BLOOD COMPONENTS TRANSFUSION INDICATIONS

1. BLOOD COMPONENTSTRANSFUSION INDICATIONS Dr. Meral SÖNMEZOĞLU Yeditepe UniversityHospital TransfusionCenter

2. BLOOD DONATION

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

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

7. Whole Blood • Whole Blood (WB) is blood taken from a suitable donor using a sterile andpyrogen free anticoagulant and container. • W B is a sourcematerial for component preparation, which is its major use. • WB for transfusion is used without further processing. • WB for transfusion should not contain irregular antibodies ofclinicalsignificance.

8. 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

9. RBC Concentrate • Red Cells is obtained by removal of a major part of the plasma from WB. • Red Cells also contains the greater part of the whole blood leucocytes(about 2.5 to 3.0 × 109 cells) and a varying content of plateletsdepending on the method of centrifugation. • For the preparation, plasma is removed from Whole Blood aftercentrifugation

10. 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

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

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

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

14. 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

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

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

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

18. 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.

19. 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

20. Platelets

21. Plasma and FFP • For the preparation, plasma is removed from Whole Blood aftercentrifugation • It must contain, on average, not less than 70 IU Factor VIII per 100 ml and at least similar quantities of the other labile coagulation factorsandnaturallyoccurringinhibitors.

22. Plasma and FFP • Contents—Coagulation Factors (1 unit/ml) • Storage • FFP—36 months at –35 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%

23. 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

24. 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

25. 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)

26. 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

27. 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

28. 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

29. 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

30. Serological Testing • 3 tests: • ABO/Rh • Antibody detection/identification • Crossmatch

31. ABO/Rh Typing • In the ABO typing, the forward and reverse MUST match • In the Rh typing, the control must be negative • Both of these will indicate what type of blood should be given

33. Blood Grouping using gel cards

34. Antibody screen and/or ID • The antibody screen will detect the presence of any unexpected antibodies in patient serum • If antibodies are detected, identification should be performed using panel cells (with an autocontrol) • IS • 37° (LISS) • AHG • If an antibody is present, units negative for the antigen must be given (remember the calculation?) • Proceed to the crossmatch…

35. Crossmatching • Purpose: • Prevent transfusion reactions • Increase in vivo survival of red cells • Double checks for ABO errors • Another method of detecting antibodies

36. Crossmatch • Two types of crossmatches • Major – routinely performed in labs • Minor – not required (by AABB since 1976)

37. Major vs Minor Crossmatch • Why is the minor crossmatch unnecessary? • Donated units are tested for antibodies • Most blood is transfused as packed cells, having little antibodies

38. Crossmatch No agglutination ~ compatible Agglutination ~ incompatible Donor RBCs (washed) Patient serum

39. 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

40. TRANSFUSION REACTIONS

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

42. 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

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

45. Disease Transmission • Hepatitis • HIV • HTLV • Cytomegalovirus • Malaria • Babesiosis • Syphilis

46. Infectious Risk of Transfusion Klein HG et al. Transfusion 2007;47:2338-2347

47. SHOT 2011 Serious Hazards of Transfusion (SHOT) Steering Group. The 2011 Annual SHOT Report (2012)

48. 1996-2011 SHOT (n=9925)