Blood Products

BLOOD TRANSFUSIONBLOOD TRANSFUSION

Suprhamanyam EvaliSuprhamanyam Evali

QUIZQUIZ What is your blood What is your blood

group? group? How How common is it in this common is it in this room?room? is it the same is it the same as the world population?as the world population?

RECESSIVE but most common??

ANSWER: it is the ancestral form. The A and B mutations appeared in the last 20,000 years and haven't spread through the population yet.

TOPICSTOPICS

Blood ComponentsBlood Components Pre-transfusion TestingPre-transfusion Testing Transfusion ReactionsTransfusion Reactions

1665 — 11665 — 1stst Documented DocumentedAnimal-to-Animal Transfusion Animal-to-Animal Transfusion

Dog-to-dog Dog-to-dog transfusion transfusion by Richard by Richard Lower.Lower.

From Petz and Swisher’s Clinical Practice of Transfusion Medicine, 2nd ed., 1989.

1667—11667—1stst Documented DocumentedAnimal-to-Human TransfusionAnimal-to-Human Transfusion

Jean Baptiste Jean Baptiste Denis infuses Denis infuses 15-year-old 15-year-old boy with boy with lamb’s blood.lamb’s blood.

From Zmijewski’s Immunohematology.

1818—11818—1stst Documented DocumentedHuman-to-Human TransfusionHuman-to-Human Transfusion

Following a 150-year Following a 150-year transfusion hiatus, transfusion hiatus, James Blundell James Blundell transfuses patient with transfuses patient with blood from a human blood from a human donor. donor.


1800’s—All Manner of Blood 1800’s—All Manner of Blood Collection Devices UtilizedCollection Devices Utilized

(You think present-(You think present-day donor centers day donor centers sometimes face sometimes face challenges in challenges in recruiting repeat recruiting repeat blood donors?)blood donors?)


1900—1900—ABH Blood Group System ID’dABH Blood Group System ID’d

Karl Landsteiner Karl Landsteiner discovers ABH system discovers ABH system when he types when he types individuals as (what we individuals as (what we now call) group A, group now call) group A, group B, and group O. In 1902, B, and group O. In 1902, his proteges identify a his proteges identify a group AB individual for group AB individual for the first time.the first time.

From Transfusion, Vol. 1, p. 2 (1961)

The Discovery of Many OtherThe Discovery of Many OtherRed Cell Antigens FollowedRed Cell Antigens Followed

Rh (C, c, D, E, e, …)Rh (C, c, D, E, e, …) Kell (K, k, …)Kell (K, k, …) Kidd (JkKidd (Jkaa, Jk, Jkbb, …), …) Duffy (FyDuffy (Fyaa, Fy, Fybb, …), …) MNSs, … MNSs, … Lewis (LeLewis (Leaa, Le, Lebb)) … … … … … …

How We Make Blood ComponentsHow We Make Blood ComponentsCollection ProcessCollection Process(1) (1) Via Whole Blood DonationVia Whole Blood Donation: : Whole blood is collected from Whole blood is collected from healthy blood donors into sterile healthy blood donors into sterile blood bags that contain blood bags that contain anticoagulant-preservative.anticoagulant-preservative.

(2) (2) Via ApheresisVia Apheresis: Machines with : Machines with internal centrifuges separate a donor’s internal centrifuges separate a donor’s blood into individual components (e.g., blood into individual components (e.g., platelets, plasma, RBCs, etc.). The platelets, plasma, RBCs, etc.). The desired components are retained, desired components are retained, while the remainder is returned to the while the remainder is returned to the donor.donor.

TAKE ALL

TAKE WHAT YOU WANT

Blood productsBlood products

Whole bloodWhole blood CellularCellular

PRBCsPRBCs PlateletsPlatelets

PlasmaPlasma FFPFFP CryoprecipitateCryoprecipitate Other proteinsOther proteins

Blood Component Preparation“A little goes a long way”

Slow centrifuge

Fast centrifuge

450ml

180-200ml

50-70ml

10-15ml

200-250ml

You may donate every 56 days

The plasma from your donation is replaced within about 24 hours. Red cells need about four to six weeks for complete replacement. That’s why at least eight weeks are required between whole blood donations

Blood component Blood component

Whole Blood Separation

Typical values of the density of blood plasma and blood cells are 1025 kg/m^3 and 1125 kg/m^3, respectively."

Differential CentrifugationDifferential CentrifugationFirst CentrifugationFirst Centrifugation

Whole Blood Main Bag

Satellite Bag 1

Satellite Bag 2

RBC’sPlatelet-rich Plasma

First

Closed System

Differential CentrifugationDifferential CentrifugationSecond CentrifugationSecond Centrifugation

Platelet-rich Plasma

RBC’s PlateletConcentrate

RBC’s

Plasma

Second

Collection of Blood ProductsCollection of Blood Products

Apheresis Apheresis (TAKE WHAT U WANT-RETURN WHAT U DON’T)(TAKE WHAT U WANT-RETURN WHAT U DON’T)

Plateletpheresis- may donate up to 24x/yearPlateletpheresis- may donate up to 24x/year Leukapheresis-granulocytes donor given Leukapheresis-granulocytes donor given

dexamethasone? G-CSF?dexamethasone? G-CSF? ErythrocytapheresisErythrocytapheresis may donate every 16 weeks may donate every 16 weeks PlasmapheresisPlasmapheresis Stem Cell collectionStem Cell collection


Cellular ComponentsCellular Components:: RRed blood cellsed blood cells

- - LeukocyteLeukocyte--reduced reduced RBCsRBCs p purifiedurified

- W- Washed ashed RBCsRBCs plasmal plasmaless RBCess RBC

- Irradiated RBCs- Irradiated RBCs smash the DNA of WBC to smash the DNA of WBC to prevent GVHDprevent GVHD

PlateletsPlatelets - - Whole blood derivedWhole blood derived platelets platelets

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


Acellular ComponentsAcellular Components::

FFresh-frozen plasma (FFP)resh-frozen plasma (FFP), Thawed plasma, Thawed plasma CryoprecipitateCryoprecipitate FFactor concentrates (VIII, IX)actor concentrates (VIII, IX) AlbuminAlbumin

Blood Component Manufacture from Whole Blood Component Manufacture from Whole BloodBlood

RBCsRBCs

Platelet-Rich Platelet-Rich PlasmaPlasma

+

or

Centrifuge

(higher g forces)

Freeze

Fresh Frozen Plasma (FFP)or

“Plasma Frozen with 24 hours”

Plasma

Platelets

+

• Leukoreduce• Possibly irradiate• Other

Blood Component Manufacture from Blood Component Manufacture from Whole BloodWhole Blood

FreshFrozenPlasma(FFP)

Cryo-Reduced Plasma

Cryoprecipitate

+•Thaw (4° C)

•Centrifuge

Using the “Leftovers” WiselyUsing the “Leftovers” Wisely

Plasma DerivativesPlasma Derivatives AlbuminAlbumin Factor VIIIFactor VIII Immune globulinImmune globulin etc. etc.

Sent for

further processing

Plasma

Plasma

(of any kind)

(of any kind)

Over 400 red cell antigens describedOver 400 red cell antigens described Each antigen is defined by a specific Each antigen is defined by a specific

antibody antibody Antigens are divided into blood group Antigens are divided into blood group

systems > 25 systemssystems > 25 systems

The most important blood group The most important blood group system system ABO!ABO!

IncompatibilitiesIncompatibilities

ABOABO RhRh Lewis (oligosaccharide)Lewis (oligosaccharide) KellKell DuffyDuffy KiddKidd MNSsUMNSsU I/I (carbohydrate)I/I (carbohydrate)

ABO System

The ABO system is defined by the presence of A, B., H (0) antigens (sugars) on surface of red cells

Determined by allelic genes A, B, O, and Hh

Genes code for specific glycosyltransferases that add sugars to oligosaccharide chains

H substance is the precursor on which A and B antigens are built

O gene is a silent allele which does not encode a functional enzyme - the structure of H substance is not altered

Precursor Substance

H antigen

A antigen B antigen

(Hh gene)(Se gene)

(B gene)(A gene)

ABO Antigen System

H antigen only = Blood group O

COMPATIBLECOMPATIBLE

Patient'sPatient'sABO ABO GroupGroup

AntigenAntigenon Red on Red CellsCells

Antibody Antibody in in SerumSerum

WholeWholeBloodBlood

Red Blood Red Blood CellsCells PlasmaPlasma

OO No A or BNo A or B Anti-A Anti-A Anti-BAnti-B OO OO

OOAABBABAB

AA AA Anti-BAnti-B AAAAOO

AAABAB

BB BB Anti-AAnti-A BBBBOO

BBABAB

ABAB A and BA and B NoneNone ABAB

ABABAABBOO

ABAB

RBC CompatibilityRBC Compatibility

Plasma CompatibilityPlasma Compatibility

The Rh or Rhesus blood system is the second most important The Rh or Rhesus blood system is the second most important system. system.

The major antigen in this system is The major antigen in this system is DD

Rh positive ( D+) 85%Rh positive ( D+) 85% Rh negative ( D-) 15%Rh negative ( D-) 15%

DD Ag is highly immunogenic Ag is highly immunogenic

Antibodies are "unexpected" and are immune - they result Antibodies are "unexpected" and are immune - they result from previous transfusion or pregnancy from previous transfusion or pregnancy

The Rhesus System

Rh factor blood grouping systemRh factor blood grouping system

Many people also have a so called Rh factor Many people also have a so called Rh factor on the red blood cell's surface. on the red blood cell's surface.

This is also an antigen and those who have it This is also an antigen and those who have it are called Rh+. are called Rh+.

Those who haven't are called Rh-.Those who haven't are called Rh-. A person with Rh- blood does not have Rh A person with Rh- blood does not have Rh

antibodies naturally in the blood plasma (as antibodies naturally in the blood plasma (as one can have A or B antibodies, for instance). one can have A or B antibodies, for instance).

Cont.Cont.

But a person with Rh- blood can But a person with Rh- blood can developdevelop Rh antibodies in the Rh antibodies in the blood plasma if he or she receives blood from a person with blood plasma if he or she receives blood from a person with Rh+ blood, whose Rh antigens can trigger the production of Rh+ blood, whose Rh antigens can trigger the production of Rh antibodies. Rh antibodies.

A person with Rh+ blood can receive blood from a person A person with Rh+ blood can receive blood from a person

with Rh- blood without any problems.with Rh- blood without any problems.

Rh COMPATIBILITY Rh COMPATIBILITY

Rh Positive PatientRh Positive Patient Rh Negative Patient Rh Negative Patient

Rh positive or Rh positive or Rh negative Components Rh negative Components Only Rh negative ComponentsOnly Rh negative Components

WHAT IS AN ANTIGLOBULIN TEST ?

The antiglobulin test is either "direct" or "indirect". The "direct antiglobulin test“or DAT is often called the “__________".

DIRECT ANTIGLOBULIN TEST

In a “direct” antiglobulin test (DAT), red cells are taken from the patient, extensively washed and then "directly" tested with anti IgG or anti complement. Agglutination indicates a positive test.

A DAT evaluates whether a patient’s red cells are coated in vivo with IgG or complement.

.. Direct Antiglobulin Test

USE OF THE DAT:USE OF THE DAT: Diagnosis of:Diagnosis of:

Haemolytic Disease of the Newborn (HDN)Haemolytic Disease of the Newborn (HDN)

Autoimmune Haemolytic Anaemia (AIHA)Autoimmune Haemolytic Anaemia (AIHA)

Drug related HaemolysisDrug related Haemolysis

Haemolytic Transfusion ReactionHaemolytic Transfusion Reaction

INDIRECT ANTIGLOBULIN TEST

Detects in vitro sensitization

Plasma added to “screening” red cells

If antibodies to red cell antigens are present, the antibodies will coat the red cells

Anti IgG added and agglutination will occur

Plasma with antibodies and reagent red cells

Sensitization Anti IgG

USE OF THE IAT:USE OF THE IAT:

Detection of unexpected Detection of unexpected antibodies antibodies

Phenotyping or detection of red Phenotyping or detection of red cell antigenscell antigens

CrossmatchingCrossmatching

conclusionconclusion

HOW TO FIGURE IT OUTHOW TO FIGURE IT OUT

RECOMMENDATIONRECOMMENDATION

RH COMMENTSRH COMMENTS

COMPATIBLECOMPATIBLE

Patient'sPatient'sABO ABO GroupGroup

AntigenAntigenon Red on Red CellsCells

Antibody Antibody in in SerumSerum

WholeWholeBloodBlood

Red Blood Red Blood CellsCells PlasmaPlasma

OO No A or BNo A or B Anti-A Anti-A Anti-BAnti-B OO OO

OOAABBABAB

AA AA Anti-BAnti-B AAAAOO

AAABAB

BB BB Anti-AAnti-A BBBBOO

BBABAB

ABAB A and BA and B NoneNone ABAB

ABABAABBOO

ABAB

Pre-Transfusion TestingPre-Transfusion Testing

ABO/Rh type – 5 minutesABO/Rh type – 5 minutes Antibody screen – 25 minutesAntibody screen – 25 minutes Antibody identification – 1 hour or much moreAntibody identification – 1 hour or much more

TestingTesting

ABOABO RhRh RBC Antibody ScreenRBC Antibody Screen Infectious DiseasesInfectious Diseases

SyphilisSyphilis HBsAgHBsAg Anti-HIV-1/2Anti-HIV-1/2 Anti-HBcAnti-HBc

TestingTesting Infectious Diseases (cont.)Infectious Diseases (cont.)

Anti-HTLV-I/IIAnti-HTLV-I/II Anti-HCVAnti-HCV HIV Nucleic acid testing (NAT)HIV Nucleic acid testing (NAT) HBV NATHBV NAT HCV NATHCV NAT WNV NATWNV NAT T. cruzi T. cruzi antibody (Chagas’ Disease)antibody (Chagas’ Disease) (On some units) Anti-CMV(On some units) Anti-CMV Future ??? Parvovirus B19, malaria, etc.Future ??? Parvovirus B19, malaria, etc.

• HIV:HIV: 1 in 2,135,000 units 1 in 2,135,000 units• HBV:HBV: 1 in 205,000-to-488,000 units 1 in 205,000-to-488,000 units • HCV:HCV: 1 in 1,935,000 units 1 in 1,935,000 units• HTLV-I/II:HTLV-I/II: 1 in 514,000-2,993,000 units 1 in 514,000-2,993,000 units• CMV:CMV: << 1: 100 (when leukoreduced or CMV- << 1: 100 (when leukoreduced or CMV-

negative blood used)negative blood used)• WNV:WNV: ? (region-specific; very low) ? (region-specific; very low)• vCJD:vCJD: ? (risk very, very low—even in U.K.) ? (risk very, very low—even in U.K.)

“Infectious Risks of Blood Transfusion.” Blood Bulletin (America’s Blood Centers). December 2001.

Infectious Transfusion RisksInfectious Transfusion Risks

Time required for unitsTime required for units

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

Uncrossmatched type specific RBCs – ~ 15 Uncrossmatched type specific RBCs – ~ 15 minutesminutes

Crossmatched RBCs – 30-45 minutesCrossmatched RBCs – 30-45 minutes Full ABO type, screen & crossmatch – 1 hourFull ABO type, screen & crossmatch – 1 hour Patient with multiple alloantibodies – may take Patient with multiple alloantibodies – may take

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

Whole BloodWhole Blood

StorageStorage 44° for up to 35 days° for up to 35 days

IndicationsIndications Massive Blood Loss/Trauma/Exchange TransfusionMassive Blood Loss/Trauma/Exchange Transfusion

ConsiderationsConsiderations Use filter as platelets and coagulation factors will not be Use filter as platelets and coagulation factors will not be

active after 3-5 daysactive after 3-5 days Donor and recipient must be ABO identical Donor and recipient must be ABO identical

RBC ConcentrateRBC Concentrate

StorageStorage 44° for up to 42 days, can be frozen° for up to 42 days, can be frozen

IndicationsIndications Many indications—ie anemia, hypoxia, etc.Many indications—ie anemia, hypoxia, etc.

ConsiderationsConsiderations Recipient must not have antibodies to donor RBC’s (note: Recipient must not have antibodies to donor RBC’s (note:

patients can develop antibodies over time)patients can develop antibodies over time) Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl) Usually transfuse over 2-4 hours (slower for chronic Usually transfuse over 2-4 hours (slower for chronic

anemiaanemia

PlateletsPlatelets

StorageStorage Up to 5 days at 20-24Up to 5 days at 20-24°°

IndicationsIndications Thrombocytopenia, Plt <15,000Thrombocytopenia, Plt <15,000 Bleeding and Plt <50,000Bleeding and Plt <50,000 Invasive procedure and Plt <50,000Invasive procedure and Plt <50,000

ConsiderationsConsiderations Contain Leukocytes and cytokinesContain Leukocytes and cytokines 1 unit/10 kg of body weight increases Plt count by 50,0001 unit/10 kg of body weight increases Plt count by 50,000 Donor and Recipient must be ABO identicalDonor and Recipient must be ABO identical

Plasma and FFPPlasma and FFP Contents—Coagulation Factors (1 unit/ml)Contents—Coagulation Factors (1 unit/ml) StorageStorage

FFP--12 months at –18 degrees or colderFFP--12 months at –18 degrees or colder IndicationsIndications

Coagulation Factor deficiency, fibrinogen replacement, DIC, liver Coagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange transfusion, massive transfusiondisease, exchange transfusion, massive transfusion

ConsiderationsConsiderations Plasma should be recipient RBC ABO compatiblePlasma should be recipient RBC ABO compatible In children, should also be In children, should also be Rh compatibleRh compatible Account for time to thawAccount for time to thaw Usual dose is 20 cc/kg to raise coagulation factors approx 20%Usual dose is 20 cc/kg to raise coagulation factors approx 20%

CryoprecipitateCryoprecipitate DescriptionDescription

Precipitate formed/collected when FFP is thawed at 4Precipitate formed/collected when FFP is thawed at 4°° StorageStorage

After collection, refrozen and stored up to 1 year at -18After collection, refrozen and stored up to 1 year at -18°° IndicationIndication

Fibrinogen deficiency or dysfibrinogenemiaFibrinogen deficiency or dysfibrinogenemia vonWillebrands DiseasevonWillebrands Disease Factor VIII or XIII deficiencyFactor VIII or XIII deficiency DIC (not used alone)DIC (not used alone)

ConsiderationsConsiderations ABO compatible preferred (but not limiting)ABO compatible preferred (but not limiting) Usual dose is 1 unit/5-10 kg of recipient body weightUsual dose is 1 unit/5-10 kg of recipient body weight

Granulocyte TransfusionsGranulocyte Transfusions

Prepared at the time for immediate transfusion (no Prepared at the time for immediate transfusion (no storage available)storage available)

Indications – severe neutropenia assoc with infection Indications – severe neutropenia assoc with infection that has failed antibiotic therapy, that has failed antibiotic therapy, andand recovery of BM recovery of BM is expectedis expected

Donor is given G-CSF and steroids or HetastarchDonor is given G-CSF and steroids or Hetastarch ComplicationsComplications

Severe allergic reactionsSevere allergic reactions Can irradiate granulocytes for GVHD preventionCan irradiate granulocytes for GVHD prevention

Leukocyte Reduction FiltersLeukocyte Reduction Filters

Used for prevention of transfusion reactionsUsed for prevention of transfusion reactions Filter used with RBC’s, Platelets, FFP, Filter used with RBC’s, Platelets, FFP,

CryoprecipitateCryoprecipitate Other plasma proteins (albumin, colloid expanders, Other plasma proteins (albumin, colloid expanders,

factors, etc.) do not need filters—NEVER use filters factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusionswith stem cell/bone marrow infusions

May reduce RBC’s by 5-10%May reduce RBC’s by 5-10% Does not prevent Graft Verses Host Disease (GVHD)Does not prevent Graft Verses Host Disease (GVHD)

Transfusion ComplicationsTransfusion Complications

Acute Transfusion Reactions (ATR’s)Acute Transfusion Reactions (ATR’s) Chronic Transfusion ReactionsChronic Transfusion Reactions Transfusion related infectionsTransfusion related infections

Acute Transfusion ReactionsAcute Transfusion Reactions

Hemolytic Reactions (AHTR)Hemolytic Reactions (AHTR) Febrile Reactions (FNHTR)Febrile Reactions (FNHTR) Allergic ReactionsAllergic Reactions TRALITRALI Coagulopathy with Massive transfusionsCoagulopathy with Massive transfusions BacteremiaBacteremia Fluid overloadFluid overload

Frequency of Transfusion ReactionsFrequency of Transfusion Reactions

Adverse EffectAdverse Effect FrequencyFrequency CommentsComments

Acute Hemolytic RxnAcute Hemolytic Rxn 1 in 25,0001 in 25,000 Red cells onlyRed cells only

Anaphylactic hypotensiveAnaphylactic hypotensive 1 in 150,0001 in 150,000 Including IgAIncluding IgA

Febrile NonhemolyticFebrile Nonhemolytic 1 in 2001 in 200 CommonCommon

AllergicAllergic 1 in 1,0001 in 1,000 CommonCommon

Delayed HemolyticDelayed Hemolytic 1 in 2,5001 in 2,500 Red cells onlyRed cells only

RBC alloimmunizationRBC alloimmunization 1 in 1001 in 100 Red cells onlyRed cells only

WBC/Plt WBC/Plt alloimmunizationalloimmunization

1 in 101 in 10 WBC and Plt onlyWBC and Plt only

Acute Hemolytic Transfusion Acute Hemolytic Transfusion Reactions (AHTR)Reactions (AHTR)

Immune and non immune hemolysisImmune and non immune hemolysis Occurs when incompatible RBC’s are transfused into a Occurs when incompatible RBC’s are transfused into a

recipient who has pre-formed antibodies (usually ABO or Rh)recipient who has pre-formed antibodies (usually ABO or Rh) Antibodies activate the complement system, causing Antibodies activate the complement system, causing

intravascular hemolysisintravascular hemolysis Symptoms occur within minutes of starting the transfusionSymptoms occur within minutes of starting the transfusion This hemolytic reaction can occur with as little as 1-2 cc of This hemolytic reaction can occur with as little as 1-2 cc of

RBC’sRBC’s Labeling error is most common problemLabeling error is most common problem Can be fatalCan be fatal

Symptoms of AHTRSymptoms of AHTR

High fever/chillsHigh fever/chills HypotensionHypotension Back/abdominal painBack/abdominal pain OliguriaOliguria DyspneaDyspnea Dark urineDark urine PallorPallor

What to do?What to do?If an AHTR occursIf an AHTR occurs

STOP TRANSFUSIONSTOP TRANSFUSION ABC’sABC’s Maintain IV access and run IVF (NS or LR)Maintain IV access and run IVF (NS or LR) Monitor and maintain BP/pulseMonitor and maintain BP/pulse Obtain blood and urine for transfusion reaction Obtain blood and urine for transfusion reaction

workupworkup Send remaining blood back to Blood BankSend remaining blood back to Blood Bank

Labs found with AHTRLabs found with AHTR

HemoglobinemiaHemoglobinemia HemoglobinuriaHemoglobinuria Positive DATPositive DAT HyperbilirubinemiaHyperbilirubinemia Abnormal DIC panelAbnormal DIC panel

Monitoring in AHTRMonitoring in AHTR

Monitor patient clinical status and vital signsMonitor patient clinical status and vital signs Monitor renal status (BUN, creatinine)Monitor renal status (BUN, creatinine) Monitor coagulation status (DIC panel– Monitor coagulation status (DIC panel–

PT/PTT, fibrinogen, D-dimer/FDP, Plt, PT/PTT, fibrinogen, D-dimer/FDP, Plt, Antithrombin-III)Antithrombin-III)

Monitor for signs of hemolysis (LDH, bili, Monitor for signs of hemolysis (LDH, bili, haptoglobin)haptoglobin)

Febrile Nonhemolytic Transfusion Febrile Nonhemolytic Transfusion Reactions (FNHTR)Reactions (FNHTR)

Definition--Rise in patient temperature >1Definition--Rise in patient temperature >1°C °C (associated with transfusion without other fever (associated with transfusion without other fever precipitating factors)precipitating factors)

Occurs with approx 1% of PRBC transfusions and Occurs with approx 1% of PRBC transfusions and approx 20% of Plt transfusionsapprox 20% of Plt transfusions

FNHTR caused by alloantibodies directed against FNHTR caused by alloantibodies directed against HLA antigensHLA antigens

Need to evaluate for AHTR and infectionNeed to evaluate for AHTR and infection

What to do?What to do?If an FNHTR occursIf an FNHTR occurs

STOP TRANSFUSIONSTOP TRANSFUSION Use of AntipyreticsUse of Antipyretics Use of Corticosteroids for severe reactionsUse of Corticosteroids for severe reactions Use of Narcotics for shaking chillsUse of Narcotics for shaking chills Future considerationsFuture considerations

May prevent reaction with leukocyte filterMay prevent reaction with leukocyte filter Use single donor plateletsUse single donor platelets Use fresh plateletsUse fresh platelets Washed RBC’s or plateletsWashed RBC’s or platelets

Washed Blood ProductsWashed Blood Products

PRBC’s or platelets washed with salinePRBC’s or platelets washed with saline Removes all but traces of plasma (>98%)Removes all but traces of plasma (>98%) Indicated to prevent recurrent or severe reactionsIndicated to prevent recurrent or severe reactions Washed RBC’s must be used within 24 hoursWashed RBC’s must be used within 24 hours RBC dose may be decreased by 10-20% by washingRBC dose may be decreased by 10-20% by washing Does not prevent GVHDDoes not prevent GVHD

Allergic Nonhemolytic Transfusion Allergic Nonhemolytic Transfusion ReactionsReactions

EtiologyEtiology May be due to plasma proteins or blood May be due to plasma proteins or blood

preservative/anticoagulantpreservative/anticoagulant Best characterized with IgA given to an IgA deficient Best characterized with IgA given to an IgA deficient

patients with anti-IgA antibodies patients with anti-IgA antibodies Presents with urticaria and wheezingPresents with urticaria and wheezing TreatmentTreatment

Mild reactions—Can be continued after BenadrylMild reactions—Can be continued after Benadryl Severe reactions—Must STOP transfusion and may require Severe reactions—Must STOP transfusion and may require

steroids or epinephrinesteroids or epinephrine Prevention—Premedication (Antihistamines)Prevention—Premedication (Antihistamines)

TRALITRALITransfusion Related Acute Lung InjuryTransfusion Related Acute Lung Injury

Clinical syndrome similar to ARDSClinical syndrome similar to ARDS Occurs 1-6 hours after receiving plasma-containing Occurs 1-6 hours after receiving plasma-containing

blood productsblood products ANTIBODY HYPOTHESIS & NEUTROPHIL ANTIBODY HYPOTHESIS & NEUTROPHIL

PRIMING (magnet) HYPOTHESISPRIMING (magnet) HYPOTHESIS Caused by WBC antibodies present in donor blood Caused by WBC antibodies present in donor blood

that result in pulmonary leukostasisthat result in pulmonary leukostasispulmonary pulmonary edemaedema

Treatment is supportiveTreatment is supportive High mortalityHigh mortality

Massive TransfusionsMassive Transfusions

Coagulopathy may occur after transfusion of Coagulopathy may occur after transfusion of massive amounts of blood (trauma/surgery)massive amounts of blood (trauma/surgery)

Coagulopathy is caused by failure to replace Coagulopathy is caused by failure to replace plasmaplasma

See electrolyte abnormalitiesSee electrolyte abnormalities Due to citrate binding of CalciumDue to citrate binding of Calcium

Bacterial ContaminationBacterial Contamination

More common and more severe with platelet More common and more severe with platelet transfusion (platelets are stored at room transfusion (platelets are stored at room temperature)temperature)

OrganismsOrganisms Platelets—Gram (+) organisms, ie Staph/StrepPlatelets—Gram (+) organisms, ie Staph/Strep RBC’s—Yersinia, enterobacterRBC’s—Yersinia, enterobacter

Risk increases as blood products age (use fresh Risk increases as blood products age (use fresh products for immunocompromised)products for immunocompromised)

Chronic Transfusion ReactionsChronic Transfusion Reactions

AlloimmunizationAlloimmunization Transfusion Associated Graft Verses Host Transfusion Associated Graft Verses Host

Disease (GVHD)Disease (GVHD) Iron OverloadIron Overload Transfusion Transmitted InfectionTransfusion Transmitted Infection

AlloimmunizationAlloimmunization

Can occur with erythrocytes or plateletsCan occur with erythrocytes or platelets ErythrocytesErythrocytes

Antigen disparity of minor antigens (Kell, Duffy, Kidd)Antigen disparity of minor antigens (Kell, Duffy, Kidd) Minor antigens D, K, E seen in Sickle patientsMinor antigens D, K, E seen in Sickle patients

PlateletsPlatelets Usually due to HLA antigensUsually due to HLA antigens May reduce alloimmunization by leukoreduction (since May reduce alloimmunization by leukoreduction (since

WBC’s present the HLA antigens)WBC’s present the HLA antigens)

Transfusion Associated GVHDTransfusion Associated GVHD

Mainly seen in infantsMainly seen in infants Etiology—Results from engraftment of donor Etiology—Results from engraftment of donor

lymphocytes of an immunocompetent donor lymphocytes of an immunocompetent donor into an immunocompromised hostinto an immunocompromised host

Symptoms—Diarrhea, skin rash, pancytopeniaSymptoms—Diarrhea, skin rash, pancytopenia Usually fatal—no treatmentUsually fatal—no treatment Prevention—Irradiation of donor cellsPrevention—Irradiation of donor cells

Transfusion Associated Transfusion Associated InfectionsInfections

Hepatitis CHepatitis C Hepatitis BHepatitis B HIVHIV CMVCMV

CMV can be diminished by leukoreduction, which CMV can be diminished by leukoreduction, which is indicated for immunocompromised patientsis indicated for immunocompromised patients

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