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RATIONAL USE OF BLOOD AND BLOOD COMPONENTS
PLATELET TRANSFUSION
อ นพ วโรจน จงกลวฒนา
CLINICAL GUIDELINE
แพทยเรยนรเกยวกบ Transfusion Therapy ไดอยางไร
KNOWLEDGE GAPS: Physician
Karp JK et al. Transfusion 2011;51:2470-79
KNOWLEDGE GAPS: Physician
• Education on transfusion indications and risks in medical school is minimal
• Undergraduate medical education curriculum consists of 1-2 hrs of didactic lecture for TM
• Physicians learn from their physician mentors…. who learned from their physician mentors.... who learned from their physician mentors…. who learned from their physician mentors….
• Practice is often by Tradition…Not evidence-based
Karp JK et al. Transfusion 2011;51:2470-79
VARIATION IN TRANSFUSION PRACTICE
CABG Surgery (1st time CABG) – STS institutions • RBC Transfusion Rate = 10-90% • FFP Transfusion Rate = 0-95% • Platelet Transfusion Rate = 0-90% Orthopedic Surgery (Total hip arthroplasty) • RBC Transfusion Rate = 7-71% Knowledge gap exists for best practice & appropriate blood use
Bennett-Guerrero E ;JAMA 2010;304(14):1568-75 Jans O, et al. Vox Sang 2011;100:374
OVERUTILIZATION
• Risk of Adverse Event ความเสยงตอการเกดปฏกรยา • Unnecessary Cost คาใชจายทสงขน โดยไมจาเปน • Blood Availability for those who need it
ไมมเลอดเหลอทจะใหแกผ ปวยทจาเปนจรงๆ
The Appropriate Use of Blood and Blood Components Physician Handbook 1st edition 2011
Replacement Therapy
Replace when there is an evidence /clinical of deficiency
ปญหาเลอดออกของผปวย ไมได เกดจากการขาดสวนประกอบของ
เลอดเสมอไป Blood products Indication for replacement
Red cell products Anemia, blood loss
Fresh frozen plasma Coagulopathy
Platelet products Thrombocytopenia
Cryoprecipitate AHF Hemophilia A
การใหเลอดเปนเพยงการเตมสงทผปวยขาด
PLATELETS
• Platelets are cytoplasmic fragments produced by megakaryocytes in the bone marrow
• Platelets are classified as cells • Platelets are discoid in shape • Platelets do not have nucleus • Average life span : 10 days • 70% in circulation, 30% in spleen
Platelet
• เกรดเลอดเปน cellular
components
• สเหมอน plasma อาจจะมส
แดงของ red cell ปนเปอน
บาง
• เมอนาสองกบแสง จะสามารถ
มองเหน swirling effect
WBD Platelet Products
PRP Technique Buffy Coat Technique
Plasma/Red Cells Level Buffy Coat
Buffy Coat Depleted Red Cell Concentrate
Platelet Poor Plasma
Platelet pool from buffy coated method
LPRC FFP
LPPC
Platelet content in each unit
• Platelet conc. – 7-10 x 1010 / unit – 4.0 x 1011 (pool 5 unit)
• Single Donor Platelet
– 3.0- 4.0 x 1011
• LPPC – 3.5 x 1011
Therapeutic doses
Basic requirements for Platelets storage
• Platelets should be stored at 22-24oC ( controlled temperature ): aging process slows down at 22-24 C as compare to 37 C
• Continuous gentle agitation must be maintained on a flat bed agitator
• pH should be above 6.2 • Plasma 50-60 mL is needed for storage 5 days storage
22 -24 C Continuous agitation
ไมควรนาไปเกบในต เยนทหอผ ปวย
ต เกบเกรดเลอด
เกบไดนาน 5 วน
Indications for Platelet Transfusions
Prevention and Treatment of hemorrhage patients
Thrombocytopenia or platelet function defects
Cause of thrombocytopenia should be established before a decision about platelet transfusion
Platelet transfusion: Indications
Bone marrow failure
Platelet function disorder
Massive blood transfusion
Cardiopulmonary bypass surgery
Disseminated intravascular coagulation
Ann Intern Med. 2015;162(3):205-213. doi:10.7326/M14-1589 Approximately 2.2 million platelet doses are transfused annually in the United States
2008 Apheresis 87%
The 2009 National Blood Collection and Utilization Survey Report
Platelet Transfusion: Indications
• Prophylactic: – Transfusing hospitalized adult patients with a
platelet count of 10 x 109 cells/L or less to reduce the risk for spontaneous bleeding
– patients having elective central venous catheter placement with a platelet count less than 20 x 109 cells/L.
– patients having elective diagnostic lumbar puncture with a platelet count less than 50 x 109 cells/L.
Ann Intern Med. 2015;162(3):205-213
Platelet Transfusion: Indications
• patients having major elective non-neuraxial surgery with a platelet count less than 50 x 109 cells/L.
• surgeries involving the central nervous system, platelets are conventionally transfused prophylactically for a pre-procedure platelet count less than 80 x 109 to 100 x 109 cells/L,
Ann Intern Med. 2015;162(3):205-213
ขอควรรเกยวกบเกรดเลอด
เปนทรพยากรทสาคญ และมจานวนไมเพยงพอ
เมอพรอมทจะให จงใหคนมารบทธนาคารเลอด เจาหนาทธนาคารเลอดจะรวม
หลายๆถง เปนถงเดยว
หลงจากรวมเปนถงเดยว ควรใหภายใน 30 – 60 นาท
ไมควรนาเขาไปเกบไวในตเยนทหอผปวย ขณะทรอเรม Transfusion
ควรใหหมดภายใน 30 – 60 นาท อาจจะใหไมตรง ABO ในกรณทไมม ตองใชชดใหเลอด (Transfusion set) ตามปรกต ไมควรใชรวมกบชดท
ให เมดเลอดแดง
Poor Response to Platelet Transfusion
• Platelet factors • Patient factors – nonimmune
– Majority of cases
• Patient factors – immune
Patient Factors – Immune
• HLA class I alloimmunization (most common) • Platelet-specific antigen alloimmunization • ABH alloimmunization • Autoantibodies • Drug-related antibodies
PAS
Primary ingredients
1. Citrate : To prevent activation of coagulation 2. Acetate : To serve as a substrate for oxidative
metabolism 3. Sodium chloride : For isotonicity and osmotic
strength 4. Phosphate : Stimulation of glycolysis and
maintainance of physiologic pH 5. Magnesium / Potassium : Decreases platelet
activation, improve morphology score and decrease lactate production
ADVANTAGES OF PAS
• Clinical advantages: – More Plasma for using in transfusion and
fractionation
– Standardize composition – Ability to control storage environment – Sterile, pathogen free – Decrease reactions by removal of plasma
• Less protein, fewer allergic reactions, • Lower ABO antibody titer • possibly TRALI ?
ALLERGIC REACTION
Fatal Shock after Transfusion of Platelets Contaminated
by Staphylococcus aureus
เมอเรองน เกดขนในโรงพยาบาลของคณ เกดขนกบผปวยทไดรบเลอดจากคณ
Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:
• ผชายอาย 60 ป ไดรบการวนจฉยเปน multiple myeloma รบไวในโรงพยาบาลดวยอาการ pancytopenia และ pneumonia.
• ผ ปวยไดรบยา melphalan และ prednisone นาน 3 สปดาห และ
มภาวะ severe global hypo-gammaglobulinemia.
• Empiric antibacterial chemotherapy with ciprofloxacin and tazobactam-piperacillin led to clinical improvement.
Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:
• At admission, the WBC count was 1100 cells/mm3 (lymphocyte count, 730 cells/mm3; monocyte count, 110 cells/mm3), and the platelet count was 26,000 platelets/mm3.
• Leukocyte-reduced platelets were transfused after the patient experienced a mild episode of hemoptysis. The unit of platelets was obtained by apheresis from a single donor 4.5 days before use.
Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:
• 20 minutes after the beginning of the transfusion, the patient developed chills, diarrhea, vomiting, tachycardia, and cardiovascular collapse.
• The transfusion was stopped immediately, after a total volume of 100 mL had been infused
• 4 hours later, the patient's temperature was 39.1°C, and severe hypotension, hypoxemia, and confusion occurred, necessitating intensive treatment.
Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:
• Gram staining of residual platelets from the transfusion bag revealed large numbers of gram-positive cocci in clusters. Cultures of samples of venous blood and residual platelets yielded S. aureus isolates
• The platelet donor was a healthy male volunteer who had undergone apheresis on several occasions. Nasal swabs showed S. aureus carriage. The result of a culture of an antecubital fossa swab specimen was negative.
คณจะอธบายใหญาตผ ปวยทราบอยางไรถงสาเหตการเสยชวต
Bacterial contamination of platelets UHCMC Cleveland 1991-2011 N=75
Transfusion Volume 54, Issue 3pt2, pages 857-862, 17 JUN 2013
PASSPORT Surveillance Cultures
• 4369 PC initially culture negative
– Re-tested after day 7 – 3 true positives: S. aureus , S. epidermidis,
S. veridans
• Residual risk: 686 per million PC (1 in ~1500) L. Dumont, BPAC, May 2008
TRALI HTR-non ABO
HTR-ABO Microbial infection
TACO Anaphylaxis Other
FY08 16 7 10 7 3 3 0
FY09 13 8 4 5 12 1 1
FY10 18 5 2 2 8 4 1
FY11 10 6 3 4 4 2 1
FY12 17 5 3 3 8 2 0
0
2
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10
12
14
16
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20
FY 08FY 09FY 10FY 11FY 12
สาเหตการตาย จากการไดรบเลอด ในสหรฐอเมรกา
Transfusion-related deaths 2010 to 2016 n=115
TACO = Transfusion associated circulatory Overload
Avoiding unnecessary transfusion
•Important strategy for reducing risks
•Supported in national patient blood management guidelines
•Three principles of patient blood management
– Optimise the patient’s blood levels before a surgical or medical intervention
– Lose less blood throughout the patient’s treatment
– Optimise recovery including tolerance of anaemia
THANK YOU!
V. CHONGKOLWATANA