1

BLOOD TRANSFUSSION

PEDIATRIC HEMATO-ONCOLOGY DIVISION MEDICAL FACULTY

SUMATERA UTARA UNIVERSITY

2

• BLOOD: - THE BIGGEST ORGAN (GIGANTIC ORGAN)- BIOLOGICAL MULTIANTIGENIC MATERIAL- CIRCULATING IN CARDIOVASCULER SYSTEM- CONSISTS OF :

1. CORPUSCULAR COMPONENT :- RED BLOOD CELLS LIVING MATERIAL- WHITE BLOOD CELLS MULTI ANTIGENIC- PLATELETS

2. NON CORPUSCULAR COMPONENT:- PLASMA : FLUID, ELECTROLYTE, PROTEIN

(ALBUMIN, TRANSFERIN, 1 - GLOBULIN, 2- GLOBULIN, - GLOBULIN, IMUNOGLOBULIN, CLOTTING FACTORS )

3

• BLOOD TRANSFUSSION:

BLOOD TRANSFERING PROCESS FROM DONOR TO RECIPIENT ORGAN TRANSPLANTATION

CONSIDER OF:

- BENEFIT AND RISK ASPECT

- IMMUNOHEMATOLOGY OF TRANSFUSSION

- INFORMED CONSENT OBTAINED TO EVERY NON EMERGENT TRANSFUSION

• GAVE BLOOD SAVE LIFE• GLOBAL BLOOD SAFETY INITIATIVE WHO 1989: ANY

TRANSFUSION WHICH IS NOT INDICATED IS CONTRAINDICATED

4

• PRINCIPLE– EVERY BLOOD TRANSFUSSION CONSISTS OF

MINIMAL ANTIGEN VARIATION AND OPTIMAL DOSES BLOOD COMPONENTS TRANSFUSSION MORE

RATIONAL THAN WHOLE BLOOD

• THE GOAL OF TRANSFUSSION ACHIEVED IF :* GOOD MANUFACTURING PRACTICE:

DONOR SELECTION, RECORDED, BLOOD SAMPLING, STORED, COMPONENT PROCESSING INCLUDE QUALITY CONTAINT* GOOD HOSPITAL PRACTICE:

INDICATION , REQUESTED VOLUME, CARED, EVALUATE PATIENT BEFORE AND AFTER TRANSFUSSION

5

PRETRANSFUSSION TESTS

COOMBS TESTBLOOD GROUP

BLOOD TUBE CLEAR LABELS

6

• PROBLEMS BLOOD TRANSFUSSION:1. INDICATIONS2. CONTRAINDICATIONS3. DOSES4. BENEFIT5. SIDE EFFECTS

BLOOD COMPONENTS TRANSFUSSION :- FIRST IN 1960- FROM WHOLE BLOOD → SEPARATES: RED BLOOD CELLS, GRANULOCYTE, PLATELETS,

FRESH FROZEN PLASMA, CRYOPRECIPITATE, ALBUMIN

7

1. RED BLOOD CELL COMPONENTS- 640 Ag, CONSISTS OF 20 BLOOD GROUPS SYSTEM: ABO, CDE, MNS, P, LEWIS, KELL, DUFFY,

LUTHERAN, KIDD, DIEGO.- BLOOD GROUP SYSTEM : * ABO: BY LANDSTEINER (1901) A,B,AB,O

BASED ON SURFACE Ag OF ERYTROCYTE

GROUP GENOTYPE NATURAL Ab (SERUM) A A/A or A/O ANTI- B B B/B or B/O ANTI- A AB A/B - O O/O ANTI A & ANTI B

8

1. A. FRESH WHOLE BLOOD - DOSE: 6 x BW (kg) x Hb - USE <1 DAY

SEVERE BLEEDING CAUSED BY TRAUMA OR SURGERY

* RHESUS : - LANDSTEINER & WIENER (1940)- BASED ON: Ag D ON ERITROCYTE SURFACE - INDONESIA : 100% Rh +- SERUM: NATURAL ANTIBODY (-) FROM BIRTH

RED BLOOD CELLS COMPONENTS

9

1.B. PACKED RED CELL (PRC) - DOSE: 4 x BW (kg) x Hb

(Ht 3/2 OF WHOLE BLOOD (Ht 70-80%) - CHILD & INFANT: 10 ml/kgBB/DAY - 1 UNIT PRC : 225-350 ml WITH Ht 55-65%

DOSES OF PRCHb (g/dL) PRC EVERY 3-4 HOURS

7-10 10 ml/kgBB5-7 5 ml/kgBB

<5, HEART FAILURE(-) 3ml/kgBB<5, HEART FAILURE() 3ml/kgBB + FUROSEMIDE<5, HEART FAILURE(+) EXCHANGE TRANSFUSSION

10

1C. PACKED RED CELLS LOW PLATELETS

1D. WASHED RED CELLS– > 85% LEUCOCYTE ARE REMOVED, AS WELL AS

99% OF THE ORIGINAL PLASMA

1E. FROZEN WASHED PACKED RED CELLS

1F. IRRADIATION RED BLOOD CELLS

11

INDICATIONS FOR RED BLOOD CELLTRANSFUSION

PACKED RED BLOOD CELLS

1. INFANT LESS THAN 4 MONTHS OLD– Hb < 13 g/dl IN NEONATES < 24 HOURS– Hb < 13 g/dl AND SEVERE PULMONARY DISEASE,

CYANOTIC HEART DISEASE OR HEART FAILURE– ACUTE BLOOD LOSS > 10% OF TOTAL BLOOD VOL– PHLEBOTOMY LOSSES OF >5-10% OF TOTAL BLOOD

VOL– Hb < 8 g/dl IN STABLE NEWBORN

12

PACKED RED BLOOD CELLS

2. PATIENTS 4 MONTHS OF AGE– SIGNIFICANT PREOPERATIVE OR POST OPERATIVE

ANEMIA– ACUTE BLOOD LOSS WITH HYPOVOLEMIA

UNRESPONSIVE TO CRYSTALLOID OR COLLOID

3. CHRONIC CONGENITAL OR ACQUIRED ANEMIA UNRESPONSE TO MEDICAL THERAPY AND Hb < 8 g/dl AND SYMPTOM OF ANEMIA

4. CHRONIC TRANSFUSION THALASSEMIA, SICKLE CELL DISEASE

13

WHOLE BLOOD (SELDOM USED)

1. MASSIVE TRANSFUSION OR ACUTE BLOOD LOSS , USUALLY ASSOCIATED WITH TRAUMA

2. CARDIOVASCULAR BY PASS SURGERY

3. EXTRACORPOREAL MEMBRANE OXYGENATION

14

GUIDELINES PRC TRANSFUSION FOR ONCOLOGY PATIENT

1. STABLE, ASYMPTOMATIC CHILD WITH Hb < 7g/dl AND LOW RETICULOCYTE COUNT

2. SYMPTOMATIC ANEMIA AND Hb < 10 g/dl

3. Hb < 8 g/dl IN PATIENT BEGINNING INDUCTION OR INTENSIFICATION COURSE OF CHEMOTHERAPY

4. ACUTE BLOOD LOSS > 10% OF TOTAL BLOOD VOL, OR ONGOING LOSS AND Hb < 8 g/dl IN A CHILD UNABLE TO PRODUCE RED CELLS

5. Hb < 7g/DL PRIOR TO GENERAL ANESTHESIA

6. RECEIVING RADIATION THERAPY Hb > 10 g/dl

15

2. PLATELETS TRANSFUSSIONINDICATIONS1. PREMATURE OR SICK INFANTS

- STABLE INFANT WITH PLATELET COUNT < 50x109 /L

- DISTRESSED INFANT WITH PLATELET COUNT < 100x109 /L

2. CHILDREN- PLATELET COUNT < 10x109 /L , IF

FEBRILE, INFECTED OR BLEEDING- PLATELET COUNT < 50x109 /L WITH

ANTICIPATED INVASIVE PROCEDURE:- LUMBAR PUNCTURE- QUALITATIVE PLATELET DEFECT- SURGERY

16

3. ONCOLOGY– NON BLEEDING PATIENT WITH PLATELET COUNT <

10x109 /L– INDUCTION CHEMOTHERAPY– BRAIN TUMORS PLATELET COUNT MAINTAIN AT >

30x109 /L– LUMBAR PUNCTURE WITH PLATELET COUNT < 30-

50x109 /L– BLEEDING PATIENT WITH NORMAL COAGULATION

STUDIES, PLATELET COUNT < 50x109 /L– SURGICAL PROCEDURE WITH PLATELET COUNT <

100x109 /L– INTRAMUSCULAR INJECTION , PLATELET COUNT <

20x109 /L

17

DOSAGE• 1 UNIT PLATELET /10kg INCREASED PLATELET 40-

50X109/L• PHERESIS PLATELET HARVESTED FROM SINGLE

DONOR , CONTAIN > 30x109/L PLATELET, EQUAL TO 6-8 UNITS OF RANDOM PLATELET

• THE VOLUME IS 250-300 ml

18

- FROM LEUCOPHERESIS, FILTER NYLON- ABO / Rh COMPATIBLE, HLA MATCHED- GAVE AS SOON AS POSSIBLE BECAUSE

CIRCULATING HALF LIFE IS 6-10 HOURS , SLOW INFUSSION IN 2-4 HOURS

- 1 UNIT : 1,0x1010 CELLS, IN ADDITION TO OTHER LEUCOCYTES, PLATELETS, AND 20-50 ml RBC

- RESUSPENDED IN APPROXIMATELY 200-300 ml OF ANTICOAGULATED PLASMA

3. GRANULOCYTE TRANSFUSSION

19

INDICATIONS

1. NEONATAL BACTERIAL SEPSIS

2. BACTERIAL OR FUNGAL SEPSIS, CULTURE POSITIVE, UNRESPONSIVE TO ANTIMICROBIAL THERAPY, ANC< 100/μL

DOSAGE• 1 UNIT GRANULOCYTE ADMINISTEREDAT 150

ml/m2/HOUR• UNITS ARE GIVEN DAILY UNTIL ANC >100/μL AND THE

INFECTION IS RESOLVING

20

FVIII CONSENTRATEFIBRINOGEN

VWFF XIII

4. PLASMA AND PLASMA PRODUCTSWHOLE BLOOD PLASMAPHERESIS

FRESH PLASMA

FRESH FROZEN PLASMA

CRYOSUPERNATAN

ALBUMIN

CRYOPRECIPITATE

21

TYPE & INDICATION OF PLASMA PRODUCTS

1. FRESH FROZEN PLASMA

- DOSES: 15-20 ml/kgBW FFP IN 1 HOUR

- CONSISTS OF :- FACTORS II,V,VII,VIII,IX,X,XI- PROTEIN C, S AND ANTITHROMBIN III- ELECTROLYTES, ALBUMIN, IMMUNOGLOBULIN,

PROTEIN COMPLEMENT

- 1 BAG FFP : 200 UNITS F.VIII

- SHOULD NOT BE USED IF COAGULOPATHY CAN BE

CORRECTED WITH SPECIFIC TREATMENT : VIT K,

CRYOPRECIPITATE, FACTOR CONCENTRATE

22

2. CRYOPRECIPITATE•CONSISTS OF : FVIII, F.XIII, FIBRINOGEN, F.VON WILLEBRAND•DOSAGE : 1 U/ 6 kg BW

3. ALBUMIN

- HIPOPROTEINEMIA- EXCHANGE PLASMA PROTEIN FLAME BURN- EXCHANGE PLASMA VOLUME

INDICATION

23

INDICATIONSFRESH FROZEN PLASMA

1. BLEEDING/INVASIVE PROCEDURE WITH CLOTTING FACTOR DEFICIENCY

2. TREATMENT OF ANTITHROMBIN III, PROTEIN C&S DEFICIENCY, OR F.XI DEFICIENCY (HEMOPHILIA C)

3. BLEEDING DURING MASSIVE TRANSFUSION

CRYOPRECIPITATE

1. BLEEDING/INVASIVE PROCEDURE WITH F.VIII, F.XIII DEFICIENCY, VON WILLEBRAND DISEASE, HYPOFIBRINOGENEMIA

2. SUPPORTIVE TREATMENT OF DIC

24

TRANSFUSSION REACTION

1. ALLERGIC REACTION– URTICARIA, WHEEZING, ANGIOEDEMATOUS REACTIONS– ANAPHYLACTOID REACTION : DYSPNEA,

PULMONARY/LARYNGEAL EDEMA, BRONCHASPASM– TRANSFUSION RELATED ACUTE LUNG INJURY– TREATMENT : STOP TRANSFUSION, ANTIHISTAMINE,

CORTICOSTEROID, EPINEPHRINE.

2. FEBRILE NON HEMOLYTIC REACTIONS– FEVER, CHILLS DURING TRANSFUSION– TREATMENT : STOP TRANSFUSION, EVALUATE VITAL SIGN AND

BLOOD PRODUCT, TREATING THE SYMPTOMS.

25

3. ACUTE HEMOLYTIC TRANSFUSION REACTION– FEVER, CHILLS, URTICARIA, DYSPNEA, CHEST PAIN,

ABDOMINAL OR LOWER BACK PAIN, TACHYCARDIA, SHOCK– LAB: ANEMIA, DIC, HEMOGLOBINEMIA, HEMOGLOBINURIA,

POSITIVE COOMBS` TEST– TREATMENT : IMMEDIATE CESSATION OF TRANSFUSION,

ADMINISTRATION OF FLUID, STEROID,MANITOL, AND MAINTAIN CARDIOVASCULAR STABILITY AND URINE OUTPUT

4. DELAYED TRANSFUSION REACTION– SYMPTOMS OCCUR IN 2-14 DAYS AFTER TRANSFUSION– UNEXPLAINED FEVER, POSITIVE DIRECT COOMBS`TEST AND

ANEMIA

26

5. ALLOIMMUNIZATION

6. GRAFT VERSUS HOST DISEASE

7. MICROBIAL CONTAMINATION1. VIRUS: - HEPATITIS B,C,D,E AND A

- HIV - EBV- HTLV I / II - HERPES VIRUS- CMV - PARVO VIRUS

2. BACTERIA : - T. PALLIDUM - M. LEPRAE - BRUCELLA ABORTUS - S. TYPHOSA - RICKETTSIA RICKETSII

3. PARACYTES- P.VIVAX, MALARIAE, FALCIPARUM,OVALE-TRYPANOSOMA CRUZI -MICROFILARIAE-AFRICAN TRYPANOSOMIASIS -T. GONDII-BABESIA MICROTI -L. DONOVANI

27

1 DIPHENHYDRAMINE

USE : TREATING PRURITUS AND RASHDOSE : 12.5-50 MG IV OVER 10-20 MIN (1 MG/KG/DOSE, MAX 50 MG)

2 EPINEPHRINE(1:1000 AQUEOUS)(1 MG/ML)

USE : SEVERE INFECTIONS: BRONCHOSPASM, HYPOTENSION, SHOCKDOSE : 0,01 ML/KG SQ (SINGLE DOSE MAX 1 MG). REPEAT Q 15 MIN X 3-4 DOSES AS NEEDED

3 EPINEPHRINE(1:200 AQUEOUS)(1,5 MG/0,3 ML)

USE : FOLLOWING STABILIZATION WITH EPINEPHRINEDOSE : 0,005 ML/KG SQ (MAX SINGLE DOSE 0,15 ML). REPEAT Q 8-12 H PRN

DRUG USED IN TREATMENT OF NON HEMOLYTIC TRANSFUSION REACTION

28

4 FLUIDS FOR HYPOTENSIVE PATIENTS, A BOLUS 20 ML/KG OF NORMAL SALINE SHOULD BE ADMINISTERED SIMOULTANEOUSLY WITH EPINEPHRINE AND STEROIDS

5 NARCOTICS USE : SPECIFIC AND EFFECTIVE TREATMENT FOR RIGORSDOSE : 0,1 MG/KG MORPHINE IV (MAX DOSE 10 MG)

6 ACETAMINOPHEN USE : TO PREVENT OR REVERSE TEMPERATURE ELEVATIONS IN MILD TO MODERATE FEBRILE REACTIONSDOSE : 10-15 MG/KG PO (MAX DOSE 800 MG)

7 STEROIDS USE : IN MODERATE TO SEVERE REACTIONS : URTICARIA, FEVER, SHAKING, CHILLS, DIAPHORESIS, OR PALLORDOSE : 1-2 MG/KG OF METHYLPREDNISOLONE (OR EQUIVALENT DOSE OF DEXAMETHASONE/ HYDROCORTISONE) IV PUSH

29

PREVENTION1. BLOOD SCREENING:

HBsAg ANTI HIV 1/2SIFILIS ANTI HCV

2. BLOOD BAG IDENTITY A. RE-TEST ABO / Rh BLOOD GROUPB. LABEL ON BLOOD BAG AND EASY TO READ, CONSISTS OF :

- NO. BLOOD BAG -BLOOD GROUP- BLOOD TYPE/ COMPONENT -SCREENING

TEST- BLOOD VOL / COMPONENT- STORED TEMP. / EXPIRED DATE