Blood Transfusion

Types, Indications and Complications

Vascular / Endovascular Surgery

History of Transfusions
Blood transfused in humans since mid1600s 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 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

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, 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 Main Bag

Satellite Bag 1

Satellite Bag 2

First

RBCs

Platelet-rich Plasma

Differential Centrifugation
Second Centrifugation

RBCs

Platelet-rich Plasma

Second

RBCs

Platelet Concentrate

Plasma

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

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 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

ContentsCoagulation 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 Account for time of heating. Usual dose is 20 cc/kg to raise coagulation factors approx 20%

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

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 ( Colony Stimulating Factor ) Complications
Severe allergic reactions

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)

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

Compatibility
Patient Blood Gp Compatible with Approx % in UK

O A B AB

O A and O B and O AB, A, B and O

47 42 8 3

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

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 RBCs in Platelet unit may sensitize the Rh- patient

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

Transfusion Complications
Acute Transfusion Reactions (ATRs) Chronic Transfusion Reactions Transfusion related infections

Acute Transfusion Reactions

Hemolytic Reactions (AHTR) Febrile Reactions (FNHTR) Allergic Reactions TRALI ( Acute Lung Injury ) Coagulopathy with Massive transfusions Bacteremia

Frequency of Transfusion Reactions

Adverse Effect
Acute Hemolytic Rxn

Frequency
1 in 25,000

Comments
Red cells only

Anaphylactic hypotensive 1 in 150,000 Including IgA Febrile Nonhemolytic Allergic Delayed Hemolytic RBC alloimmunization WBC/Plt alloimmunization 1 in 200 1 in 1,000 1 in 2,500 1 in 100 1 in 10 Common Common Red cells only Red cells only WBC and Plt only

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

Symptoms of AHTR
High fever/chills Hypotension Back/abdominal pain Oliguria Dyspnea Dark urine Pallor

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 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 Repeat crossmatch Repeat Blood group typing Blood culture

Labs found with AHTR

Hemoglobinemia Hemoglobinuria 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 >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

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

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

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 reactionsCan be continued after antihistamine Severe reactionsMust STOP transfusion and may require steroids or epinephrine

PreventionPremedication (Antihistamines)

TRALI
Transfusion Related Acute Lung Injury
Clinical syndrome similar to ARDS Occurs 1-6 hours after receiving plasmacontaining 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 RBCs

Bacterial Contamination
More common and more severe with platelet transfusion (platelets are stored at room temperature) Organisms
PlateletsGram (+) organisms, ie Staph/Strep RBCsYersinia, 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 WBCs present the HLA antigens)

Transfusion Associated GVHD

Mainly seen in infants, BMT patients EtiologyResults from engraftment of donor lymphocytes of an immunocompetent donor into an immunocompromised host SymptomsDiarrhea, skin rash, pancytopenia Usually fatalno treatment PreventionIrradiation 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 Depletion Filter Febrile Transfusion Reactions
Alloimmunization

Gamma Irradiation

CMV Negative

Single Donor Platelets (Apheresis)

X1
X

X
X

CMV
Transfusion Related GVHD

?2
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 Stop the Transfusion 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

Q1- With regard to hemolytic transfusion reactions , Which of the following is true ? A. B. C. D. They generally caused by ABO incompatibility . Urticaria and pruritus are the commonest symptoms . Acidification of urine prevents precipitation of hemoglobin Intra venous diphenylhydramine shoud be given immediately.

Q1- With regard to hemolytic transfusion reactions , Which of the following is true ? A. B. C. D. They generally caused by ABO incompatibility . Urticaria and pruritus are the commonest symptoms . Acidification of urine prevents precipitation of hemoglobin Intra venous diphenylhydramine shoud be given immediately.

Q2- The most common cause of transfusion reaction is :

A. Air embolism. B. Contaminated blood. C. Human Error. D. Unusual circulating anti-bodies.

Q2- The most common cause of transfusion reaction is :

A. Air embolism. B. Contaminated blood. C. Human Error. D. Unusual circulating anti-bodies.

Q3- The most common clinical manifestation of a hemolytic transfusion is :

A. Flank pain. B. Jaundice. C. Oliguria. D. A shaking chills.

Q3- The most common clinical manifestation of a hemolytic transfusion is :

A. Flank pain. B. Jaundice. C. Oliguria. D. A shaking chills.

Q4- The most common fatal infectious complication of a blood transfusion is :

A. AIDS. B. CMV. C. Malaria. D. Viral Hepatitis.

Q4- The most common fatal infectious complication of a blood transfusion is :

A. AIDS. B. CMV. C. Malaria. D. Viral Hepatitis.

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%

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%

Thank you all