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Blood Transfusion
Types, Indications andComplications
Vascular / Endovascular Surgery
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History of Transfusions
Blood transfused in humans since mid-
1600s
1828First successful transfusion
1900Landsteiner described ABO groups
1916First use of blood storage
1939Levine described the Rh factor
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Transfusion Overview
Integral part of medical and surgical treatment
Most often used in Hematology/Oncology, and
other specialties as well (surgery, ICU, etc) Objectives
Blood components
Indications for transfusion
Safe delivery
Complications
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Blood Components
Prepared from Whole blood collection or apheresis
Whole blood is separated by differential centrifugation
Red Blood Cells (RBCs)
Platelets
Plasma
Cryoprecipitate
Others
Others include Plasma proteinsIVIg, CoagulationFactors, albumin, Anti-D, Growth Factors, Colloid volumeexpanders
Apheresis may also used to collect blood components
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Differential Centrifugation
First Centrifugation
Whole Blood
Main Bag
Satellite Bag
1
Satellite Bag
2
RBCs Platelet-richPlasma
First
Closed System
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Differential Centrifugation
Second Centrifugation
Platelet-rich
Plasma
RBCs PlateletConcentrate
RBCs
Plasma
Second
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Whole Blood
Storage
4 for up to 35 days
Indications Massive Blood Loss/Trauma/Major Operations.
Considerations
Use filter as platelets and coagulation factors will not
be active after 3-5 days
Donor and recipient must be ABO identical
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RBC Concentrate
Storage
4 for up to 42 days, can be frozen
Indications Many indicationsie anemia, hypoxia, etc.
Considerations
Recipient must not have antibodies to donor RBCs
(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 chronicanemia
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Platelets
Storage Up to 5 days at 20-24
Indications Thrombocytopenia, Plt
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Plasma and FFP
ContentsCoagulation Factors (1 unit/ml)
Storage
FFP--12 months at18 degrees or colder
Indications Coagulation Factor deficiency, fibrinogen replacement, DIC, liver
disease, exchange transfusion, massive transfusion
Considerations
Plasma should be recipient RBC ABO compatible Account for time of heating.
Usual dose is 20 cc/kg to raise coagulation factors approx 20%
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Cryoprecipitate
Description Precipitate formed/collected when FFP is heated 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
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Granulocyte Transfusions
Prepared at the time for immediate transfusion (nostorage available)
Indicationssevere neutropenia assoc withinfection that has failed antibiotic therapy, andrecovery of BM is expected
Donor is given G-CSF ( Colony Stimulating
Factor ) Complications
Severe allergic reactions
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Leukocyte Reduction Filters
Used for prevention of transfusion reactions
Filter used with RBCs, Platelets, FFP,
Cryoprecipitate Other plasma proteins (albumin, colloid
expanders, factors, etc.) do not need filters
May reduce RBCs by 5-10%
Does not prevent Graft Verses Host Disease(GVHD)
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RBC Transfusions
Preparations Type
Typing of RBCs for ABO and Rh are determined for
both donor and recipient Screen
Screen RBCs for atypical antibodies
Approx 1-2% of patients have antibodies
Crossmatch
Donor cells and recipient serum are mixed and
evaluated for agglutination
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Compatibility
PatientBlood Gp
Compatible with Approx% in UK
O O 47
A A and O 42
B B and O 8
AB AB, A, B and O 3
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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 .
Filter useroutinely leukodepleted
MonitoringVS q 15 minutes, clinical status
Do NOT mix with medications
Complications
Rapid infusion may result in Pulmonary edema
Transfusion Reaction
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Platelet Transfusions
Preparations ABO antigens are present on platelets
ABO compatible platelets are ideal
This is not limiting if Platelets indicated and typespecific not available
Rh antigens are not present on platelets
Note: a few RBCs in Platelet unit may sensitize the
Rh- patient
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Platelet Transfusions
Administration Dose
May be given as single units .
Usual dose is approx 4 units/m2
Procedure
Should be administered over 20-40 minutes
Filter use
Premedicate if hx of Transfusion Reaction ComplicationsTransfusion Reaction
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Transfusion Complications
Acute Transfusion Reactions (ATRs)
Chronic Transfusion Reactions
Transfusion related infections
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Acute Transfusion Reactions
Hemolytic Reactions (AHTR)
Febrile Reactions (FNHTR)
Allergic Reactions
TRALI ( Acute Lung Injury )
Coagulopathy with Massive transfusions
Bacteremia
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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
alloimmunization
1 in 10 WBC and Plt only
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Acute Hemolytic Transfusion
Reactions (AHTR) Occurs when incompatible RBCs 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
RBCs
Labeling error is most common problem
Can be fatal
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Symptoms of AHTR
High fever/chills
Hypotension
Back/abdominal pain
Oliguria
Dyspnea
Dark urine
Pallor
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What to do?
If an AHTR occurs STOP TRANSFUSION
ABCs
Maintain IV access and run IVF (NS or LR)
Monitor and maintain BP/pulse
Give diuretic
Obtain blood and urine for transfusion reactionworkup
Send remaining blood back to Blood Bank
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Blood Bank Work-up of AHTR
Check paperwork to assure no errors
Check plasma for hemoglobin
Repeat crossmatch
Repeat Blood group typing
Blood culture
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Labs found with AHTR
Hemoglobinemia
Hemoglobinuria
Hyperbilirubinemia
Abnormal DIC panel
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Monitoring in AHTR
Monitor patient clinical status and vitalsigns
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)
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Febrile Nonhemolytic Transfusion
Reactions (FNHTR) Definition--Rise in patient temperature >1C
(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
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What to do?
If an FNHTR occurs STOP TRANSFUSION
Use of Antipyretics
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 RBCs or platelets
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Washed Blood Products
PRBCs or platelets washed with saline
Removes all but traces of plasma (>98%)
Indicated to prevent recurrent or severe reactions Washed RBCs must be used within 24 hours
Does not prevent GVHD
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Allergic Nonhemolytic Transfusion
Reactions Etiology
May be due to plasma proteins or bloodpreservative/anticoagulant
Best characterized with IgA given to an IgA deficientpatients with anti-IgA antibodies
Presents with urticaria and wheezing
Treatment
Mild reactionsCan be continued after antihistamine
Severe reactionsMust STOP transfusion and mayrequire steroids or epinephrine
PreventionPremedication (Antihistamines)
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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 pulmonaryleukostasis
Treatment is supportive
High mortality
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Massive Transfusions
Coagulopathy may occur after transfusionof 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 RBCs
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Bacterial Contamination
More common and more severe withplatelet transfusion (platelets are stored at
room temperature) Organisms
PlateletsGram (+) organisms, ie Staph/Strep
RBCsYersinia, enterobacter
Risk increases as blood products age (usefresh products for immunocompromised)
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Chronic Transfusion Reactions
Alloimmunization
Transfusion Associated Graft Verses Host
Disease (GVHD)
Iron Overload
Transfusion Transmitted Infection
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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
WBCs present the HLA antigens)
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Transfusion Associated GVHD
Mainly seen in infants, BMT patients
EtiologyResults from engraftment of
donor lymphocytes of an immunocompetentdonor into an immunocompromised host
SymptomsDiarrhea, skin rash,pancytopenia
Usually fatalno treatment
PreventionIrradiation of donor cells
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Transfusion Associated
Infections Hepatitis C
Hepatitis B
HIV
CMV
CMV can be diminished by leukoreduction,
which is indicated for immunocompromised
patients
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Prevention
Leukocyte
Depletion
Filter
Gamma
Irradiation
CMV
Negative
Single Donor
Platelets
(Apheresis)
Febrile Transfusion
Reactions X1
XAlloimmunization X X
CMV ?2 X
Transfusion Related
GVHDX
1 In PRBC transfusion
2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood
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Summary
Blood Components
Indications
Considerations
Preparation and Administration of blood
products
Acute and chronic transfusion reactions
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Transfusion Reaction Summary
AHTR can be fatal
Stop the Transfusion
Monitor for symptoms and complete evaluation FNHTR is a diagnosis of exclusion
TRALI (ARDS-like reaction)
Chronic Transfusion reactions Prevention methodsusing filters, irradiation and
premedication
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Q1- With regard to hemolytic transfusion reactions , Which of the
following is true ?
A. They generally caused by ABO incompatibility .
B. Urticaria and pruritus are the commonest symptoms .
C. Acidification of urine prevents precipitation of hemoglobin
D. Intra venous diphenylhydramine shoud be given immediately.
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Q1- With regard to hemolytic transfusion reactions , Which of the
following is true ?
A. They generally caused by ABO incompatibility .
B. Urticaria and pruritus are the commonest symptoms .
C. Acidification of urine prevents precipitation of hemoglobin
D. Intra venous diphenylhydramine shoud be given immediately.
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Q2- The most common cause of transfusion reaction is :
A. Air embolism.
B. Contaminated blood.
C. Human Error.
D. Unusual circulating anti-bodies.
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Q2- The most common cause of transfusion reaction is :
A. Air embolism.
B. Contaminated blood.
C. Human Error.
D. Unusual circulating anti-bodies.
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Q3- The most common clinical manifestation of a hemolytic
transfusion is :
A. Flank pain.
B. Jaundice.
C. Oliguria.
D. A shaking chills.
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Q3- The most common clinical manifestation of a hemolytic
transfusion is :
A. Flank pain.
B. Jaundice.
C. Oliguria.
D. A shaking chills.
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Q4- The most common fatal infectious complication of a blood
transfusion is :
A. AIDS.
B. CMV.
C. Malaria.D. Viral Hepatitis.
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Q4- The most common fatal infectious complication of a blood
transfusion is :
A. AIDS.
B. CMV.
C. Malaria.D. Viral Hepatitis.
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Q5- One unit of Fresh blood arises the Hb% concentration by :
A. 0.1 gm%
B. 1 gm%
C. 2 gm%
D. 2.2 gm%
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Q5- One unit of Fresh blood arises the Hb% concentration by :
A. 0.1 gm%
B. 1 gm%
C. 2 gm%
D. 2.2 gm%
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Thank you all