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Introduction to Transfusion

Introduction to Transfusion. Kathleen M. Madden MD Jay S. Raval MD Department of Pathology. Objectives. Understand indications for transfusions Describe the expected laboratory response patients should achieve with transfusion Explain the indications for blood component modification

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Introduction to Transfusion

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  1. Introduction to Transfusion Kathleen M. Madden MD Jay S. Raval MD Department of Pathology

  2. Objectives • Understand indications for transfusions • Describe the expected laboratory response patients should achieve with transfusion • Explain the indications for blood component modification • Highlight key facts of UNM’s Massive Transfusion Protocols

  3. Who does not need a RBC transfusion? • A. 54 y/o F with ovarian cancer, no other medical problems, starting chemotherapy, Hgb 8.9 g/dL • B. 75 y/o M, history of myocardial infarction, admitted with pneumonia, Hgb 7.4 g/dL • C. 22 y/o F involved in a motor vehicle collision, hypotensive and tachycardic, Hgb 11.4 g/dL

  4. Who does not need a RBC transfusion? • A. 54 y/o F with ovarian cancer, no other medical problems, starting chemotherapy, Hgb 8.9 g/dL • B. 75 y/o M, history of myocardial infarction, admitted with pneumonia, Hgb 7.4 g/dL • C. 22 y/o F involved in a motor vehicle collision, hypotensive and tachycardic, Hgb 11.4 g/dL

  5. The main indication for RBC transfusion is tissue ischemia secondary to decreased O2 transport https://www.researchgate.net/figure/Oxygen-transport-by-Hb-within-RBC-10_fig2_321474640

  6. Emergency RBC transfusion indications include: • Active hemorrhage • Hypovolemic shock • Laboratory evidence of ischemia • Lactic acidosis • Acute decrease in Hgb/Hct • Clinical evidence of decreased O2 transport • Dyspnea, tachypnea, tachycardia

  7. Non-emergent RBC transfusion indications include: • Hgb <7g/dL (Hct <21%) • Hgb <8-10 g/dL (Hct <24-30%) in a patient with a known cardiac history • No symptomatic anemia (yet) at these transfusion thresholds

  8. Considerations when transfusing RBCs • One RBC unit should increase the Hgb by 1g/dL and Hct by 3% in a 70 kg adult • Same as 4 mL/kg in a child • Single-unit transfusions should be ordered for non-bleeding patients • Additional units ordered after reassessing patient and rechecking post-transfusion Hgb/Hct

  9. ASH/AABB Transfusion Recommendations • Don’t transfuse more units of blood than absolutely necessary • Don’t transfuse RBCs for iron deficiency without hemodynamic instability • Don’t perform serial blood counts on clinically stable patients • Don’t transfuse group O negative blood except to O negative patients and in emergencies to women of childbearing potential. http://www.choosingwisely.org/societies/american-association-of-blood-banks/

  10. How long will it take you to get your RBC units? • Type and Screen must be up to date for type-specific RBCs • Type and Screen takes 30-60 minutes if no antibodies are present • Electronic Crossmatch • Pt has >1 Type and Screen and no history of or current antibodies or ABO discrepancies • Very rapid • Antibodies present - additional time needed to identify antibody and provide antigen-negative or crossmatch compatible blood

  11. Emergency Release RBCs • Can be provided if your patient is hemorrhaging and unstable and • There is no current type and screen • There is not time for the Blood Bank to provide antigen-negative or crossmatch compatible RBCs • O-negative RBCs: women and girls of child-bearing age • O-positive RBCs: all men and women who appear >50 years old • *Uncrossmatched blood mustbe approved by the Transfusion Medicine Service*

  12. Plasma Pearls • Source of all coagulation factors as well as fibrinogen • 1 IU/mL of both pro- and anti-coagulant factors • Approximately 400mg fibrinogen • INR of plasma is variable but can be as high as 1.5

  13. Indications for Plasma transfusion • Bleeding with decreased coagulation factors (INR >1.5-2.0) • Prior to major surgical procedure with INR > 1.5-2.0 • Therapeutic plasma exchange for selected conditions • Specific factor replacement when factor concentrates are unavailable

  14. When is plasma not indicated? • Non-bleeding patient with elevated INR • Volume replacement • Protein source for nutritional support • If your bleeding patient has an elevated INR and you are unsure if they need plasma, you can order a ROTEM for whole blood evaluation of their ability to clot.

  15. Why is plasma transfusion more effective at higher INR? Hall D., Walsh T.S. (2015) FFP Transfusion in Intensive Care Medicine. In: Juffermans N., Walsh T. (eds) Transfusion in the Intensive Care Unit. Springer, Cham

  16. Plasma Transfusions • Dose is 15-20 mL/kg • NOT 2 units! • For a 70kg patient, this is 8 units plasma • ABO compatible with the recipient • Takes approximately 30 minutes to thaw plasma

  17. Hepatic Failure Patients and Plasma Transfusion • Both pro- and anti-coagulant factors made by liver • Consequently liver failure resets the patient to have lower thresholds for bleeding and thrombosis • PT/aPTT do not predict which patients will bleed - plasma should not be empirically given to correct lab abnormalities without bleeding

  18. What is cryoprecipitate? • The big proteins: • Fibrinogen • Minimum Fgn:150 mg • vWF (carries factor 8) • Minimum Factor 8:80 IU • Factor 13 • Fibronectin • The proteins “cryoprecipitate” (cold precipitate) out of solution Fibrinogen von Willebrand factor + Factor 8 In practice, cryoprecipitate is used almost exclusively to replace fibrinogen (mostly in bleeding patients)

  19. Indications for Cryoprecipitate Transfusion • Fibrinogen deficiency • Target fibrinogen >100 mg/dL for adequate hemostasis • Massive transfusion patients: >150 mg/dL • Postpartum hemorrhage: >200 mg/dL

  20. Cryoprecipitate Dosing • 1 pool of cryoprecipitate = 5 units • 1 pool is approximately 75 mL • Transfusing a 70kg patient 2 pools of cryoprecipitate should increase fibrinogen by 70 mg/dL • Pediatric dosing: can call Transfusion Medicine fellow/resident for help targeting a fibrinogen goal • Once thawed, the expiration is 6 hours

  21. Which patient needs a platelet transfusion? • A. 36 y/o M with a splenic laceration from a stab to the abdomen, platelet count 94 K • B. 10 y/o F with B-cell acute lymphoblastic leukemia between chemotherapy cycles, platelet count 31 K • C. 72 y/o F on Clopidogrel admitted with a subdural hematoma after a fall, platelet count 188 K • D. 54 y/o M with AML admitted for chemotherapy, no bleeding signs, platelet count 17 K

  22. Which patient needs a platelet transfusion? • A. 36 y/o M with a splenic laceration from a stab to the abdomen, platelet count 94 K • B. 10 y/o F with B-cell acute lymphoblastic leukemia between chemotherapy cycles, platelet count 31 K • C. 72 y/o F on Clopidogrel admitted with a subdural hematoma after a fall, platelet count 188 K • D. 54 y/o M with AML admitted for chemotherapy, no bleeding signs, platelet count 17 K

  23. Platelets: the Goldilocks of Blood Components • Platelet-rich plasma solution • Storage requirements: • Oxygen-permeable bag • Kept at room temperature • Gently agitated/rocked • Must “rest” for 12 hours before bacterial testing can be started • Highest-risk blood component for bacterial contamination and septic transfusion reactions http://simpsons.wikia.com/wiki/Goldilocks

  24. Indications for Platelet Transfusion: Quantitative Defects

  25. Indications for Platelet Transfusion: Qualitative Defects • Platelet dysfunction • Antiplatelet medications • Congenital platelet functional defects • Following surgery using cardiopulmonary bypass

  26. Platelet Dosing • For a 70kg adult, 1 unit of platelets should increase the platelet count by 25-50K • For pediatric patients, the dosing is 10-15 mL/kg

  27. How long will it take to get your platelets? • After collection and before expiration we have about a 3-3.5 day window to transfuse platelets • On a good day, the Blood Bank has 7-9 platelet units for the hospital and cancer center • You may be asked to give half-units to your patients (should see a 15-25K increase in platelet count) when we have a shortage and are trying to get more platelets • You may be asked to hold on transfusing non-emergent patients until we can bring more platelets into the inventory

  28. Blood Components & Indications Plasma Bleeding w/INR >1.5 – 2.0 (coagulopathic) Massive hemorrhage Therapeutic plasma exchange Factor deficiency w/o concentrate Cryoprecipitate Platelets Low fibrinogen <10K (inpt) - prophylactic <20K (outpt) - prophylactic <50K active bleed/major surgery <100K CNS/eye injury/surgery Massive hemorrhage Aspirin/Plavix use with active bleed RBCs Decreased tissue oxygenation Symptomatic anemia Massive hemorrhage

  29. Blood Product Modification • Leukoreduction • Washing • Irradiation

  30. Leukoreduction • All cellular products (RBCs, platelets) are leukoreduced • Main reasons for leukoreduction: • Decrease incidence of febrile non-hemolytic transfusion reactions • Prevention of CMV transmission • Prevention of HLA alloimmunization https://blood.ca/en/blog/2016-11/things-we-do-safety-leukoreduction

  31. Washed Blood Products • Removal of plasma proteins to decrease hypersensitivity to blood products • 1-2 L of saline is used to remove ~99% of plasma • Indications may include: • IgA deficiency • History of severe allergic/anaphylactoid reactions to blood transfusions

  32. Issues with providing washed blood products • Washing changes expiration of blood products • Platelets = 4 hr • RBCs = 24 hr • Takes approximately 1 hour for washing process, then time for transportation to UNMH. Products must also be taken into Blood Bank inventory and then allocated • Quantitatively and qualitatively inferior unit secondary to washing process

  33. Used for cellular products RBCs Platelets Granulocytes Ionizing radiation damages the DNA of the irradiated cell but leaves normal cellular function intact Indication for irradiation: prevent Transfusion-Associated Graft vs Host Disease (TA-GVHD) How does irradiation work?

  34. What is TA-GVHD? • Graft-vs-host reaction that occurs after transfusion due to • Immunologically competent donor cells • Antigenic difference between graft and host detected by the donor cells • Inability of the host to reject the donor cells effectively • Affected organs include skin, GI tract, bone marrow, spleen, liver • Mortality >90% https://www.sciencedirect.com/science/article/pii/S0001581416300986

  35. What are the common indications for irradiation? • Hematopoietic stem cell transplant recipients • Congenital Cellular Immune Deficiency • Intrauterine/neonatal transfusions • Infants up to 6 months old • All pediatric malignancies • Hematologic malignancies • Transfusion from family members or HLA-matched products • Treatment with purine analogs, anti-thymocyte globulin, or Alemtuzumab

  36. When is irradiation NOT indicated? • Solid organ transplantation • Adult solid organ tumors • Autoimmune diseases • HIV/AIDS • Caveat: if patient is severely lymphopenic (ALC < 500) or treated with medications for which irradiation is indicated, cellular blood products will be irradiated

  37. Changing gears to massive transfusions

  38. What is a massive transfusion? • Acute administration of >1/2 estimated blood volume in 3 hours • Replacement of 10% of the total blood volume/minute • Anticipated replacement of total blood volume in 24 hours • Pediatric patients: transfusion of >40 mL/kg RBCs

  39. When should you consider activating the MTP? • If you think any of the above circumstances apply to your patient OR • If your patient is bleeding and you are concerned that it is already uncontrolled or it may become uncontrolled, activate the MTP!

  40. How will activation of the Massive Transfusion Protocol help your patients? • Protocol is designed to mimic whole blood resuscitation • Each round of the MTP contains RBCs, Plasma, and Platelets • Having the MTP Protocol set up in advance streamlines the allocation and rapid delivery of blood products to patients • MTP is designed so that once activated, you do not need to continuously reorder blood products

  41. Important points to remember when ordering a MTP for your patient • You must choose the appropriate MTP in powerchart • Pediatric Massive Transfusion • Trauma/Surgical Massive Transfusion • Obstetric Massive Transfusion • You MUST initiate and sign the powerplan • You MUST call the Blood Bank to notify them that you activated a MTP • 272-2591

  42. Information to provide to the Blood Bank • Patient’s name and MRN • Patient’s location • Attending physician responsible for the patient • Point of contact name and phone number • For pediatric patients: estimated/known weight in kg

  43. Cryoprecipitate is not provided nor built into the ADULT MTP rounds. One pool of cryoprecipitate is provided with each of the first two OB MTP rounds Adult and OB MTP Rounds

  44. Pediatric MTP rounds are weight-based Cryoprecipitate is not provided nor built into the MTP rounds – it must be ordered separately Blood product dosing for pediatric patients: 15mL/kg

  45. The most important initial labs are included in the MTP powerplans • Type and screen • Emergency Hemorrhage Panel (EHP) • Tests included: Hemoglobin, Platelet Count, PT/INR, Fibrinogen • Results in 15 minutes upon specimen arrival to the lab • Hand deliver a lavender top and a light blue top tube to the lab • New EHP should be sent after every round or every 30-60 minutes

  46. Picking up MTP rounds • The clinical service is responsible for picking up all blood products required during the MTP • RBCs and other blood products are generally available for pickup at the Blood Bank unless otherwise arranged • The Blood Bank will notify the Point of Contact when each new round is ready to be picked up • A new round will automatically be prepared once previous round is picked up

  47. Endpoints of Massive Transfusion • Physician declares hemostasis based on the absence of bleeding • The treating physicians agree the patient is adequately resuscitated based on normalizing vital signs • Further resuscitation is deemed to be futile • The point of contact must notify the Blood Bank when the MTP has ended

  48. Remember: If your patient is bleeding and you’re concerned it is already uncontrolled or may become uncontrolled, activate the MTP

  49. Questions?

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