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David Harford
Hematology/Oncology
 History of Transfusions
‡ Blood transfused in humans since mid-
1600¶s
‡ 1828 ± First successful transfusion
‡ 1900 ± Landsteiner described ABO groups
‡ 1916 ± First use of blood storage
‡ 1939 ± Levine described the Rh factor
 Transfusion Overview
‡ Integral part of medical treatment
‡ Most often used in Hematology/Oncology, but
other specialties as well (surgery, ICU, etc)
‡ Objectives
± Blood components
± Indications for transfusion
± Safe delivery
± Complications
 Blood Components
‡ Prepared from Whole blood collection or apheresis
‡ Whole blood is separated by differential centrifugation
± Red Blood Cells (RBC¶s)
± Platelets
± Plasma
‡ Cryoprecipitate
‡ Others
‡ Others include Plasma proteins²IVIg, Coagulation
Factors, albumin, Anti-D, Growth Factors, Colloid volume
expanders
‡ Apheresis may also used to collect blood components
 Differential Centrifugation
First Centrifugation
Closed System

Whole Blood Satellite Bag Satellite Bag

Main Bag 1 2
First

Platelet-rich
RBC¶s Plasma
Differential Centrifugation
Second Centrifugation

RBC¶s Platelet-rich
Plasma
Second

Platelet Plasma
RBC¶s Concentrate
 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
 RBC Concentrate
‡ Storage
± 4° for up to 42 days, can be frozen
‡ Indications
± Many indications²ie 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
 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
 Plasma and FFP
‡ Contents²Coagulation Factors (1 unit/ml)
‡ Storage
± FFP--12 months at ±18 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%
 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
 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
 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 filters²
NEVER use filters with stem cell/bone marrow
infusions
‡ May reduce RBC¶s by 5-10%
‡ Does not prevent Graft Verses Host Disease
(GVHD)
 RBC Transfusions
Preparations
‡ 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
 RBC Transfusions
Administration
‡ 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 use²routinely leukodepleted
± Monitoring²VS q 15 minutes, clinical status
± Do NOT mix with medications
‡ Complications
± Rapid infusion may result in Pulmonary edema
± Transfusion Reaction
 Platelet Transfusions
Preparations
‡ 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
 Platelet Transfusions
Administration
‡ Dose
± May be given as single units or as apheresis units
± Usual dose is approx 4 units/m2²in 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
‡ Complications²Transfusion Reaction
 Transfusion Complications
‡ Acute Transfusion Reactions (ATR¶s)
‡ Chronic Transfusion Reactions
‡ Transfusion related infections
 Acute Transfusion Reactions
‡ Hemolytic Reactions (AHTR)
‡ Febrile Reactions (FNHTR)
‡ Allergic Reactions
‡ TRALI
‡ Coagulopathy with Massive transfusions
‡ Bacteremia
Frequency of Transfusion Reactions
Adverse Effect Frequency Comments

Acute Hemolytic Rxn 1 in 25,000 Red cells only

Anaphylactic hypotensive 1 in 150,000 Including IgA

Febrile Nonhemolytic 1 in 200 Common

Allergic 1 in 1,000 Common

Delayed Hemolytic 1 in 2,500 Red cells only

RBC alloimmunization 1 in 100 Red cells only

WBC/Plt 1 in 10 WBC and Plt only

alloimmunization
 Acute Hemolytic Transfusion
Reactions (AHTR)
‡ Occurs when incompatible RBC¶s are transfused into a
recipient who has pre-formed antibodies (usually ABO or
Rh)
‡ Antibodies activate the complement system, causing
intravascular hemolysis
‡ Symptoms occur within minutes of starting the transfusion
‡ This hemolytic reaction can occur with as little as 1-2 cc of
RBC¶s
‡ Labeling error is most common problem
‡ 




 Symptoms of AHTR
‡ High fever/chills
‡ Hypotension
‡ Back/abdominal pain
‡ Oliguria
‡ Dyspnea
‡ Dark urine
‡ Pallor
 What to do?
If an AHTR occurs
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‡ Maintain IV access and run IVF (NS or LR)
‡ Monitor and maintain BP/pulse
‡ Give diuretic
‡ Obtain blood and urine for transfusion reaction
workup
‡ Send remaining blood back to Blood Bank
 Blood Bank Work-up of AHTR
‡ Check paperwork to assure no errors
‡ Check plasma for hemoglobin
‡ DAT
‡ Repeat crossmatch
‡ Repeat Blood group typing
‡ Blood culture
 Labs found with AHTR
‡ Hemoglobinemia
‡ Hemoglobinuria
‡ Positive DAT
‡ Hyperbilirubinemia
‡ Abnormal DIC panel
 Monitoring in AHTR
‡ Monitor patient clinical status and vital
signs
‡ Monitor renal status (BUN, creatinine)
‡ Monitor coagulation status (DIC panel±
PT/PTT, fibrinogen, D-dimer/FDP, Plt,
Antithrombin-III)
‡ Monitor for signs of hemolysis (LDH, bili,
haptoglobin)
 Febrile Nonhemolytic Transfusion
Reactions (FNHTR)
‡ Definition--Rise in patient temperature >1°C
(associated with transfusion without other fever
precipitating factors)
‡ Occurs with approx 1% of PRBC transfusions and
approx 20% of Plt transfusions
‡ FNHTR caused by alloantibodies directed against
HLA antigens
‡ Need to evaluate for AHTR and infection
 What to do?
If an FNHTR occurs
‡ STOP TRANSFUSION
‡ Use of Antipyretics²responds to Tylenol
‡ Use of Corticosteroids for severe reactions
‡ Use of Narcotics for shaking chills
‡ Future considerations
± May prevent reaction with leukocyte filter
± Use single donor platelets
± Use fresh platelets
± Washed RBC¶s or platelets
 Washed Blood Products
‡ PRBC¶s or platelets washed with saline
‡ Removes all but traces of plasma (>98%)
‡ Indicated to prevent recurrent or severe reactions
‡ Washed RBC¶s must be used within 24 hours
‡ RBC dose may be decreased by 10-20% by
washing
‡ Does not prevent GVHD
 Allergic Nonhemolytic Transfusion
Reactions
‡ Etiology
± May be due to plasma proteins or blood
preservative/anticoagulant
± Best characterized with IgA given to an IgA deficient
patients with anti-IgA antibodies
‡ Presents with urticaria and wheezing
‡ Treatment
± Mild reactions²Can be continued after Benadryl
± Severe reactions²Must STOP transfusion and may
require steroids or epinephrine
‡ Prevention²Premedication (Antihistamines)
 TRALI
Transfusion Related Acute Lung Injury
‡ Clinical syndrome similar to ARDS
‡ Occurs 1-6 hours after receiving plasma-
containing blood products
‡ Caused by WBC antibodies present in
donor blood that result in pulmonary
leukostasis
‡ Treatment is supportive
‡ High mortality
 Massive Transfusions
‡ Coagulopathy may occur after transfusion
of massive amounts of blood
(trauma/surgery)
‡ Coagulopathy is caused by failure to replace
plasma
‡ See electrolyte abnormalities
± Due to citrate binding of Calcium
± Also due to breakdown of stored RBC¶s
 Bacterial Contamination
‡ More common and more severe with
platelet transfusion (platelets are stored at
room temperature)
‡ Organisms
± Platelets²Gram (+) organisms, ie Staph/Strep
± RBC¶s²Yersinia, enterobacter
‡ Risk increases as blood products age (use
fresh products for immunocompromised)
 Chronic Transfusion Reactions

‡ Alloimmunization
‡ Transfusion Associated Graft Verses Host
Disease (GVHD)
‡ Iron Overload
‡ Transfusion Transmitted Infection
 Alloimmunization
‡ Can occur with erythrocytes or platelets
‡ Erythrocytes
± Antigen disparity of minor antigens (Kell, Duffy, Kidd)
± Minor antigens D, K, E seen in Sickle patients
‡ Platelets
± Usually due to HLA antigens
± May reduce alloimmunization by leukoreduction (since
WBC¶s present the HLA antigens)
 Transfusion Associated GVHD
‡ Mainly seen in infants, BMT patients, SCID
‡ Etiology²Results from engraftment of
donor lymphocytes of an immunocompetent
donor into an immunocompromised host
‡ Symptoms²Diarrhea, skin rash,
pancytopenia
‡ Usually fatal²no treatment
‡ Prevention²Irradiation of donor cells
 Transfusion Associated
Infections
‡ Hepatitis C
‡ Hepatitis B
‡ HIV
‡ CMV
± CMV can be diminished by leukoreduction,
which is indicated for immunocompromised
patients
 Prevention
Leukocyte Gamma CMV Single Donor
Depletion Irradiation Negative Platelets
Filter (Apheresis)

Febrile Transfusion
Reactions X1 X
Alloimmunization
X X
CMV
?2 X
Transfusion Related
GVHD X
1 In PRBC transfusion
2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood
 Summary
‡ Blood Components
± Indications
± Considerations
‡ Preparation and Administration of blood
products
‡ Acute and chronic transfusion reactions
 Transfusion Reaction Summary
‡ AHTR can be fatal
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‡ Monitor for symptoms and complete evaluation
‡ FNHTR is a diagnosis of exclusion
‡ TRALI (ARDS-like reaction)
‡ Chronic Transfusion reactions
‡ Prevention methods ± using filters, irradiation and
premedication