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Basics of Transfusion Therapy
Resident Education Lecture Series
Hemoglobin Level and Symptoms
HGB (GM%) SYMPTOMS
9-11 MINIMAL
7.5 EXERTIONAL DYSPNEA
6.0 WEAKNESS
3.0 DYSPNEA AT REST
2-2.5 HEART FAILURE
LINMANNEJM 279:812, 1968
RBC Transfusion: Indications
Acute Blood Loss
Symptomatic Anemia
Suboptimal O2 Capacity
Exchange (SS, Co)
RBC Transfusion: The Bathtub Principle
Kidney
Kidney
Kidney
100
30
0
100
40
0
Blood Volume Blood VolumeBlood Volume
100
30
0
Pre-Transfusion Testing
BLOOD TYPING: ABO, D Antigens only
(Other antigens are weak immunogens)
ANTIBODY SCREEN: Patient serum vs. cell panel
CROSSMATCH Major: Patient Serum vs. Donor Cells
RBC Products PRBC MOST TRANSFUSIONS
WHOLE BLOOD ACUTE BLEEDINGEXCHANGEPLASMA NEEDED
WASHED REMOVE PLASMA
FROZEN RARE RBC PHENOTYPE
IRRADIATED IMMUNODEFICIENT CMV NEGATIVE IMMUNODEFICIENT
SERONEGATIVE, NEONATE
RBC Transfusion Volume
Usual: Up to 15cc/Kg in 3-4 hours
Unusual: Acute Hemorrhage: replace ongoing losses
Chronic Anemia, Heart Failure, îBP
2cc/Kg/Gm HGBDiureticExchange
Transfusion Volume
10cc/Kg PRBC 2.4 GM% in HGB
10cc/kg = X cc/kg 2.4 GM% Desired HGB rise
PRBC cc = Blood Volume x (HGBF- HGBI)
HGBT
BV=70cc/KG, 80-90cc/KG newborn
Hemolytic Transfusion Reactions
Acute HTR 1/25,000Fatal Acute HTR 1-4/1,000,000
Delayed HTR 1/5-10,000
Symptoms and Signs of Acute Hemolytic Reactions
Severe Back Pain Substernal Tightness, Dyspnea Hypotension / Circulatory collapse Vomiting, diarrhea Icterus Hemoglobinuria Renal shutdown Diffuse Oozing from
wounds/punctures
Response to Suspected Hemolytic Reaction
Stop Transfusion Hydrate Specimens to Blood Bank
Unit/BagSerumRed cellsUrine
Acute Hemolysis: Diagnosis
Do a direct antiglobulin test on post-transfusion sample
Obtain post-transfusion blood and urine and inspect visually
Recheck paperwork Recheck ABO type of unit and pre-and
post-transfusion specimens Run urinalysis - to check for
hemoglobinuria
Cause of Acute HTR ABO incompatibility:source of error
10% at phlebotomy/labeling23% in Transfusion Lab67% transfusion administration (at the
bedside)
Nonhemolytic Transfusion Reactions
Leukocyte Associated FNHTR Transfusion GVHD Neonatal Neutropenia
Immunoglobulin Associated Urticaria/Fever Ig E TRALI
Platelet Associated Post transfusion Purpura Neonatal
Thrombocytopenia
Metabolic/ Physical Citrate Toxicity Hypothermia Circulatory Overload
Massive Transfusions Haemostatic Abnormalities Metabolic complications Hgb-O2 Curve Shift
TRANSFUSION-RELATED INFECTION
Risk of Transfusion-Transmitted Infection
HIV 1 in 2,000,000Hepatitis C 1 in 2,000,000Hepatitis B 1 in 175,000Hepatitis A RareHTLV I/II 1 in 3,000,000Bacteria 1/3,000 (for platelets)
Malaria, T Cruzi, Babesia, Yersinia, Syphilis, Lyme, CJD, West Nile Virus…??
Post Transfusion HCV
Percent Number
Incidence 5-10 150-300,000Chronic 50 75-150,000Cirrhosis 20 15-30,000
Neonatal Post Transfusion CMV
Incidence:25% of seronegative infantsreceiving >50ml CMVseropositive blood
Severity 50% severe or lethal manifestations
Neonatal Transfusion CMV Prevention by Filtering Blood
Seroconvert/Total
Filtered PRBC: 0/30
Unfiltered PRBC: 9/42
Gilbert, L1:98:228, 1989
Prevention of Post Transfusion Infection
Don’t Transfuse Minimize Transfusion Limited Donors (dedicated units) Autologous Transfusions Erythropoetin Donor Screening: HIV Ab, HIV NAT, HCV Ab,
HCV NAT, HBV Ag, Ab, HBc Ab, VDRL, West Nile NAT, HTLVI/II Ab, CMV Ab, Bacterial Culture (Platelets)
Strategies to Decrease Operative RBC Transfusion
HemostasisHemodilutionCell salvage
DDAVPAutologous Transfusion
Erythropoetin
Neutropenia: infection risk
0
10
20
30
40
50
60
0 1 2 3 4 5
PMNs (/microL)
% p
ati
en
t d
ay
s w
ith
in
fec
tio
n
100 100-500 500-1000 1000
Relapse
Remission
Bodey. Ann Int Med 64:328, 1966.
WBC Indications 2004
PMN:Newborn SepsisCongenital/Acquired
NeutropeniaPMN DysfunctionRefractory Gram Negative
Sepsis Ly: Disseminated Varicella-Zoster
WBC transfusion:Logistics
Donors Receive G-CSF +/- Decadron 2-3 Hour Cytapheresis 1010 Cells by Standards Donors pretested for ID markers Cells decay rapidly: limited value at
> 6 hours post-collection Quantitative impact limited
Fresh Frozen Plasma
200-250 ml of plasma containing all clotting factors, AT III, Protein C & S.
Compatibility Important Can Give: A plasma to A or O patient
B plasma to B or O patientO plasma to O patientAB plasma to anyone
Indications: FFP
Replacement of Coagulation Factors Abnormal Bleeding with coagulopathy
Multiple factor deficiency: Liver disease DIC Reversal of Warfarin Dilutional
Isolated factor deficiency-no concentrate Factor XI, XIII
Replacement of regulatory proteins TTP, Hereditary angioedema
Not indicated for: volume expansion, reversal of Heparin, correction of INR < 1.5
Guidelines: FFP Use
Usual dosing: Adult 10ml/Kg Peds 10-15ml/Kg
15-20% rise in factor levels Usually does not correct laboratory
coagulation status to “normal”
Cryoprecipitate
10-15 ml per unit (bag) Fibrinogen 250 mg Factor VIII80-120 units Von Willebrand Factor 40-70% of FFP Factor XIII 20-30% of FFP Fibronectin 20-40 mg
Cryoprecipitate: Dosing
1-2 Units / 10 Kg Expect 60-100 mg/dl rise in fibrinogen Goal: Fibrinogen 70-100 mg/dl
Platelets: Risk of Spontaneous Hemorrhage
Count Site > 40,000 Minimal20-40,000 GI Mucosa 5-20 Skin, Mucus Membranes < 5 CNS, Lung
0
10
20
30
40
0 50 100 150 200 250 300
Platelets (/microL)
Ble
edin
g t
ime
(min
)
ITP
AA
WAS
ASA
Uremia
vWD
Harker. NEJM 287:155, 1972.
Prophylactic Platelet TX Guidelines
Platelet Count/μl Recommendation
0-5,000 Always 5-10,000 If Febrile of Minor Bleeding 11-20,000 If coagulopathy or minor
procedure >20,000 If Major Bleed or invasive
procedure
Transfused Platelets/Survival 6 units = 1 single donor unit (SDP);
available as ¼, ½ and full SDP Dose: child 1 unit/5-6 kg
adult 1 unit/8-10 kg Lifespan: 7-10 Days Native
2-3 Days Transfused Factors shortening Lifespan:
Fever, Sepsis HLA, Platelet Specific Abs DIC Product Age?
TRAP TrialEffect of Leukodepletion on Alloimmunization
No Rxpooled
FilterPooled
UV-BPooled
FilterSDP
Number 131 137 130 132
LCYTX-AB 45% 18% 21% 17%
LYCTX-ABrefractory
13% 3% 5% 4%
When in Doubt: Call the Transfusion Service!
266-2119
From ABP Certifying Exam Content Outline
2. Transfusion and collection of blood Understand the risk of transmitting infectious
diseases during blood transfusion(s) Recognize that erythrocyte transfusions may be
associated with hemolytic, febrile, and urticarial reactions
Understand the role of erythrocyte transfusions in the management of anemia
Credits
Bruce Camitta MDM W Lankiewicz MD