SAMA EMERGENCY COURSEAssad University hospitalSatarday , February 26,

2012

Alexander Bogdanov- Blood Transfusion

Whole Blood• 450 ml of donated blood+50 ml of

anticoagulant• Significant RBC, Plasma, Protein, platelets,

Leukocytes, and stable coagulation factors.• Insignificant labile factors V, VIII,• After 24 h platelets and leukocytes loose

viability• Indicated in trauma hypovolemic and actively

bleeding patient• No other indications

Packed Red Blood Cells (PRBC)

• The most common type of transfusions

• 250-350 ml of Red blood cells• Indicated in chronic anemia• Indicated in active bleeding with and

without hypovolemia• Not indicated in platelets or

leukocytes replacement

Washed RBC• Washing RBC in saline • Removing immunoglobline IgA• Prevent Anaphylaxis and urticarial

reaction

Leukocytes-Reduced RBC• Removing 99.9 % of leukocytes

from PRBC• Special filters • Indications:• Prevent febrile non-hemolytic

reaction• Prevent alloimmunization• Prevent post transfusion purpura

Irradiated RBC• 2500 c Gray gamma irradiation• Prevent post transfusion GVHD• All immune suppressed individuals

should receive only irradiated blood products

• FFP, and cryoprecipitate need no irradiation

Random-Donor platelets• 50-70 ml volume• Indicated in bleeding patient with low

platelets• Indicated in non-bleeding patient with

platelets less than 10 000• Indicated in bleeding patient with platelets

function abnormality• Not indicated in none bleeding ITP patient• Contraindicated in TTP, some DIC

HLA matched platelets• Hemapheresis from HLA matched

individual donor• Refractoriness to platelets transfusion

• HLA alloimmunization• Fever, Sepsis• DIC • Hyperspleenisim• Bleeding

• Indicated only in HLA alloimmunization• Low platelets 1h and 24 h post RDP

transfusion indicates alloimmunization.

• Leukapheresis from single donor • A unit contain 10x 10 granulocytes• Should be infused immediately after

collection• Indicated in septic neonates, granulocytes

dysfunction, profound neutropenia and sepsis

• Granulocyte concentrates transfusion has conflicting trials results

Granulocyte Concentrates

Fresh Frozen Plasma FFP• Separating and freezing plasma

within 6 h of phlebotomy• 1ml FFP contain 1unit labile and

stable Coagulation factors• Indicated in factors deficiency

when no single factor is available• Indicated in liver dysfunction,

massive transfusion

Cryoprecipitate• 5-20 ml• 80U VIII, vWF,fibrinogen, some

XIII, fibronectin• Indicated in fibrinogen

replacement• Not indicated in hemophilia A• Not indicated in vW disease

TRANSFUSION is BAD

• IMMUNE-MEDIATED REACTIONS• Acute Hemolytic Transfusion Reactions• Delayed Hemolytic and Serologic

Transfusion React• Febrile Nonhemolytic Transfusion

Reaction• NONIMMUNOLOGIC REACTIONS• Fluid Overload • Electrolyte Toxicity • Iron Overload• INFECTIOUS COMPLICATIONS

INFECTIOUS COMPLICATIONS

• Hepatitis, A, B, C, D, G ………. • HIV, HTLV-I, HTLV-II, ………• CMV• EBV• Malaria, Syphlis, Trypanosoma,

Toxolplasmosis, Bebesiosis, Brucelosis.• Bacteria Gram +ve or Gram -ve

Acute Hemolytic Transfusion Reactions

• ABO Incompatible BloodABO Incompatible Blood• IgM, ANTI A, OR B Agglutinates IgM, ANTI A, OR B Agglutinates

transfused RBCtransfused RBC• Fever, chills, chest arm and flank pain, Fever, chills, chest arm and flank pain,

dyspnia, hemoglobinuria, oligouria, dyspnia, hemoglobinuria, oligouria, shock, and DICshock, and DIC

• +ve coombs test, and hemolysis lab+ve coombs test, and hemolysis lab• Treatment is suportiveTreatment is suportive

Delayed Hemolytic and Serologic Transfusion Reactions

• Primery or secondary immunization against RBC alloantibodies

• Kell, Duffy, Kidd, RH system antigens

• Rapid fall in Hg after transfusion• Most cases subclinical• Occasional fever chills, nausea,

hemoglobinurea

Febrile Nonhemolytic Transfusion Reaction

• Agglutinating, or cytotoxic antibodies against antigen on transfused granulocyte

• Common in multitransfused patient• Complement activation and cytokins release• Chills, fever, rigor, • Hemolytic transfusion reaction should be ruled

out• Leukocytes reducing filters in future blood

products

Allergic Reactions • Urticaria• Anaphylactic reaction• Alloimmunization

• To red cells antigens– Delayed hemolytic transfusions reaction

• To platelets antigens– Refractoriness– Neonatal thrombocytopenia– Post transfusion purpura P1-A

Graft-Versus-Host Disease

• Live T lymphocytes transfused to immune suppressed patient

• Allo-lymphocytes with different HLA recognize self HLA as foreign HLA

• Fever, elevated LFT’s, diarrhea, erythema

• Cytopenia, • No available therapy• Prevention by irradiation blood products

Post transfusion Purpura • Very serious side effect of transfusion • Most people are positive P1-A1 antigen• Negative patient may develop antigen

destroy all platelets• Develop in 5-10 days post transfusion• Plasmapheresis• Washed RBC for future transfusion

Transfusion-Related Acute Lung Injury

• Potent leukoagglutinins • Antibody-antigen leading to leak

syndrome in lung• Respond quickly to supportive

treatment

Emergency Transfusion• What products to use• From where are they to be obtained• To what degree are they to be tested• How will they be transported • How will they be stored• Triage is vital in mass casualty situations, ensuring

that scarce resources are used for those with the best chance of recovery.

• Patients survive with low hemoglobin levels for considerable periods,

• Speedy treatment of hypovolemia is imperative

Sudden increase the demand for blood

• May create a sudden massive influx of donors• Restricts or eliminates the ability to collect,

test, processor distribute blood• Restricts or prevent the use of the available

inventory of blood components (liquid and frozen)

• Requires immediate replacement or re-supply of blood from another region/country

Blood Volume Loss Of:

• 15 - 30 percent -- should be treated with crystalloids or colloids, not RBCs, in young, healthy patients;

• 30 - 40 percent -- requires rapid volume replacement, and RBC transfusion is probably necessary;

• >40 percent -- is life-threatening and volume replacement, including RBC transfusion, is required

Hemoglobin and Transfusion

• More than 10g/dL transfusion is rarely indicated.

• Hemoglobin 6-10 g/dL indications for transfusion should be based on the patient’s risk of inadequate oxygenation from ongoing bleeding and/or high-risk factors.

• Hemoglobin < 6 g/dL transfusion is almost always indicated.

Massive transfusion• Transfusion more than50 %of a patient's

blood volume in 12 to 24 hours• Hemostatic and metabolic complications • Selection of the appropriate amounts and

types of blood components to be administered

• Volume status• Tissue oxygenation• Management of bleeding and coagulation

abnormalities• Changes in ionized calcium, potassium, and

acid-base balance

ALTERNATIVES TO TRANSFUSION

• Autologous blood transfusions–Preoperative – Intraoperative–Postoperative blood salvage

• Usage of Growth factors–Erythropoietin–G-CSF, GM-CSF–Erythropoietin, IL-11

• Blood substitutes

BLOOD GROUP ANTIGENS AND ANTIBODIES

• The foundation of transfusion medicine • No mistake is excused• Compatibility test done on transfused RBC and recipient plasma• Compatibility test for RBC and whole blood• No compatibility test foe platelets, FFP , and cryoprecipitate• Compatibility test detects unexpected RBC alloantibodies • Cross match

BLOOD COMPONENTS

• Red blood cells• White blood cells• Platelets• Plasma • Different proteins, Coagulation

factors, Albumin

Case # 2• 60 Y F while taking blood Unit

developed 39 fever and rigor• Your next best step is • Immediate discontinuation of transfusion• NSAID or Paracetamol, • Solo-cortef and Phenergan• Call your senior resident• Ignore fever• Further testing

Case # 3• 16 Y O M with Bleeding ulcer, HG 4.5,

BP80/60, HR 140/m. Bright red blood per NG tube. Hx of multiple transfusions

• Blood group A +, all 10 U of PRBC were not compatible

• You do what of the following– Transfuse Non compatible blood– Cross match 10 more units– Call hematology– Wait until he cardiopulmonary arrest– Call surgery

Case # 4• 20 Y M came to ER with severe hemolytic

anemia G6PD• Hg 2 Gm, Decline any transfusion for religious

reason• Your best management

– Oxygen– Fluid– Erythropoietin– Transfusion after general anesthesia– Call hematology

How many Unit to transfuse

• No magic number• Indication • Diagnosis• Medical plan

ABO ANTIGENS AND ANTIBODIES

• The major blood groups of this system are A, B, AB, and O • The genes determine the A and B found on chromosome 9p

RH SYSTEM

• Second most important blood group system • On chromosome 1• 15 percent of people lack this antigen • Exposure of these Rh-ve people to Rh-ve cells, by either transfusion or

pregnancy, can result in the production of anti-D alloantibody.

OTHER BLOOD GROUP SYSTEMS AND ALLOANTIBODIES

• Other ABO, D, antigen on RBC• Kell, Duffy, Kidd blood group• Not normally present unless

immunized by transfusion or pregnancy

• Antibody screen• Washing RBC and better selection

PRETRANSFUSION TESTING

• Hepatitis B, C, B core• Antibodies for Human T

lymphocyte Virus I,II (HTLVI,II)• HIV,I, II