blood and blood products (1)

7/29/2019 Blood and Blood Products (1)

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TUTORIAL

Blood & Blood Products


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Blood & Blood Products

Summary

Blood components/ Blood products

Guidelines on administration of bloodcomponents ASA- 2006, BCSH- 2009

Adverse effects of blood transfusion

Safe transfusion practices


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History of Transfusions

Blood transfused in humans since mid-1600s

British physician WilliamHarvey discovered the

circulation of bloodin

1616 (published in 1628)


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1818

British obstetrician James

Blundell performs the first

successful transfusion of

human blood to a patient

for the treatment of

postpartum hemorrhage.


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Karl Landsteiner1930 Nobel Prize Laureate

1900

Blood typing A, B, O

1939 Levine described

the Rh factorThis lead to dramatic

decrease in the incidence of

hemolytic disease of the

newborn.


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BCSH Guideline on the Administration of Blood Components 2009

Blood componentA therapeutic constituent of humanblood

Eg: Cellular

Red cells

Platelets

White cells (buffy coat)

Stem cells

Plasma components

FFP

Cryoprecipitate

Cryo Supernatant Plasma (CSP)

Blood productAny therapeutic substance derived fromplasma

Eg:

Human albumin solution

Clotting factor concentrates

(Fac Vlll, IX, PCC) Immunoglobulins

Anti-D immunoglobulin


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Advantages

Better utilization of scarce source

Decrease risk of sensitization

Effective(higher) dose without volumeoverload

Decrease risk of TTI

Cost effectiveness


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Differential CentrifugationFirst Centrifugation

Whole Blood

Main Bag

Satellite Bag

1

Satellite Bag

2

RBCsPlatelet-rich

Plasma

First

Closed System


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Differential CentrifugationSecond Centrifugation

Platelet-rich

Plasma

RBCsPlatelet

Concentrate

RBCs

Plasma

Second


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Red cell components

Red cell concentrate

Leuko depleted red cells

Washed red cells Frozen red cells

Irradiated red cells


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Red cell concentrate

Whole blood is collected in bags containingcitrate-phosphate-dextrose-adenine (CPDA)solution.

CPDA blood has a Hct of 70-75% , shelf live of35 days.

Store at 2-6 C

The PRBCs are prepared by centrifugation ofthe whole blood.


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Red cells in additive Solution

Plasma removed & 100ml of additive solution added

Lower Hct, 60%

Less citrate per unit

Longer shelf life, 42 days

One unit of RBCs will increase the Hb 1g/dL and Hct 3%


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RBC preparationsSaline-washed RBCs - used for patients that experience reactions to foreign

proteins Plasma replaced by 50-100ml of NS

Shelf life 6hrs(prepared by open system)

Indications For pt getting recurrent severe allergic reactions

Ig A deficiency

As a method of leuko reduction

Leuko-depleted RBCs-

white cells removed by washing, irradiation, or leukofiltration

Indications:- Hx of recurrent febrile non-haemolytic reactions for RBCs Transfusion dependant patients

Eg:Thalassaemia, Sickle cell anaemia


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ASA Task Force Guidelines

RBCs should usually be administered when the

hemoglobin concentration is low;for example < 6 g/dL in a young otherwise healthypatient and the blood loss is acute; and transfusionis usually unnecessary when the hemoglobin

>10g/dL

The determination of whether intermediate levels ofhemoglobin (between 6-10)justify or require RBCs

should be based on any ongoing indication oforganischemia, potential or ongoing bleeding, patientsintravascular volume status and the patients riskfactor for complications ofinadequate oxygenation


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Indications for RCCSurgical patients

Depend of patients clinical condition and the Hb%

Pre-op :-

Any pt- Hb


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Suggested threshold for for RBC

transfusion in infants 24h Hb 7g/dL Chronic oxygen dependancy Hb 11g/dL

Neonate in ICU Hb 12g/dL

Cumulative blood loss in 1st week 10% Acute blood loss 10%


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FFP (fresh frozen plasma)

The plasma has been separatedfrom freshly donated whole bloodand frozen within 24 hours to atemperature that will maintain theactivity ofall the coagulation factors

(including labile factors V and VIII)

stored at 30 C or below for up to24 months or even longer

When needed, the plasma is thawedrapidly at 37 C and then transfusedwithout delay


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FFP

DOSE- 15 ml/kg ( 4 units = 1 adult dose)

Up to 30 ml/kg can be used if fluid intake is possible

Achieve a minimum of30% of plasma factor concentration with

10-15mL/kg of FFP

When the patient cannot be given large volumes of FFP factorconcentrates can be used.


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FFP

If there is a delay in transfusion after the FFP

packs are received

FFP may be stored at 4C in an approved blood storagerefrigerator but should be transfused to the patient

within 24 hrs. ( FVIII is destroyed in this process)

Before transfusion it is essential to keep the pack out side

for it to reach the room temperature. Or use blood

warming devices.


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Indications for FFP

Multiple coagulation factor deficiencies(DIC, advanced liver failure, massive transfusion)

For correction of known coagulation factordeficiencies for which specific correlates areunavailable

For urgent reversal of warfarin therapy (5-8ml/kg)

For correction of microvascular bleeding in thepresence of increased PT/INR & APTT


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Indications for FFP

For correction of microvascular bleeding secondary to coagulationfactor deficiency in patients with massive transfusion and when PT

/APTT cannot be obtained in a timely fashion

For single coagulation factor deficiency when specific factorconcentrate are not available(Fac V)

For cases of antithrombin III deficiency Treatment of immunodeficiencies

Treatment ofTTP (plasma exchange)

FFP is contraindicated for augmentation of plasma volume ,

albumin concentration or nutritional support

Prolonged PT and APTT

Should not be instituted based on laboratory tests alone


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Platelets

Platelets are supplied either as singledonor units / multiple donors

One unit of platelets will increase the

platelet count of a 70 kg adult by 5 to10,000/mm

Platelet viability is optimal at 22 C butstorage is limited to 4-5 days

Platelets have both the ABO and HLAantigens. ABO compatibility is ideal,but not required.


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Platelet transfusions

Indications for platelet transfusions

Bone marrow failure (


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Platelet transfusion

Platelet pack -50 ml

Start the infusion as soonas possible after the pack isreceived. Infuse over aperiod of 30 to 60 minutes.

Do not refrigerateplatelet packs

Platelet from single donation is suspended

in 50 ml of plasma.

Stored at the diffusion of oxygen into the

pack, which, with constant gentle agitation,

maintains 22C.

Platelets are stored in permeable bags that

allow aerobic metabolism and reduces the

rate of fall of pH.


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Contraindications for Platelet transfusion

TTP

HIT

ITP (relative CI)


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Cryoprecipitate

Precipitate remains when the FFP is thawedslowly at 4 C

Contains -Factor VIIIFactor XIIIvon Willebrand factor (vWF)

FibrinogenFibronectin

Indications -Fibrinogen deficiencies / hypo or

dysfibrinogenomiaFactor VIII deficiency/ hemophilia AFac Xlll, vWF deficiency

Dose- 1-1.5 packs/10 kg(10 units = 1 adult dose)


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Cryoprecipitate

1 unit of cryoprecipitate (yield from 1u FFP)contains sufficient fibrinogen to increasefibrinogen level 5 to 7 mg/dL

It is storedat -20C and thawed immediately priorto use

ABO compatibility is not essential because of the

limited antibody content of the associatedplasma vehicle (10 to 20 mL)

Viruses can be transmitted


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Cryo Supernatant plasma

Hypoprotenemic oedema (Nephrotic, Burns)

TTP

Plasma exchangeHaemoplilia B


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Prothrombin complex concentrate

(PCC)Combination of blood clotting factors : II, VII, IX , X, and

anti thrombotic agents : protein C and S

Indications :

When rapid correction of prothrombin complex levels is necessary,such as major bleeding or emergency surgery.

Reversal of warfarin therapy or vitamin K deficiency in patientsexhibiting major bleeding manifestations;

and in patients requiring urgent (< 6 hours) surgical procedures

Disadvantage - Expensive

Lack other clotting factors

It has traces of activated clotting factors ( mainly found in older preparations)which may worsen the coagulopathy


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Fibrinogen concentrate

Severe hypofibrinogenaemia

(


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Recombinant Factor VIIa An analogue of naturally occurring protease

There are some reports of the successful use ofrecombinant factor VIIa in patients with DIC andlife-threatening bleeding

However, the efficacy and safety of thistreatment in DIC is unknown and it should beused with caution.

British Journal of Haematology, 2009 145, 2433


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Concentrated WBCS

Prepared by cetrifugation of blood (after separationof RBCS) under controlled conditions

Can be stored for up to 24 hours

Transfused to treat life-threatening infections inpeople who have a greatly reduced number of WBCsor whose WBCs are functioning abnormally

The use of white blood cell transfusions is rare,because improved antibiotics.


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Transfusion Risks

Risks of blood transfusion can be divided into

two catagories :

Infectious

Non-Infectious


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Infectious Risks

The transmittable risks are numerous and include:

Hepatitis A, B, C, D, E

Human T-cell lymphotropic viruses(HTLV-1 & HTLV-2)

HIV-1 & HIV-2

Cytomegalovirus

West Nile Virus

Epstein-Barr virus


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Infectious Risks (cont)

Parvovirus B19

GBV-C virus (also called hepatitis G)

Transfusion-transmitted virus (TTV)

SEN virus

Prions including Creutzfeldt-Jakob and variant

Lyme Disease

Bacterial infections including: malaria, Chagasdisease, ehrlichiosis, babesiosis, and syphilis.


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Bacterial Contamination

Bacterial Contamination occurs at a much higherfrequency than any other infections and isassociated with substantial mortality

Rate of bacterial infection/contaminationRBCs 1 : 30,000

Platelets 1 : 2,000


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Exposure Estimates

Hepatitis B 1 in 350,000

Hepatitis C 1 in 2,000,000

HIV 1 in 2,000,000

HTLV 1 in 2,900,000

Bacterial reactions fromRBC 1 in 30,000

Platelets 1 in 2,000


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Noninfectious Risks

Generally immunologically mediated

Reactions can occur as a result of the

antibodies that are constitutive (Anti-A or

Anti-B) or ones that have been formed as a

result of prior exposure to donor RBCs, WBC,

platelets, or proteins


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Noninfectious Risks

Acute hemolytic transfusion reaction (1 : 25,000 -50,000)

Delayed hemolytic transfusion reaction (1 : 2,500)

Minor allergic reactions (1 : 200 to 250)

Anaphylactic/-toid reactions (1 : 25,000 to 50,000)

Febrile reactions (1 : 200)

Transfusion related acute lung injury (1 : 5,000)

f l


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Transfusion-Related Acute Lung Injury

(TRALI)

TRALI is a noncardiogenic form of pulmonaryedema associated with blood product (any)administration

Occurs most frequently with RBCs, FFP, andplatelets

The incidence is 1 : 5000 (units transfused)

TRALI has a mortality of 5 to 8%

TRALI was the most common cause oftransfusion related death (from 2001-2003)


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TRALI (cont.)

TRALI occurs when agents present in the

plasma phase of donor blood activate

leukocytes in the host

Those agents are usually antileukocyte

antibodies in donor bloodformed as a result

of a previous transfusion or pregnancy

TRALI usually requires a preexisting conditionsuch as sepsis, trauma or surgery


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TRALI (cont.)

The clinical appearance is similar to ARDS

Symptoms usually begin within 6 hours after

the transfusion and often more rapidly, thepatient develops dyspnea, cyanosis, chills,fever, hypotension and noncardiogenicpulmonary edema

CXR reveals bilateral infiltrates

Severe pulmonary insufficiency can develop


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TRALI (cont.)

Treatment is largely supportive

The transfusion should be stopped if the

reaction is recognized in time

The patient should receive oxygen andventilatory support as necessary, usually with

a low tidal volume strategy


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Other Non-Infectious Risks

Hypothermia

Volume Overload

Dilutional coagulopathy

Decrease in 2,3-DPG

Acid-Base changes

Hyperkalemia

Citrate Intoxication

Microaggregate Delivery

S f t f i ti


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Safe transfusion practicesTime limits:

RBC :-4hrs

Platelets:-within 30 min

Plasma :- 2-4 hrs

Blood warming / avoid hypothermia:Indications: Rapid & multiple transfusions >50ml/kg/hr

Exchange transfusion in infants

Children transfused with >15ml/kg/hr Severe cold agglutinin disease

Rapid infusion via CV line

Uncontrolled warming could cause death


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Avoid hypothermia

Hypothermia has profound effects on thecoagulation system. Even modest hypothermiacan greatly augment bleeding and needs to betreated or prevented.

Prevention - pre-warming of resuscitation fluids temperature controlled blood warmers patient warming devices such as

warm air blankets

A h i


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Apheresis

Process which whole blood is collected from adonor and separated into components. Some ofthese components are retained and theremainder returned to the donor

Blood component donation

Eg: Plasma (plasmapheresis),

Platelets(plateletpheresis),

Leukocytes (leukapheresis).


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Avoid undesirable practices

Eg:

Blood warming by hot water

Delay in transfusing after issue from blood bank

Lack of monitoring of patient during transfusion

Use of unmonitored refrigerator for storage in

nursing station

Routine pre-transfusion medication

Addition of medicined to bag

Optimise f


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Optimise

Oxygenation

Cardiac output

Tissue perfusionMetabolic state

Aim for

Temp >35 C

pH > 7.2 Base excess < -6

Calcium level >1.1mmol/L

Lactate level 50,000/cc

PT/APTT/INR 1g/dl

Monitor

(every 30-60min)

FBC

Coagulation screen

Ionised Calcium levels

ABG


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Safe transfusion practices

Rational use of blood & blood components

to treat conditions leading to significant

morbidity and mortality that cannot be

prevented or managed effectively by other

means.


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