BLOOD COMPONENTSBLOOD COMPONENTSTRANSFUSION INDICATIONS TRANSFUSION INDICATIONS

Dr. Meral SÖNMEZOĞLUDr. Meral SÖNMEZOĞLUYeditepe University HospitalYeditepe University Hospital

Transfusion CenterTransfusion Center

Differential CentrifugationFirst Centrifugation

Whole Blood Main Bag

Satellite Bag 1

Satellite Bag 2

RBC’sPlatelet-rich Plasma

First

Closed System

Differential CentrifugationSecond Centrifugation

Platelet-rich Plasma

RBC’s PlateletConcentrate

RBC’s

Plasma

Second

Whole Blood

Whole Blood Whole Blood (WB) (WB) is blood taken from a is blood taken from a suitable donor using a sterile andsuitable donor using a sterile and pyrogen free anticoagulant and pyrogen free anticoagulant and container. container.

WW B B is a sourceis a source material for component material for component preparation, which is its major use. preparation, which is its major use.

WBWB for transfusion is used without for transfusion is used without further processingfurther processing..

WWBB for transfusion should not contain for transfusion should not contain irregular antibodies ofirregular antibodies of clinical clinical significance.significance.

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

Red Cells is obtained by removal of a Red Cells is obtained by removal of a major part of the plasma frommajor part of the plasma from WB. WB.

Red Cells also contains the greater part of Red Cells also contains the greater part of the whole blood leucocytesthe whole blood leucocytes (about 2.5 to (about 2.5 to 3.0 × 109 cells) and a varying content of 3.0 × 109 cells) and a varying content of plateletsplatelets depending on the method of depending on the method of centrifugation.centrifugation.

For the preparation, plasma is removed from For the preparation, plasma is removed from Whole Blood afterWhole Blood after centrifugationcentrifugation

RBC Concentrate

Storage 4° for up to 42 days, can be frozen

Indications Many indications—ie 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

Function of RBCs

Oxygen Transport Delivery of oxygen from lungs to tissues

Oxygen transport is dependent on Hematocrit Cardiac output Oxygen extraction

Normovolemic Anemia

As hematocrit falls Blood viscosity decreases Cardiac output increases (Stroke volume,

pulse) Delivery of O2 O2 extraction Consumption of O2 remains constant

Limits of Compensation

At very low hemoglobin levels (approximately 4 g/dL)

O2 delivery does not meet demand

Anerobic metabolism lactic acidosis cardiac arrest

Indications for RBC transfusions

1940s Recommended that surgery patients have a

hemoglobin of 8 to 10 g/dL Led to a general rule of hemoglobin > 10 g/dL of

surgery patients1980s Development of invasive monitoring techniques

lead to a better understanding of oxygen delivery and consumption

Lower hemoglobin levels could be tolerated

Hemoglobin and Hematocrit Levels in Healthy Adults

Hemoglobin (g/dL)

Hematocrit (%)

Mean -2SD Mean -2SD

Female 14.0 12.0 41 36

Male 15.5 13.5 47 41Hematology: Basic Principles and Practice. Elsevier 2005

Transfusion Trigger:Multicenter, Randomized Control Study

of ICU Patients

Transfusion Strategy

Hb Trigger

Maintenance Level

Conservative 7.0 g/dL 7.0 to 9.0 g/dL

Liberal 10.0 g/dL 10.0 to 12.0 g/dL

Herbert PC et al. N Engl J Med. 1999;340: 409-417

Transfusion Trigger:Multicenter, Randomized Control Study of ICU

Patients30-day mortality P

Restrictive 18.7% 0.11

Liberal 23.3%

Less acutely ill

30-day mortality P

Restrictive 8.7% 0.03

Liberal 16.1%

Cardiac disease patient

30-day mortality P

Restrictive 20.5% 0.69

Liberal 22.9%

Herbert PC et al. N Engl J Med. 1999;340: 409-417

Restrictive vs Liberal Transfusion in Other Conditions

No differencePediatric ICU patients 7.0 g/dL vs 9.5 g/dL Lacroix J, et al. N Engl J Med. 2007:356;1609-1619Moderate to severe head injury 7.0 g/dL vs 10.0 g/dL McIntyre LA et al. Neutrocrit Care 2006;5:4-9

Possible differenceCardiovascular disease 7.0 g/dL vs 10.0 g/dL Liberal transfusions may be better in patients with

acute myocardial infarction and unstable angina Hebert PC et al. Crit Care Med. 2001;29:227-234.

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

Platelets

Plasma and FFP

For the preparation, plasma is removed from For the preparation, plasma is removed from Whole Whole Blood afterBlood after centrifugationcentrifugation

It must contain, on average, not less than 70 IU Factor It must contain, on average, not less than 70 IU Factor VIII per 100 VIII per 100 ml ml and at least similar quantities of the other and at least similar quantities of the other labile coagulation factorslabile coagulation factors and naturally occurring and naturally occurring inhibitors.inhibitors.

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

FFP—36 months at –35 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 filters—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 TransfusionsPreparations

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 TransfusionsAdministration

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 use—routinely leukodepleted Monitoring—VS q 15 minutes, clinical status Do NOT mix with medications

Complications Rapid infusion may result in Pulmonary edema Transfusion Reaction

Platelet TransfusionsPreparations

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 TransfusionsAdministration

Dose May be given as single units or as apheresis units Usual dose is approx 4 units/m2—in 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

Complications—Transfusion Reaction

Serological TestingSerological Testing

3 tests:3 tests: ABO/RhABO/Rh Antibody detection/identificationAntibody detection/identification Crossmatch Crossmatch

ABO/Rh TypingABO/Rh Typing

In the ABO typing, the forward and reverse In the ABO typing, the forward and reverse MUST matchMUST match

In the Rh typing, the control must be In the Rh typing, the control must be negativenegative

Both of these will indicate what type of Both of these will indicate what type of blood should be givenblood should be given

Antibody screen and/or IDAntibody screen and/or ID The antibody screen will detect the presence of The antibody screen will detect the presence of

any unexpected antibodies in patient serumany unexpected antibodies in patient serum If antibodies are detected, identification should be If antibodies are detected, identification should be

performed using panel cells (with an autocontrol)performed using panel cells (with an autocontrol) ISIS 37° (LISS)37° (LISS) AHGAHG

If an antibody is present, units negative for the If an antibody is present, units negative for the antigen must be given (remember the antigen must be given (remember the calculation?)calculation?)

Proceed to the crossmatch…Proceed to the crossmatch…

CrossmatchingCrossmatching

PurposePurpose:: Prevent transfusion reactionsPrevent transfusion reactions Increase Increase in vivoin vivo survival of red cells survival of red cells Double checks for ABO errorsDouble checks for ABO errors Another method of detecting antibodiesAnother method of detecting antibodies

CrossmatchCrossmatch

Two types of crossmatchesTwo types of crossmatches Major – routinely performed in labsMajor – routinely performed in labs Minor – not required Minor – not required ((by AABB since 1976by AABB since 1976))

Major vs Minor CrossmatchMajor vs Minor Crossmatch

Why is the minor Why is the minor crossmatch crossmatch

unnecessary?unnecessary? Donated units are Donated units are

tested for antibodiestested for antibodies Most blood is Most blood is

transfused as transfused as packed cells, having packed cells, having little antibodieslittle antibodies

Crossmatch Crossmatch

Donor RBCs (washed)

Patient serum

No agglutination ~ compatible

Agglutination ~ incompatible

Conclusions

Although RBCs are much safer than 20 years ago, transfusion practices have become more restrictive

The transfusion threshold at most institutions is a hemoglobin of 7 to 8 g/dL for most patients

Higher thresholds are used for specific patients

TRANSFUSION REACTIONSTRANSFUSION REACTIONS

Transfusion Reactions are…Transfusion Reactions are…

Adverse reactions associated with the

transfusion of blood and its components

Transfusion reactionsTransfusion reactions

Non-threatening to fatalNon-threatening to fatal Hemolytic or non-hemolytic – may or may Hemolytic or non-hemolytic – may or may

not cause RBC destructionnot cause RBC destruction Acute to delayedAcute to delayed

Acute – rapid onsetAcute – rapid onset Delayed – days to weeks Delayed – days to weeks

Reactions may involve antigen-antibody Reactions may involve antigen-antibody interactionsinteractions

May involve infectious agentsMay involve infectious agents

Transfusion Fatalities Reported to the FDA (FY 2004 to 2006)

Number and %

TRALI 86 (39%) Other (Non ABO Hemolytic Reactions) 67 (31%) Bacterial Contamination 20 (9%) ABO Hemolytic 15 (7%) Uncertain 31 (14%) Total 219

Disease TransmissionDisease Transmission

HepatitisHepatitis HIVHIV HTLVHTLV CytomegalovirusCytomegalovirus MalariaMalaria BabesiosisBabesiosis SyphilisSyphilis

Infectious Risk of TransfusionInfectious Risk of Transfusion

Klein HG et al. Transfusion 2007;47:2338-2347

SHOT 2011SHOT 2011Serious Hazards of Transfusion (SHOT) Steering Group. The 2011 Annual SHOT Report (2012)

1996-2011 SHOT (n=9925)