Transfusion MedicineJanejira Kittivorapart, MD.

Department of Transfusion Medicine

Faculty of Medicine Siriraj Hospital

Mahidol University

Blood Transfusion

Patients

Blood Bank

Physicians

OUTLINE

Type, indication and composition of blood products

Blood utilization

Processes of blood transfusion

Special requests

Platelet refractoriness

Transfusion reactions & their managements

Preparation of Blood Components

Whole Blood

Plasma

FFP

CRYO

Buffy coat

WBC Platelet

LPB

Whole Blood

Platelets & Plasma

Platelet FFP

Cryoprecipitate CRP

Packed red cells

Type of component Composition/storage Indications

Whole Blood Volume 500 mlHct > 33%Shelf life at 2 – 6°CCPDA-1 35 days

Hypovolemic anemia:- Active bleeding, surgery

Packed red cells (PRC) Volume 250 – 300 mlHct < 80%Shelf life at 2-6°C CPDA-1 35 days

• Loss of RBC mass• Symptomatic anemia

Red cells in additive solution (Adsol blood) Volume 300 – 350 ml

Hct 55-65%Shelf life 42 days Contatained mannitol but not Sodium citrate

• Same as PRC• Emergency situations• Autologous donation

Type of Component Composition/storage Indications

Leukocyte poor blood (LPB, LPRC)Prepared by centrifugation

Volume 250-300 mlHct ≤ 80%WBC ≤ 12 x 108 cells/bagShelf life same as WB, PRC

•↓ Febrile nonhemolytic transfusion reaction

•↓ Alloimmunization to WBC antigens (i.e. HLA)

•↓Transmission of CMV

Proved only WBC < 5x106

Leukocyte depleted blood Prepared by filtration

Volume 250-300 mlHct ≤ 80%WBC ≤ 5 x 106 cells/bagShelf life same as WB, PRC

Type of Component Composition/storage Indications

Platelet concentrate Platelets 5.5x1010/unitShelf life 5 days 22 ± 2°C Soft continuous agitation

Therapeutic• Thrombocytopenic

bleeding• Platelet dysfunction with

bleeding

Prophylaxis• Spontaneous hemorrhage> 10,000/µl> 20,000/µl- DIC, sepsis, fever• Pre-operative

Pooled 4 donors(pooled-buffy coat)

Shelf life 5 days 22 ± 2°C Soft continuous agitation

Single donor platelet Platelets 3x1011/unitShelf life 5 days 22 ± 2°C Soft continuous agitation

AS Plasma … mlPRC Plasma …. ml

Type of Component Composition/storage Indications

Fresh frozen plasma (FFP)

Volume 150-300 mlAll coagulation factors Shelf life at ≤ - 18°C 1 yrThawed FFP at 37°C, shelf life 24 hNo Refrozen

• Abnormal PT, APTT• Multiple coagulation factors deficiencies :- liver disease, massive transfusion, DIC, warfarin reversal (bleeding)• Hemophilia B • Plasma exchange in TTP

Cryoprecipitate Volume 5-10 mlFactor VIII:C ≥ 80 IU/bag Fibrinogen 150 mg/bagFactor XIII vWFShelf life at ≤ - 18°C 1 yrThawed and pooled CRYO kept at 20-24°C for 4 h

• Source of FVIII in hemophilia A, vWD• Source of fibrinogenDIC, hypofibrinogenemia• Source of vWF

• Fibrin glue (CRYO: fibrinogenHuman thrombin)

DosageBlood

/ComponentDose What to be expected?

RBCs 10 ml/kg/doseChronic anemia: 1-2 u/dosePed, Hb<5 g/dl: 2x Hb ml/kg(i.e. Hb 4 g/dl 8 ml/kg/dose)

↑ Hb 1 g/dl per one unit transfused

Platelet conc. 10 kg/unit Infant: 5-10 ml/kg

• Absolute Platelet Increment

1 u->↑ plts 5,000-7,000/uL• CCI

FFP 10-20 ml/kg(500-1000 ml in a 50 kg patient)

PTR within 1.5 x of normal(clotting factor 50% of normal)

Cryoprecipitate 5-10 kg/bag (5-10 units in a 50 kg patient)

Fibrinogen 100 – 150 mg/dl

IN REAL SITUATION…

Case 156 y.o. male, HBV with cirrhosis Child C• Present with UGIB • BP110/70 mmHg, HR 110/min, good consciousness• CBC: Hb 7 g/dL, Hct 22%, WBC6500/mm3 Platelet

90,000/µL • PT 48s (<13 s), aPTT 72s (28-32 s), Fibrinogen 53 mg/dL • LFT: compatible with liver cirrhosis

What is your management?

Case 2

• 69 y.o. female; BW 60 Kg• Pre-op drainage for her parotid space abscess• CBC: Hb 12 g/dl, WBC 5,600/mm3, Plt 260,000/µl• Clinician requests for platelet conc. 6 U

What is your management?

Sample Collection

เจาะเลื�อดเพื่�อขอจองเลื�อดEDTA tube 6 ml• Active patient identification• Permission• Consent form • Labeling sample –

Don’t forget to sign your name

AT BLOOD BANK

Processing

Check from previous history • Recheck name and surname, HN• Check blood group and previous antibody

Check cell and serum grouping

Antibody screening

Type & Screen

Cells and Serum Grouping

Crossmatching

Donor cells VS Patient serum

– Immediate spin – to detect antibody at room TIgM antibody :- ABO blood group

– Incubation at 37C- IgG Ab Rh blood group– Indirect antiglobulin

Test – Coombs control cells

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TRANSFUSION PRACTICE

FREQUENTLY ASKED QUESTIONS

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FAQ

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– Platelets– Cryoprecipitate

OUTLINE

Type, indication and composition of blood products

Blood utilization

Processes of blood transfusion

Special requests

Platelet refractoriness

Transfusion reactions & their managements

SPECIAL REQUESTS

1. Irradiated Blood

• Purpose: inactivated T-cell lymphocytes

Not eradicated!• Dose: 25 Gy with at least 15 Gy periphery• TA-GVHD prevention• Age - Platelet: same age as origin

- RBCs: 28 days • Hyperkalemia

TA-GVHD– Very high mortality rate (almost 100%)– Pancytopenia + GVHD – 8-10 days after transfusion– No available effective treatment

1. There must be differences in the HLA Ag expressed between donor & recipient2. Immunocompetent cells must be presented in the graft3. The host must be incapable of rejecting the immunocompetent cells

3 requirements of GVHD (Billingham)

Indications: Irradiation1. High risk groups• PBSCT/BMT – allogeneic & autologous• Received purine analogue agent • After ATG administration• Intrauterine transfusion• Compromised T-cell functions – SCID, Digeorge

syndrome, etc.

2. The donor is a blood relative of the recipient

3. The donors is selected for HLA compatability by typing or crossmatching

Case

• G1P0, GA 36 week twin pregnancy patients• One of her fetus was detected to be anemic by

ultrasonography.• The obstretician requested for intrauterine

transfusion • We prepared the prestorage group O Rh

negative red cells with irradiation and washed

2.Washed Component

• History of severe allergy or anaphylaxis after transfusion

• Usually allergic to plasma protein :- IgA deficiency, haptoglobin deficiency, etc.

• Purpose: Plasma removal • Age: Within 4 h after bag opening• In particular situation – 6 times wash

3.Rh Negative

• Incompatible Rh platelet administration• Anti-D immunoglobulin (Rhesonativ®)• Anti-D 250 µg / 15 ml of Rh D+ RBCs

(PC 30 units, SDP 3 units)• IM/SC injection• Within 72 h after exposure• Monitor at least 20 min after injection

Patient, Rh D negative

pt

pt

pt

ptpt

ptpt

pt

pt

Platelet Rh D+ Rh D- Patient

pt

pt

d d

pt

ptd

d

pt

RBCs in Platelet bag

pt

Anti-D injection

Platelet Rh D+ Rh D- Patient

pt

pt

pt

pt

Anti-D bind to D antigens

pt

d d

d

d

4.Platelet Crossmatch

• Platelet refractoriness• Immune vs Non-immune causes• Screening methods

- Fail from what expected

(1 unit ↑ platelet 5,000 – 7,000/µl)

- Corrected count increment (CCI)

CCI

CCI = Platelet count increment X BSA(m2)(x1011)

no. of platelet transfused

• Failure transfusion : 1 hour CCI < 5,500

or 24 hour CCI < 2,500

CCI Interpretation1 hour 24 hours

Not Decrease Decrease (<2,500) Consumption of Plt

Decrease (<5,500) - Suspected Plt Ab

PC: 5.5 x 1010 x unitsSDP: 3 x 1011

Alloimmune Thrombocytopenia

• Request for platelet crossmatching• ALWAYS! monitor 1-hour increment • Either Paroxysmal or Persistent• No effective treatment • Prevention: Leukodepleted blood products

OUTLINE

Type, indication and composition of blood products

Blood utilization

Processes of blood transfusion

Special requests

Platelet refractoriness

Transfusion reactions & their managements

TRANSFUSION REACTIONS

• Acute transfusion reaction .. Within 24 hours– Acute hemolytic transfusion reaction– Bacterial sepsis– Febrile non-hemolytic transfusion reaction (FNHTR)– Anaphylaxis/ allergic reactions– Transfusion related acute lung injury (TRALI)– Transfusion associated circulatory overload (TACO)

• Delayed transfusion reaction .. >24 hours– Delayed hemolytic transfusion reaction– Iron overload – Transfusion-associated graft versus host disease (TA-GvHD)

Transfusion Reactions

Symptoms/signs of Acute Transfusion Reaction

- Immediately STOP the transfusion

- Retain the IV port

Urticaria

Fever

- Premed with CPM

- Closed observation

FNHTR Bacterial contamination

Allergy

Anaphylaxis

- ABC approach- Adrenaline IM- Return product

to blood bank- Saline wash in

future Transfusion

Hemolytic reaction

- Vigorous IV infusion- Urine output monitoring- Take H/C, CBC, BUN, Cr, K,

DIC profile- Prophylaxis antibiotic- Return product and the giving

set to blood bank

FNHTR- Febrile non-hemolytic transfusion reaction

Acute dyspnea ± Hypotension

TACO TRALI

- Oxygen supplement

- Diuretics IV- I/O monitoring

- Treat as ARDS - Respiration and

ventilation support- Usually recovers

within 72-96 h

TACO - transfusion associated circulatory overload

TRALI – transfusion related acute lung injury

Hemolytic Transfusion Reactions

AHTR DHTR• Occur within 24 hours

• Intravascular hemolysis

• Usually fatality and need intensive care

• The most common cause is ABO incompatibility

• Occur many days to years after transfusion

• Majority is extravascular hemolysis

• Usually mild symptoms with some degrees of anemia

• Kidd, Duffy, Kell and MNS systems were reported

Form for Transfusion Reactions

Investigation

SUMMARY• Introducing every type of blood and components• Blood utilization • Blood transfusion• Special requests

– Irradiated products, TA-GVHD– Washed components– Rh negative– Crossmatching platelets

• Transfusion reactions & their managements

“True success is not in the learning, but in its

application to the benefit of mankind.”

HRH Prince Mahidol of Songkla

QUESTIONs

&

ANSWERs