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TRANSFUSION INDICATIONS AND REACTIONS

TRANSFUSION INDICATIONS AND REACTIONS. Dr. Meral SÖNMEZOĞLU Yeditepe University Hospital Transfusion Center. Early History of Transfusion. Harvey’s theory of circulation, 1628 Physick, Philadelphia, 1795 Blundell, England, 1818

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TRANSFUSION INDICATIONS AND REACTIONS

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  1. TRANSFUSION INDICATIONS AND REACTIONS Dr. Meral SÖNMEZOĞLU Yeditepe UniversityHospital TransfusionCenter

  2. Early History of Transfusion • Harvey’s theory of circulation, 1628 • Physick, Philadelphia, 1795 • Blundell, England, 1818 • Problems of sterility, coagulability, intravenous routes ignored

  3. Karl Landsteiner (1868-1943) • Discovered ABO blood groups, 1900 • Nobel Prize, 1930

  4. Classic Nine Blood Group Systems • ABO, 1900 • MN and P, 1927 • Rh, 1940 • Lutheran, 1945 • Kell, 1946 • Lewis, 1946 • Duffy, 1950 • Kidd, 1951

  5. Major kan grup sistemleri

  6. Diğer kan grup sistemleri

  7. Compatibility Testing • IgM antibodies- direct agglutination; reactive in cold (room temp or below); either intra- or extravascular hemolysis • IgG antibodies- often require antiglobulin reagent to allow agglutination; reactive at body temp (37 C); usually extravascular hemolysis

  8. Compatibility Testing (2) • Type- determine recipient’s ABO and Rh (D) type • Forward type- Ag on RBCs • Backward type- Corresponding Ab in serum • Screen- two/three RBC panel to detect unexpected antibodies • Antibody identification using extended panel

  9. Compatibility Testing (3) • Immediate spin • Incubation at 37 C • Antiglobulin phase

  10. Compatibility Testing (4) • Crossmatch- donor RBCs with recipient serum, look for agglutination • Screen- detect weak antibodies • Crossmatch- detect Ab against low-incidence Ag

  11. Compatibility Testing (5) • Autocontrol- recipient serum/recipient RBCs; if agglutination occurs, then do DAT • (+)DAT may be autoantibody, but alloantibody needs to be excluded • Elute Ab from RBCs, test against panel of RBCs to identify Ab

  12. ABO KanGrup Sistemi

  13. ABO Blood Grouping • ABO kan gruplaması iki şekilde yapılır: • Eritrositler A ve/veya B antijenlerinin varlığına göre tiplendirilir: forward (doğrudan) gruplama • Serum/plazma anti-A ve/veya anti-B antikorlarının varlığı veya yokluğu için test edilir: revers (dolaylı) gruplama

  14. Possible Blood group Genotypes

  15. Possible Blood group Genotypes

  16. ABO Antijen ve Antikorları

  17. A A A A B B B B ABO TYPING Back or reverse type with A and B cells • Commercially available A and B cells are added to two tubes of plasma • AB B A O

  18. Rh Blood Group System • Rh proteins encoded by two linked genes on chromosome 1: RHD and RHCE, a haplotype unit • Major antigens: D, C, c, E, and e • D: epitope on RhD protein • C,c and E,e: antithetical antigens on RhCE protein • No d antigen exists

  19. Differential CentrifugationFirst Centrifugation Closed System Whole Blood Main Bag Satellite Bag 1 Satellite Bag 2 First Platelet-rich Plasma RBC’s

  20. Differential CentrifugationSecond Centrifugation Platelet-rich Plasma RBC’s Second Platelet Concentrate Plasma RBC’s

  21. Whole Blood • Storage • 4° for up to 35 days • Indications • Massive Blood Loss/Trauma/Exchange Transfusion • Considerations • Use filter as platelets and coagulation factors will not be active after 3-5 days • Donor and recipient must be ABO identical

  22. RBC Concentrate • Storage • 4° for up to 42 days, can be frozen • Indications • Many indications—ie anemia, hypoxia, etc. • Considerations • Recipient must not have antibodies to donor RBC’s (note: patients can develop antibodies over time) • Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl) • Usually transfuse over 2-4 hours (slower for chronic anemia

  23. Function of RBCs Oxygen Transport Delivery of oxygen from lungs to tissues Oxygen transport is dependent on Hematocrit Cardiac output Oxygen extraction

  24. Normovolemic Anemia As hematocrit falls Blood viscosity decreases Cardiac output increases (Stroke volume,  pulse) Delivery of O2  O2 extraction  Consumption of O2 remains constant

  25. Limits of Compensation At very low hemoglobin levels (approximately 4 g/dL) O2 delivery does not meet demand Anerobic metabolism  lactic acidosis  cardiac arrest

  26. Indications for RBC transfusions 1940s Recommended that surgery patients have a hemoglobin of 8 to 10 g/dL Led to a general rule of hemoglobin > 10 g/dL of surgery patients 1980s Development of invasive monitoring techniques lead to a better understanding of oxygen delivery and consumption Lower hemoglobin levels could be tolerated

  27. Hemoglobin and Hematocrit Levels in Healthy Adults Hematology: Basic Principles and Practice. Elsevier 2005

  28. Transfusion Trigger:Multicenter, Randomized Control Study of ICU Patients Herbert PC et al. N Engl J Med. 1999;340: 409-417

  29. Transfusion Trigger:Multicenter, Randomized Control Study of ICU Patients Herbert PC et al. N Engl J Med. 1999;340: 409-417

  30. Restrictive vs Liberal Transfusion in Other Conditions No difference Pediatric ICU patients 7.0 g/dL vs 9.5 g/dL Lacroix J, et al. N Engl J Med. 2007:356;1609-1619 Moderate to severe head injury 7.0 g/dL vs 10.0 g/dL McIntyre LA et al. Neutrocrit Care 2006;5:4-9 Possible difference Cardiovascular disease 7.0 g/dL vs 10.0 g/dL Liberal transfusions may be better in patients with acute myocardial infarction and unstable angina Hebert PC et al. Crit Care Med. 2001;29:227-234.

  31. Optimal Hematocrit? Laboratory and mathematical model Maximize delivery of oxygen O2 delivery is proportional to hematocrit and blood flow rate. As hematocrit increases viscosity increases and flow rate decrease Optimal hematocrit is approximately 35% Crowell JW and Smith EE. J Appl Physiol 1967;22:501-504 Clinical Risks associated with increasing the hemoglobin/hematocrit justify the clinical benefits

  32. Platelets • Storage • Up to 5 days at 20-24° • Indications • Thrombocytopenia, Plt <15,000 • Bleeding and Plt <50,000 • Invasive procedure and Plt <50,000 • Considerations • Contain Leukocytes and cytokines • 1 unit/10 kg of body weight increases Plt count by 50,000 • Donor and Recipient must be ABO identical

  33. Plasma and FFP • Contents—Coagulation Factors (1 unit/ml) • Storage • FFP--12 months at –18 degrees or colder • Indications • Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange transfusion, massive transfusion • Considerations • Plasma should be recipient RBC ABO compatible • In children, should also be Rh compatible • Account for time to thaw • Usual dose is 20 cc/kg to raise coagulation factors approx 20%

  34. Cryoprecipitate • Description • Precipitate formed/collected when FFP is thawed at 4° • Storage • After collection, refrozen and stored up to 1 year at -18° • Indication • Fibrinogen deficiency or dysfibrinogenemia • vonWillebrands Disease • Factor VIII or XIII deficiency • DIC (not used alone) • Considerations • ABO compatible preferred (but not limiting) • Usual dose is 1 unit/5-10 kg of recipient body weight

  35. Granulocyte Transfusions • Prepared at the time for immediate transfusion (no storage available) • Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, and recovery of BM is expected • Donor is given G-CSF and steroids or Hetastarch • Complications • Severe allergic reactions • Can irradiate granulocytes for GVHD prevention

  36. Leukocyte Reduction Filters • Used for prevention of transfusion reactions • Filter used with RBC’s, Platelets, FFP, Cryoprecipitate • Other plasma proteins (albumin, colloid expanders, factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusions • May reduce RBC’s by 5-10% • Does not prevent Graft Verses Host Disease (GVHD)

  37. RBC TransfusionsPreparations • Type • Typing of RBC’s for ABO and Rh are determined for both donor and recipient • Screen • Screen RBC’s for atypical antibodies • Approx 1-2% of patients have antibodies • Crossmatch • Donor cells and recipient serum are mixed and evaluated for agglutination

  38. RBC TransfusionsAdministration • Dose • Usual dose of 10 cc/kg infused over 2-4 hours • Maximum dose 15-20 cc/kg can be given to hemodynamically stable patient • Procedure • May need Premedication (Tylenol and/or Benadryl) • Filter use—routinely leukodepleted • Monitoring—VS q 15 minutes, clinical status • Do NOT mix with medications • Complications • Rapid infusion may result in Pulmonary edema • Transfusion Reaction

  39. Platelet TransfusionsPreparations • ABO antigens are present on platelets • ABO compatible platelets are ideal • This is not limiting if Platelets indicated and type specific not available • Rh antigens are not present on platelets • Note: a few RBC’s in Platelet unit may sensitize the Rh- patient

  40. Platelet TransfusionsAdministration • Dose • May be given as single units or as apheresis units • Usual dose is approx 4 units/m2—in children using 1-2 apheresis units is ideal • 1 apheresis unit contains 6-8 Plt units (packs) from a single donor • Procedure • Should be administered over 20-40 minutes • Filter use • Premedicate if hx of Transfusion Reaction • Complications—Transfusion Reaction

  41. Conclusions Although RBCs are much safer than 20 years ago, transfusion practices have become more restrictive The transfusion threshold at most institutions is a hemoglobin of 7 to 8 g/dL for most patients Higher thresholds are used for specific patients

  42. TRANSFUSION REACTIONS

  43. Transfusion Reactions are… Adverse reactions associated with the transfusion of blood and its components

  44. Transfüzyon öncesi değerlendirme İzleme & Değerlendirme Kan çıkışı Bağışçı organizasyonu Transfüzyon endikasyonu Bağışçı tarama Kan transfüzyonu Transfüzyon öncesi testler Kan toplama ve hazırlama Enfeksiyöz hastalık testleri Ürün: Kan güvenliği Tüm işlemler: Kan TransfüzyonGüvenliği

  45. Enfeksiyon dışı Riskler İzleme & Değerlendirme Kan çıkışı Bağışçı organizasyonu Transfüzyon endikasyonu Bağışçı tarama Kan transfüzyonu Transfüzyon öncesi testler Kan toplama ve hazırlama Enfeksiyöz hastalık testleri Ürün: Kan güvenliği Tüm işlemler: Kan TransfüzyonGüvenliği

  46. Dzik WH, Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion. 2003 Sep;43(9):1190-9.

  47. Transfusion reactions • Non-threatening to fatal • Hemolytic or non-hemolytic – may or may not cause RBC destruction • Acute to delayed • Acute – rapid onset • Delayed – days to weeks • Reactions may involve antigen-antibody interactions • May involve infectious agents

  48. Transfusion Fatalities Reported to the FDA (FY 2004 to 2006)

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