basics of transfusion therapy

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Basics of

TransfusionTherapy

Resident EducationLecture Series

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Hemoglobin Level and Symptoms

HGB (GM%) SM!T"MS

#$ M&'&ML

*+ ,-,.T&"'L /S!',

0*1 2,3',SS

4*1 /S!', T .,ST  

5$5*+ H,.T 6&L7.,

LINMAN

NEJM 279:812, 1968

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.B8 Transfusion9 &ndications

cute Blood Loss

Symptomatic nemia Suboptimal "5 8apacity

,:change (SS; 8o)

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RBC Transfusion: The Bathtu !rin"i#$e

Kidney

Kidney

Kidney

1%%

&%

%

1%%

'%

%

B$oo( )o$u*e B$oo( )o$u*eB$oo( )o$u*e

1%%

&%

%

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!re$Transfusion Testing

BL""/ T!&'G9 B"; / ntigens only

("ther antigens are <ea= immunogens) 'T&B"/ S8.,,'9

!atient serum vs* cell panel

8."SSMT8HMa>or9 !atient Serum vs* /onor 8ells

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.B8 !roducts PRBC MOST TRANSFUSIONS

2H"L, BL""/ 87T, BL,,/&'G,-8H'G,!LSM ',,/,/

2SH,/ .,M"?, !LSM

6."@,' .., .B8 !H,'"T!,

&../&T,/ &MM7'"/,6&8&,'T   8M? ',GT&?, &MM7'"/,6&8&,'T 

S,."',GT&?,; ',"'T,

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.B8 Transfusion ?olume

7sual9 7p to +ccA3g in 4$ hours

7nusual9 cute Hemorrhage9replace ongoing losses

8hronic nemia; Heart 6ailure; CB!

5ccA3gAGm HGB/iuretic

,:change

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Transfusion ?olume

1ccA3g !.B8 5* GM% in HGB

1ccA=g D - ccA=g  5* GM% /esired HGB rise

!.B8 cc D Blood ?olume : (HGB6$ HGB&)

HGBT 

B?D1ccA3G; E1$#1ccA3G ne<born

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Hemolytic Transfusion .eactions

cute HT. A5+;1116atal cute HT. $A;111;111

/elayed HT. A+$1;111

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Symptoms and Signs of cute

Hemolytic .eactions Severe Bac= !ain Substernal Tightness; /yspnea

Hypotension A 8irculatory collapse ?omiting; diarrhea &cterus Hemoglobinuria

.enal shutdo<n /iffuse "oFing from <oundsApunctures

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.esponse to Suspected Hemolytic

.eaction Stop Transfusion Hydrate

Specimens to Blood Ban=7nitABagSerum

.ed cells7rine

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cute Hemolysis9 /iagnosis

/o a direct antiglobulin test on post$transfusion sample

"btain post$transfusion blood and urine andinspect visually Recheck paperwork .echec= B" type of unit and pre$and post$

transfusion specimens .un urinalysis $ to chec= for hemoglobinuria

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8ause of cute HT. B" incompatibility9source of error1% at phlebotomyAlabeling54% in Transfusion Lab0% transfusion administration (at the

bedside)

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'onhemolytic Transfusion .eactions

Leu=ocyte ssociated 6'HT. Transfusion G?H/

'eonatal 'eutropenia &mmunoglobulin ssociated 7rticariaA6ever &g , T.L&

!latelet ssociated !ost transfusion !urpura 'eonatal Thrombocytopenia

MetabolicA !hysical 8itrate To:icity Hypothermia

8irculatory "verload Massive Transfusions Haemostatic bnormalities Metabolic complications Hgb$"5 8urve Shift

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TRAN+-+I.N/RELATE0 INECTI.N

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.is= of Transfusion$

Transmitted &nfectionH&? in 5;111;111Hepatitis 8 in 5;111;111

Hepatitis B in +;111Hepatitis .areHTL? &A&& in 4;111;111

Bacteria A4;111 (for platelets)Malaria; T 8ruFi; Babesia; ersinia;

Syphilis; Lyme; 8/; 2est 'ile ?irusII

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!ost Transfusion H8?

!ercent 'umber

&ncidence +$1 +1$411;1118hronic +1 +$+1;111

8irrhosis 51 +$41;111

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'eonatal !ost Transfusion 8M?

&ncidence9 5+% of seronegative infants

receiving J+1ml 8M?

seropositive blood

Severity +1% severe or lethal manifestations

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'eonatal Transfusion 8M?

!revention by 6iltering BloodSeroconvertATotal

6iltered !.B89 1A41

7nfiltered !.B89 #A5

Gilbert; L9#E955E; #E#

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!revention of !ost Transfusion

&nfection /onKt Transfuse MinimiFe Transfusion

Limited /onors (dedicated units) utologous Transfusions ,rythropoetin /onor Screening9 H&? b; H&? 'T; H8? b;

H8? 'T; HB? g; b; HBc b; ?/.L; 2est'ile 'T; HTL?&A&& b; 8M? b; Bacterial8ulture (!latelets)

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Strategies to /ecrease "perative .B8

TransfusionHemostasis

Hemodilution

8ell salvage

//?!

utologous Transfusion,rythropoetin

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'eutropenia9 infection ris=

0

10

20

30

40

50

60

0 1 2 3 4 5

!MNs *i"roL3

   4   #

  a   t   i  e  n   t   (  a  5  s  6   i   t   h

   i  n   f  e  "   t   i  o  n

100 100-500 500-1000 1000

Relapse

Remission

Bodey. Ann Int Med  64:328, 1966.

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2B8 &ndications 511

!M'9 'e<born Sepsis

8ongenitalAcuired 'eutropenia

!M' /ysfunction.efractory Gram 'egative Sepsis

Ly9 /isseminated ?aricella$@oster

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2B8 transfusion9

Logistics /onors .eceive G$8S6 A$ /ecadron 5$4 Hour 8ytapheresis 11  8ells by Standards /onors pretested for &/ mar=ers 8ells decay rapidly9 limited value at> hour! po!t"collectio#

Nuantitative impact limited

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6resh 6roFen !lasma

511$5+1 ml of plasma containing allclotting factors; T &&&; !rotein 8 O S*

8ompatibility &mportant 8an Give9 plasma to or " patient

B plasma to B or " patient

" plasma to " patientB plasma to anyone

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&ndications9 66!

.eplacement of 8oagulation 6actors bnormal Bleeding <ith coagulopathy

Multiple factor deficiency9 Liver disease /&8 .eversal of 2arfarin /ilutional

&solated factor deficiency$no concentrate 6actor -&; -&&&

.eplacement of regulatory proteins TT!; Hereditary angioedema 'ot indicated  for9 volume e:pansion; reversal of

Heparin; correction of &'. P %*+ 

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Guidelines9 66! 7se

7sual dosing9 dult 1mlA3g

  !eds 1$+mlA3g

+$51% rise in factor levels 7sually does not correct laboratory

coagulation status to QnormalR

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8ryoprecipitate

1$+ ml per unit (bag) 6ibrinogen 5+1 mg

6actor ?&&& E1$51 units ?on 2illebrand 6actor 1$1% of 66! 6actor -&&& 51$41% of 66!

6ibronectin 51$1 mg

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8ryoprecipitate9 /osing

$5 7nits A 1 3g

,:pect 01$11 mgAdl rise in fibrinogen Goal9 6ibrinogen 1$11 mgAdl

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!latelets9 .is= of Spontaneous

Hemorrhage

  8ount Site

 J 1;111 Minimal

51$1;111 G& Mucosa

  +$51 S=in; Mucus Membranes

  P + 8'S; Lung

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0

10

20

30

40

0 50 100 150 200 250 300

!$ate$ets *i"roL3

   B   $  e  e   (   i  n  7   t   i  *  e   1  *   i  n   3

&T!

2S

S

7

remia

v2/

Harker. NEJM  287:155, 1972.

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!rophylactic !latelet T- Guidelines

  !latelet 8ountAl .ecommendation

  1$+;111 l<ays

  +$1;111 &f 6ebrile of Minor Bleeding $51;111 &f coagulopathy or minor

procedure

  J51;111 &f Ma>or Bleed or invasive

procedure

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Transfused !lateletsASurvival

0 units D single donor unit (S/!)available as U; V and full S/! /ose9 child unitA+$0 =g

adult unitAE$1 =g  Lifespan9 $1 /ays 'ative

  5$4 /ays Transfused 6actors shortening Lifespan9

6ever; Sepsis HL; !latelet Specific bs /&8 !roduct geI

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T.! Trial

,ffect of Leu=odepletion on lloimmuniFation'o .:

pooled

6ilter

!ooled

7?$B

!ooled

6ilter

S/!

'umber 4 4 41 45

L8T-$B +% E% 5% %

L8T-$B

refractory

4% 4% +% %

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2hen in /oubt9 8all the TransfusionServiceW

500$5#

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From ABPCertifyin E!am Content "ut#ine

2 Transfusion an( "o$$e"tion of $oo(

$nderstand t%e ris& of transmittin infectious

diseases durin '#ood transfusion(s) Reconi*e t%at eryt%rocyte transfusions may 'e

associated +it% %emo#ytic, fe'ri#e, and urticaria#reactions

$nderstand t%e ro#e of eryt%rocyte transfusionsin t%e manaement of anemia

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Credits

Bruce Camitta -.

- / Lan&ie+ic* -.