursb.Dose: 10 mL/kg BW or initial loading dose of 15 mL/kg BWc.Correction of significant coagulopathy:~Prolonged PT and aPTT required > 2 units of FFP

oAdministrationa.Must not be refrigeratedb.If transfusion cannot proceed immediately, return the unit to the BB

for proper storage within 1 hour from release

3. GeneraloMedications

a.Do not add medications directly to a unit of blood during transfusionb.Medications by IV push~Stop transfusion prior to administration of meds via IV~Clear the line at the medical injection site with 5-10 mL NSS~Administer the medication~Re-flush the line with saline~Restart the transfusion

oSuspected transfusion reactiona.Stop the transfusion immediatelyb.Disconnect the IV line from the needle.c.Attach a new IV set and prime with saline. Flush the line with NSS

used to initiate the transfusion and reconnect the line.

d.Open the line to slow drip.e.It may be possible to restart transfusion after evaluation and

treatment of the patient.

COMPLICATIONS OF TRANSFUSION

Hemolytic Transfusion Reactions1. Intravascular Due to immune mechanism; mediated by IgM and complement Signs and symptoms:

a. Anxiety e. Tachypneab.Restlessness f. Tachycardiac.Nausea and vomiting g. Chills followed by feverd.Chest or lumbar pain h. Cyanosis

Causes:a.ABO incompatibility (misID of patient or blood)b.Antibodies other than anti-A or anti-Bc.Exposure of red cells to hypertonic solutionsd.Improper storage of blood

2. Extravascular Occurs outside the circulatory system (reticuloendothelial cells) Most commonly involves the antibodies of the Rh system May not occur until a week or more after the transfusion Much milder than those of intravascular hemolysis~ Include malaise, fever, decreased hemoglobin

Coombs test and hyperbilirubinemia Febrile Non-hemolytic ReactionsoMost common type of transfusion reactionoCaused by sensitization to white cell, platelet or plasma antigens,

especially in people who have received multiple transfusions

oSigns and symptoms:1. Chills followed by fever within an hour after starting the transfusion2. Headache3. Nausea and vomiting4. Back or leg pain

oMgt: Use of leukocyte filters during transfusion; Anti pyreticsAllergic ReactionsoMediated by IgEoSx: Hives, rash and pruritus that may progress to laryngeal edema and

bronchial spasm

oMgt: Administration of antihistamine before transfusionAnaphylactic ReactionsoPotentially fataloUsually occur in people with antibodies against IgA immunoglobulinsoSigns and symptoms:

1. Generalized flushing2. Dyspnea3. Bronchospasm4. Substernal pain5. Laryngeal edema and collapse6. Gastrointestinal distress (nausea and vomiting)

Circulatory OverloadoDevelops in people with cardiac or renal impairmentoOverload capacity of heart circulatory failure pulmonary edemaoSigns and symptoms:

1. Dry cough Productive cough2. Precordial and back pain3. Dyspnea4. Cyanosis

Infectious DiseasesoTransmission of diseases such as hepatitis, malaria, syphilis,

toxoplasmosis and AIDS

Graft vs Host DiseaseoOccurs when immunocompetent donor lymphocytes (commonly found

in PRBC and granulocytes) are transfused and multiply in severely

immunodeficient recipients

Bacterial Contamination (Eg. Pseudomonas and colifor ms)oCause: improper preparation of donor phlebotomy site or inadequate

refrigeration

Air Embolismo Introduction of air into the circulationoSx: cyanosis and circulatory collapse

Citrate IntoxicationoWhen toxic levels of citrate is reached Depression of blood calcium Muscle twitching and spasm Possible cardiac arrest

Hemorrhagic ReactionoSince refrigeration destroys platelets, stored blood is low in viable

platelts

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