transfusion medicine

Transfusion Medicine Transfusion Medicine

Meredith Reyes, MDMeredith Reyes, MD

OverviewOverview

Blood ComponentsBlood Components– CollectionCollection– IndicationsIndications– ModificationsModifications

Pre-transfusion TestingPre-transfusion Testing Transfusion ReactionsTransfusion Reactions

Collection of Blood Collection of Blood ProductsProducts Whole blood donationWhole blood donation

Whole Blood Separation

Collection of Blood Collection of Blood ProductsProducts ApheresisApheresis

– PlateletpheresisPlateletpheresis– LeukapheresisLeukapheresis– ErythrocytapheresisErythrocytapheresis– PlasmapheresisPlasmapheresis– Stem Cell collectionStem Cell collection

Blood Blood productsproducts Cellular ComponentsCellular Components::

– RRed blood cellsed blood cells

- - LeukocyteLeukocyte--reduced reduced RBCsRBCs

- W- Washed ashed RBCsRBCs

- Irradiated RBCs- Irradiated RBCs

– PlateletsPlatelets - - Whole blood derivedWhole blood derived platelets platelets

- S- Single-donor platelets ingle-donor platelets (Apheresis (Apheresis Platelets)Platelets)

– GGranulocyteranulocytess

Blood productsBlood products

Acellular ComponentsAcellular Components:: – FFresh-frozen plasma (FFP)resh-frozen plasma (FFP), Thawed , Thawed

plasmaplasma– CryoprecipitateCryoprecipitate– FFactor concentrates (VIII, IX)actor concentrates (VIII, IX)**– AlbuminAlbumin**– IVIG*IVIG*

* Provided by pharmacy* Provided by pharmacy

Red Blood Red Blood CellsCells Prepared from whole bloodPrepared from whole blood

or apheresis donationor apheresis donation 250-300 mL250-300 mL

– 200-250 mL RBCs + < 50 mL plasma 200-250 mL RBCs + < 50 mL plasma + preservative/additive solution+ preservative/additive solution

Stored 21-42 days at 1-6Stored 21-42 days at 1-6°C°C Hct 55-65%Hct 55-65%

RBC RBC CompatibilityCompatibility

Indications for RBC Indications for RBC unitsunits Increase OIncrease O2 2 carrying capacitycarrying capacity SymptomaticSymptomatic anemia anemia

– Acute or chronic hemorrhageAcute or chronic hemorrhage Acute loss of >30% of blood volumeAcute loss of >30% of blood volume

– HemolysisHemolysis– Marrow failureMarrow failure– Hb < 8.0 gm/dLHb < 8.0 gm/dL

Don’t just look at hemoglobin level!Don’t just look at hemoglobin level!– Need to consider cardiac output, volume status, Need to consider cardiac output, volume status,

patient history, etc.patient history, etc. ExceptionsExceptions

– Sickle cell anemiaSickle cell anemia– Cardiac or pulmonary diseaseCardiac or pulmonary disease

TRICC TrialTRICC Trial

Transfusion Requirements in Transfusion Requirements in Critical CareCritical Care– Restrictive transfusionRestrictive transfusion

Hemoglobin maintained at 7-9 gm/dLHemoglobin maintained at 7-9 gm/dL Averaged 2.6 units RBCsAveraged 2.6 units RBCs

– Liberal transfusionLiberal transfusion Hemoglobin maintained at 10-12 gm/dLHemoglobin maintained at 10-12 gm/dL Averaged 5.6 units RBCsAveraged 5.6 units RBCs

– All outcomes evaluated favored All outcomes evaluated favored restrictive transfusion grouprestrictive transfusion group

Contraindications for Contraindications for RBC unitsRBC units Acute blood loss <20-30% blood Acute blood loss <20-30% blood

volumevolume– Crystalloids often adequateCrystalloids often adequate

Nutritional anemiasNutritional anemias Almost never indicated for Hb Almost never indicated for Hb ≥ ≥

10 gm/dL10 gm/dL

Expected Results of Expected Results of RBC TransfusionRBC Transfusion Dependent upon:Dependent upon:

– Recipient blood volumeRecipient blood volume– Pretransfusion Hb levelPretransfusion Hb level– Clinical condition (hemolysis, fluid balance, active Clinical condition (hemolysis, fluid balance, active

bleeding)bleeding)– Hb content of unitHb content of unit

With one RBC unit for average adult:With one RBC unit for average adult:– Hemoglobin - Hemoglobin - 1 gm/dL 1 gm/dL– Hemotocrit - Hemotocrit - 3% 3%– May take 24 hours to see full effectMay take 24 hours to see full effect

RBC transfusion suppresses recipient red cell RBC transfusion suppresses recipient red cell production!production!

Ordering only one unit of RBCs is ok!Ordering only one unit of RBCs is ok!

What is the difference What is the difference between a Type & Screen between a Type & Screen and Type & Cross?and Type & Cross?

Type & ScreenType & Screen– ABO type and antibody screen/identificationABO type and antibody screen/identification– Valid for 3 months if no transfusion or Valid for 3 months if no transfusion or

pregnancy historypregnancy history– Valid for 3 days if transfused or pregnantValid for 3 days if transfused or pregnant

Type & Cross (Crossmatch)Type & Cross (Crossmatch)– ABO type and antibody screen/identificationABO type and antibody screen/identification– Requested number of units crossmatched for Requested number of units crossmatched for

patient and taken out of inventorypatient and taken out of inventory Should only be ordered if you anticipate transfusion!Should only be ordered if you anticipate transfusion!

The difference is…The difference is…

Pre-Transfusion Pre-Transfusion TestingTesting ABO/Rh type – 5 minutesABO/Rh type – 5 minutes Antibody screen – 25 minutesAntibody screen – 25 minutes Antibody identification – 1 hour or Antibody identification – 1 hour or

much moremuch more

Time required for unitsTime required for units

Uncrossmatched Group O-neg RBCs - Uncrossmatched Group O-neg RBCs - < 5 minutes< 5 minutes

Uncrossmatched type specific RBCs – Uncrossmatched type specific RBCs – ~ 15 minutes~ 15 minutes

Crossmatched RBCs – 30-45 minutesCrossmatched RBCs – 30-45 minutes Full ABO type, screen & crossmatch – 1 Full ABO type, screen & crossmatch – 1

hourhour Patient with multiple alloantibodies – Patient with multiple alloantibodies –

may take many hours!may take many hours! FFP – 30-45 minutes for thawingFFP – 30-45 minutes for thawing Cryo – 15 minutes for thawingCryo – 15 minutes for thawing

When to order RBC When to order RBC unitsunits When you are ready to transfuse!When you are ready to transfuse!

– After units are out of refrigeration they must After units are out of refrigeration they must be transfused be transfused within 4 hourswithin 4 hours!!

To be returned to stock units must be out of To be returned to stock units must be out of refrigeration < 30 minutesrefrigeration < 30 minutes

Temperature must not be >10Temperature must not be >10°C°C

– Many units are wasted because they are not Many units are wasted because they are not transfused in timetransfused in time

– If not ready just order a type & screen or type If not ready just order a type & screen or type & cross& cross

Cannot be re-issued if sterility Cannot be re-issued if sterility compromisedcompromised

How do you give an How do you give an RBC unit?RBC unit? 23 gauge needle or larger (18 23 gauge needle or larger (18

gauge preferred)gauge preferred) Run at 2-5 mL/minRun at 2-5 mL/min

– Maximum time to transfuse 4 hoursMaximum time to transfuse 4 hours– Vital signs within 15 minutes of startVital signs within 15 minutes of start

Compatible solutionsCompatible solutions– 0.9% normal saline0.9% normal saline

Modified RBC unitsModified RBC units

Leukocyte-reduced RBCsLeukocyte-reduced RBCs– Pre-storage (95% of RBCs used at Pre-storage (95% of RBCs used at

MHH & LBJ)MHH & LBJ)– Post-storage (using issued filter)Post-storage (using issued filter)– Indications:Indications:

Prevention of HLA alloimmunizationPrevention of HLA alloimmunization Prevention of febrile non-hemolytic Prevention of febrile non-hemolytic

transfusion reactionstransfusion reactions Prevention of CMV transmissionPrevention of CMV transmission Prevention of transfusion associated Prevention of transfusion associated

immunosuppressionimmunosuppression


CMV negative RBCsCMV negative RBCs– Donor is seronegative for CMVDonor is seronegative for CMV– Indications:Indications:

Protect patient from severe CMV infectionProtect patient from severe CMV infection Premature infants (<1200 gms) born to CMV Premature infants (<1200 gms) born to CMV

seronegative mothersseronegative mothers CMV-seronegative pregnant womenCMV-seronegative pregnant women CMV-seronegative bone marrow and hematopoietic CMV-seronegative bone marrow and hematopoietic

progenitor cell or solid organ transplant recipientsprogenitor cell or solid organ transplant recipients CMV-seronegative patients who are severely CMV-seronegative patients who are severely

immunosuppressedimmunosuppressed– **Leukocyte-reduced PRBCs are considered **Leukocyte-reduced PRBCs are considered

equivalent to CMV seronegative units with equivalent to CMV seronegative units with regard to risk of CMV transmissionregard to risk of CMV transmission


Washed RBCsWashed RBCs– 99% of plasma is removed99% of plasma is removed– Shelf life of 24 h after washingShelf life of 24 h after washing– 180 ml and Hct 75%180 ml and Hct 75%– Indications:Indications:

History of severe or frequent allergic History of severe or frequent allergic transfusion reactionstransfusion reactions

IgA deficiencyIgA deficiency Hyperkalemia, especially in a child or Hyperkalemia, especially in a child or

infantinfant


Irradiated RBCsIrradiated RBCs– RBCs exposed to cesiumRBCs exposed to cesium

Crosslinks T-lymphocyte DNACrosslinks T-lymphocyte DNA– Prevents proliferationPrevents proliferation

Changes expiration date to 28 days after Changes expiration date to 28 days after irradiationirradiation

– Indication:Indication: Prevention of transfusion-associated GVHDPrevention of transfusion-associated GVHD

Transfusion Transfusion Associated GVHDAssociated GVHD

Partial match between recipient and Partial match between recipient and donor HLA typedonor HLA type– Donor lymphocytes aren’t recognized Donor lymphocytes aren’t recognized

as foreign, proliferate and attack the as foreign, proliferate and attack the recipient tissuesrecipient tissues

Or due to severe Or due to severe immunosuppression in recipientimmunosuppression in recipient

Signs appear within 3-50 daysSigns appear within 3-50 days– fever, skin rash, diarrhea, marrow fever, skin rash, diarrhea, marrow

aplasiaaplasia– mortality rate ~90%mortality rate ~90%

Patients at risk for TA-Patients at risk for TA-GVHDGVHD Congenital immunodeficienciesCongenital immunodeficiencies Intrauterine transfusionIntrauterine transfusion Recipients of blood from 1st degree Recipients of blood from 1st degree

relatives or HLA “matched” unitsrelatives or HLA “matched” units Bone marrow or stem cell transplant Bone marrow or stem cell transplant

recipientsrecipients Hodgkin’s disease recipientsHodgkin’s disease recipients NOT indicated for HIV patientsNOT indicated for HIV patients


Frozen RBCsFrozen RBCs– RBCs frozen in glycerol & stored up to RBCs frozen in glycerol & stored up to

10 years10 years– Used to preserve rare blood typesUsed to preserve rare blood types– RBCs must be washed multiple times RBCs must be washed multiple times

prior to transfusionprior to transfusion Expire 24 hours after thawing and Expire 24 hours after thawing and

washingwashing

– VERY expensiveVERY expensive

PlateletsPlatelets

Whole blood derived plateletsWhole blood derived platelets– ““Random donor platelets”Random donor platelets”– 50 mL50 mL– DoseDose

10-15 mL/kg10-15 mL/kg 4-6 units for an average adult4-6 units for an average adult

– Stored 5 days at room temperature with Stored 5 days at room temperature with agitationagitation

– Must transfuse within 4 hours after poolingMust transfuse within 4 hours after pooling– Expected increment of 5-10K/Expected increment of 5-10K/μμL/L/unit (or 20-unit (or 20-

60K/ 60K/ μμL/L/dose)dose)– $50/unit (max of $300/dose)$50/unit (max of $300/dose)

PlateletsPlatelets Apheresis plateletsApheresis platelets

– ““Single donor platelets”Single donor platelets”– Also referred to asAlso referred to as “ “Jumbo platelets”Jumbo platelets”– 100 mL100 mL– DoseDose

1 apheresis unit1 apheresis unit– Stored 5 days at room temperature with Stored 5 days at room temperature with

agitationagitation– Expected increment of 30-40K/Expected increment of 30-40K/μμL/L/dose (unit)dose (unit)– $500/unit!$500/unit!– Advantage = single donorAdvantage = single donor

Less infectious riskLess infectious risk Less risk of HLA alloimmunizationLess risk of HLA alloimmunization

PlateletsPlatelets

Express ABO antigensExpress ABO antigens– Will get best increment with ABO Will get best increment with ABO

compatible plateletscompatible platelets DO NOT express Rh antigensDO NOT express Rh antigens

– Can give regardless of Rh type Can give regardless of Rh type – However, platelets contain a small However, platelets contain a small

amount of RBCsamount of RBCs Rh-negative woman of child-bearing age Rh-negative woman of child-bearing age

should receive Rh negative plateletsshould receive Rh negative platelets

Indications for Indications for PlateletsPlatelets ThrombocytopeniaThrombocytopenia

– <10,000 in uncomplicated patients<10,000 in uncomplicated patients– <20,000 if febrile or septic<20,000 if febrile or septic– <50,000 if bleeding or undergoing major <50,000 if bleeding or undergoing major

surgerysurgery– <100,000 for neurosurgery or ophthalmologic <100,000 for neurosurgery or ophthalmologic

proceduresprocedures ThrombocytopathyThrombocytopathy

– Congenital defectsCongenital defects– Drugs (ASA, Plavix)Drugs (ASA, Plavix)– External agents (cardiac bypass or ECMO)External agents (cardiac bypass or ECMO)

Failure of expected Failure of expected platelet incrementplatelet increment Consumption (after 24 hours)Consumption (after 24 hours)

– FeverFever– InfectionInfection– Drugs (Amphotericin)Drugs (Amphotericin)– BleedingBleeding– HepatosplenomegalyHepatosplenomegaly– DICDIC

Anti-HLA or platelet-antigen antibodies Anti-HLA or platelet-antigen antibodies (after 10-60 minutes)(after 10-60 minutes)

Modified Platelet UnitsModified Platelet Units

Washed plateletsWashed platelets Leukocyte-reduced plateletsLeukocyte-reduced platelets IrradiatedIrradiated

Contraindications for Contraindications for PlateletsPlatelets TTP/HUSTTP/HUS Heparin-induced thrombocytopenia Heparin-induced thrombocytopenia

(HIT)(HIT) ITP (relative contraindication)ITP (relative contraindication) Uremia-related platelet dysfunctionUremia-related platelet dysfunction

– DDAVPDDAVP– CryoprecipitateCryoprecipitate– RBC transfusion (keep HCT > 30%)RBC transfusion (keep HCT > 30%)

GranulocytesGranulocytes

Collected via apheresisCollected via apheresis– Donor stimulated with dexamethasone & G-CSFDonor stimulated with dexamethasone & G-CSF

250-300 mL250-300 mL Should be given once daily for at least 5 days Should be given once daily for at least 5 days IndicationsIndications

– Persistent fever or infection not responding to Persistent fever or infection not responding to antimicrobial therapyantimicrobial therapy

– Severe neutropenia (<500/Severe neutropenia (<500/μμL)L)– Reversible bone marrow hypoplasiaReversible bone marrow hypoplasia

Must have CMV-negative donor to prevent CMV Must have CMV-negative donor to prevent CMV transmissiontransmission

Must be given within 24 hours of collectionMust be given within 24 hours of collection

Fresh Frozen Plasma Fresh Frozen Plasma (FFP)(FFP) Whole blood plasmaWhole blood plasma

– 200 -250 ml200 -250 ml Also collected by apheresis = Jumbo FFPAlso collected by apheresis = Jumbo FFP

– 400-600 mL400-600 mL All coagulation factors and other proteinsAll coagulation factors and other proteins Stored frozen for 1 yearStored frozen for 1 year DoseDose

– 10-15 mL/kg10-15 mL/kg– 2-4 whole blood units OR 1-2 Jumbo FFP2-4 whole blood units OR 1-2 Jumbo FFP

Expect 20-30% increase in all factor levelsExpect 20-30% increase in all factor levels

Plasma CompatibilityPlasma Compatibility

Indications for FFPIndications for FFP

Coagulopathy due to Coagulopathy due to multiplemultiple factor deficienciesfactor deficiencies– Liver diseaseLiver disease– Reversal of nutritional Vit K Reversal of nutritional Vit K

deficiency or Warfarin overdosedeficiency or Warfarin overdose– Massive transfusionMassive transfusion– TTP/HUSTTP/HUS– PT/PTT > 1.5 x normalPT/PTT > 1.5 x normal

CryoprecipitateCryoprecipitate

Made from 1 unit partially thawed FFPMade from 1 unit partially thawed FFP 15 mL15 mL Fibrinogen, factor VIII, VWF, factor XIIIFibrinogen, factor VIII, VWF, factor XIII Stored 1 year frozen, 6 hours thawedStored 1 year frozen, 6 hours thawed If pooled must be given in 4 hoursIf pooled must be given in 4 hours DoseDose

– 1 unit/10 kg1 unit/10 kg– 10-20 units in average adult10-20 units in average adult

Indications for cryoIndications for cryo

Fibrinogen deficiencyFibrinogen deficiency Von Willebrand's diseaseVon Willebrand's disease Uremic thrombocytopathyUremic thrombocytopathy Factor XIII deficiencyFactor XIII deficiency Topical fibrin glueTopical fibrin glue **Not for replacement of Factor **Not for replacement of Factor

VIII!VIII!

Other productsOther products

AlbuminAlbumin Factor concentratesFactor concentrates

– Factor VIIIFactor VIII– Factor IXFactor IX

IVIGIVIG

The number one risk of The number one risk of transfusion is…transfusion is…

A.A. Hemolytic reactionHemolytic reaction

B.B. Infectious diseaseInfectious disease

C.C. TRALITRALI

D.D. Circulatory OverloadCirculatory Overload

The #1 infectious risk The #1 infectious risk of transfusion is…of transfusion is…

A.A. Hepatitis BHepatitis B

B.B. Hepatitis CHepatitis C

C.C. HIVHIV

D.D. Bacterial Contamination/SepsisBacterial Contamination/Sepsis

E.E. HTLV 1/2HTLV 1/2

F.F. MalariaMalaria

Risks of TransfusionRisks of Transfusion

Infectious diseaseInfectious disease– Units tested for HIV, Hep B, Hep C, Units tested for HIV, Hep B, Hep C,

syphilis, WNV, HTLV, Chagas diseasesyphilis, WNV, HTLV, Chagas disease HIV 1 : 2 millionHIV 1 : 2 million Hep C 1 : 2 millionHep C 1 : 2 million Hep B 1 : 250,000Hep B 1 : 250,000 Bacterial infection of clinical importanceBacterial infection of clinical importance

– 1:25,000 for platelets1:25,000 for platelets– 1:250,000 for RBCs1:250,000 for RBCs

Transfusion ReactionsTransfusion Reactions

STOP the transfusionSTOP the transfusion Send all tubing and a patient sample to the Send all tubing and a patient sample to the

blood bankblood bank LabsLabs

– BilirubinBilirubin– LDHLDH– HaptoglobinHaptoglobin– Urine hemoglobinUrine hemoglobin

Blood Bank Work-upBlood Bank Work-up– Clerical check & visual inspectionClerical check & visual inspection– Pre & Post transfusion ABO re-type (patient & unit)Pre & Post transfusion ABO re-type (patient & unit)– Pre & Post transfusion Direct Antiglobulin Test Pre & Post transfusion Direct Antiglobulin Test

(Direct Coomb’s)(Direct Coomb’s)

Hemolytic Transfusion Hemolytic Transfusion ReactionReaction Acute (within 24 hours) or delayed Acute (within 24 hours) or delayed

(within several days)(within several days) Incompatible RBCs Incompatible RBCs

– Due to ABO incompatibility (IgM) Due to ABO incompatibility (IgM) Intravascular hemolysisIntravascular hemolysis

– Due to alloimmunization from prior Due to alloimmunization from prior transfusion and/or pregnancy (usually transfusion and/or pregnancy (usually IgG)IgG) Extravascular hemolysis Extravascular hemolysis

Most common cause = Most common cause = clerical errorclerical error– Also low titer antibodies not detected on Also low titer antibodies not detected on

initial screen (Rh and Kidd)initial screen (Rh and Kidd)

PathophysiologyPathophysiology

Hypotension

Vasoconstriction, renal ischemia

Platelet activation

Hemolytic Transfusion Hemolytic Transfusion ReactionsReactions Signs and Symptoms:Signs and Symptoms:

– Fever, Chills/rigorsFever, Chills/rigors– AnxietyAnxiety– Flushing/PallorFlushing/Pallor– Chest/ abdominal/ back painChest/ abdominal/ back pain– N/V/DN/V/D– DyspneaDyspnea– HypotensionHypotension– HemoglobinuriaHemoglobinuria– JaundiceJaundice– Oliguria/anuriaOliguria/anuria– Pain or oozing at transfusion sitePain or oozing at transfusion site

Hemolytic Transfusion Hemolytic Transfusion ReactionsReactions Treatment = supportiveTreatment = supportive

– IV fluids for hypotension IV fluids for hypotension – Diuretics - maintain urine output at Diuretics - maintain urine output at

30-100 mL/h30-100 mL/h– Low dose dopamine (severe cases)Low dose dopamine (severe cases)– HeparinHeparin

Hemolytic Transfusion Hemolytic Transfusion ReactionsReactions PreventionPrevention

– Blood type & antibody screen every 3 daysBlood type & antibody screen every 3 days– Minimum of 2 identifiers used to ID patient Minimum of 2 identifiers used to ID patient

(NOT room number), initials of (NOT room number), initials of phlebotomist phlebotomist

Labeling of specimen at bedsideLabeling of specimen at bedside

– Maintain patient blood type & antibody Maintain patient blood type & antibody history recordshistory records

– Barcoded bracelets, transfusion safety Barcoded bracelets, transfusion safety officers, transfusion teamofficers, transfusion team

RBC AutoantibodiesRBC Autoantibodies

Antibodies that react with all RBCs, Antibodies that react with all RBCs, including the patient’s ownincluding the patient’s own– Causes: medications, autoimmune Causes: medications, autoimmune

disease, idiopathicdisease, idiopathic– May or may not be clinically significantMay or may not be clinically significant

Ordering RBCsOrdering RBCs– Crossmatch will be positiveCrossmatch will be positive– Monitor closely for signs of hemolysisMonitor closely for signs of hemolysis

Febrile Non-hemolytic Febrile Non-hemolytic Transfusion ReactionsTransfusion Reactions Majority of transfusion reactionsMajority of transfusion reactions Increase in temperatureIncrease in temperature

– 11°° C C– 22°° F F– No other cause for feverNo other cause for fever

All labs unchanged from pre-All labs unchanged from pre-transfusiontransfusion

Febrile Non-hemolytic Febrile Non-hemolytic Transfusion ReactionsTransfusion Reactions PathophysiologyPathophysiology

– Pyrogenic cytokines in cellular unitsPyrogenic cytokines in cellular units Pre-transfusionPre-transfusion

– WBCs in unit make cytokines during storageWBCs in unit make cytokines during storage– Platelets Platelets

Post-transfusionPost-transfusion– Recipient anti-WBC antibody stimulates donor Recipient anti-WBC antibody stimulates donor

WBCsWBCs– RBCsRBCs

Febrile Non-hemolytic Febrile Non-hemolytic Transfusion ReactionsTransfusion Reactions TreatmentTreatment

– Anti-pyreticsAnti-pyretics PreventionPrevention

– Leukoreduced unitsLeukoreduced units– Acetaminophen premedication*Acetaminophen premedication*

Bacterial Bacterial ContaminationContamination #1 infectious risk of transfusion#1 infectious risk of transfusion Mostly a problem with platelet Mostly a problem with platelet

unitsunits– Gram positive cocciGram positive cocci

Rarely a problem with RBC unitsRarely a problem with RBC units– Yersinia enterocoliticaYersinia enterocolitica most common most common

Bacterial Bacterial ContaminationContamination SymptomsSymptoms

– High fever/rigors (>2High fever/rigors (>2° F increase)° F increase)– Abdominal Abdominal

cramping/nausea/vomiting cramping/nausea/vomiting – ShockShock

Blood product may be discoloredBlood product may be discolored

Bacterial Bacterial ContaminationContamination TreatmentTreatment

– Stop transfusionStop transfusion– Culture patient and product bagCulture patient and product bag– IV antibioticsIV antibiotics– Pressor supportPressor support

PreventionPrevention– Proper phlebotomy technique at donationProper phlebotomy technique at donation– Careful donor historyCareful donor history– pH testing and/or culture of platelet unitspH testing and/or culture of platelet units

Allergic Transfusion Allergic Transfusion ReactionsReactions 45% of all transfusion reactions45% of all transfusion reactions More common with FFPMore common with FFP SymptomsSymptoms

– PruritusPruritus– UrticariaUrticaria

PathophysiologyPathophysiology– IgE in the patient reacts with donor plasma IgE in the patient reacts with donor plasma

proteinsproteins– Donor plasma has IgE which reacts with Donor plasma has IgE which reacts with

patient plasma proteinspatient plasma proteins

Allergic Transfusion Allergic Transfusion ReactionsReactions TreatmentTreatment

– BenadrylBenadryl– CorticosteroidsCorticosteroids– The only reaction in which the The only reaction in which the

transfusion can be resumedtransfusion can be resumed PreventionPrevention

– Benadryl premedication*Benadryl premedication*– Washed RBCs/plateletsWashed RBCs/platelets

Anaphylactic Anaphylactic Transfusion ReactionsTransfusion Reactions More severe allergic reactionMore severe allergic reaction PathophysiologyPathophysiology

– IgA deficient patients with anti-IgAIgA deficient patients with anti-IgA Almost immediate reactionAlmost immediate reaction

– Clinical symptoms range from urticaria to Clinical symptoms range from urticaria to shock & cardiac arrestshock & cardiac arrest

TreatmentTreatment– Epinephrine, corticosteroidsEpinephrine, corticosteroids

PreventionPrevention– Washed productsWashed products– IgA deficient productsIgA deficient products

Transfusion Associated Transfusion Associated Circulatory Overload Circulatory Overload (TACO)(TACO) 1 in 100 transfusions1 in 100 transfusions High volume or rate of transfusion exceeds High volume or rate of transfusion exceeds

ability of patient’s cardiovascular system to ability of patient’s cardiovascular system to handle additional workloadhandle additional workload– Underlying cardiovascular of pulmonary pathologyUnderlying cardiovascular of pulmonary pathology– ElderlyElderly– Normovolemic anemia (thalassemia)Normovolemic anemia (thalassemia)

Symptoms:Symptoms:– Dyspnea, OrthopneaDyspnea, Orthopnea– HypoxemiaHypoxemia– Pulmonary edemaPulmonary edema– Hypertension (>50 mmHg increase in SBP)Hypertension (>50 mmHg increase in SBP)– Increased central venous pressureIncreased central venous pressure– Increased BNPIncreased BNP

TACOTACO

TreatmentTreatment– Stop or slow rate of infusionStop or slow rate of infusion

Split unit into aliquotsSplit unit into aliquots Washed RBCs – less volumeWashed RBCs – less volume

– DiureticsDiuretics– OxygenOxygen– Supportive careSupportive care

PreventionPrevention– Vigilant assessment of pt’s ins/outsVigilant assessment of pt’s ins/outs– Slow rates of infusion/aliquotsSlow rates of infusion/aliquots– DiureticsDiuretics

Transfusion Related Transfusion Related Acute Lung Injury (TRALI)Acute Lung Injury (TRALI)

All components implicatedAll components implicated– FFP most commonlyFFP most commonly

1 in 1000 transfusions1 in 1000 transfusions– Extremely underreportedExtremely underreported

PathophysiologyPathophysiology– Anti-HLA in donor plasma activates Anti-HLA in donor plasma activates

PMNs in pulmonary capillaries of PMNs in pulmonary capillaries of recipient recipient capillary leakage capillary leakage

– Anti-HLA antibodies form after prior Anti-HLA antibodies form after prior transfusion or pregnancytransfusion or pregnancy

TRALITRALI

SymptomsSymptoms– Sudden new onset hypoxemia (O2 sat Sudden new onset hypoxemia (O2 sat

<90%) or increased FiO2 requirement<90%) or increased FiO2 requirement– CXR with bilateral infiltrates (like CXR with bilateral infiltrates (like

ARDS)ARDS)– Absent signs of circulatory overloadAbsent signs of circulatory overload

Pre/Post transfusion BNP ratio <2Pre/Post transfusion BNP ratio <2

– No preexisting lung injury or ARDSNo preexisting lung injury or ARDS– Onset within 6 hours of transfusionOnset within 6 hours of transfusion

TRALITRALI

TreatmentTreatment– Supportive measuresSupportive measures

PreventionPrevention– Use of male plasmaUse of male plasma– Defer implicated donorsDefer implicated donors

Test donor for anti-HLA antibodiesTest donor for anti-HLA antibodies Compare to HLA type of patientCompare to HLA type of patient

Other complications of Other complications of transfusiontransfusion AlloimmunizationAlloimmunization

– 18-47% in sickle cell patients18-47% in sickle cell patients– 5-11% in thalassemia patients5-11% in thalassemia patients– 20% without underlying hematologic/oncologic 20% without underlying hematologic/oncologic

diseasedisease Iron overloadIron overload Metabolic abnormalities Metabolic abnormalities

– HypocalcemiaHypocalcemia– HyperkalemiaHyperkalemia

CoagulopathyCoagulopathy HypothermiaHypothermia GVHDGVHD

Take Home Points…Take Home Points…

While extremely safe when used While extremely safe when used appropriately, transfusion is still appropriately, transfusion is still not without risk.not without risk.

Know what you are ordering and Know what you are ordering and the implications of your orders.the implications of your orders.

Blood is not a limitless resource!Blood is not a limitless resource! Don’t make assumptions…call the Don’t make assumptions…call the

blood bank!blood bank!

transfusion medicine

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