Transfusion and complication - Srinakharinwirot University · 2019-01-15 · Transfusion and...

Transfusion and complication

Nisa Makruasi, MDDivision of Hematology, Department of Medicine,

HRH Princess Maha Chakri Sirindhon Medical Center,Srinakharinwirot University

Outlines

• Blood components• Transfusion reaction• Compatibility test• Special case: AIHA, massive

transfusion, bleeding case, DIC, thalassemia, hemophilia

Whole blood

• Cellular component– Red cells: PRC, LPB, LD-PRC– Platelets: random platelets, LPPC, SDP– Buffy coats

• Plasma component: FFP– FFP, Cryoprecipitate, Cryo-removed– Plasma Plasma fractionation: Factor VIII

concentrate, Prothrombin complex concentrate, Immunoglobulins, Albumin, etc...

Fresh whole blood

• No valid indications for transfusionif blood components are available

• Should be interpreted by Blood Bankwhich components is needed ?

Fresh whole blood

v450 ml or 350 ml vVolume 500 ml.( rbc, wbc, plt, plasma),

Hct ~40%, shelf life at 2–6oC• CPD 21 days, CPDA–1 35 days, AS 42 daysvIndication: loss of both rbc mass and plasma

volume (active bleeding, exchange transfusion, surgery)

• Contraindication: severe chronic anemia

PRCv Volume 250 – 300 ml, rbc, wbc, platelet,

reduced plasma, Hematocrit < 80%• Shelf life at 2 – 6oC, closed system (same as WB),

open system (24 hrs)v Indication

vLoss of rbc mass: bone marrow production, rbc survival, bleeding

v acute or chronic symptomatic anemiav Contraindication: CRF, nutritional anemia (IDA),

should not be used to (enhance general well – being, promote wound healing, prevent infection, prevent future anemia, expand blood volume)

Evaluation of WB, PRC

by repeat Hb / Hct after 4 hrs. of transfusion

• Hb increment ~ 1 gm / bag

• Hct increment ~ 3% / bag

Leukocyte depletion

•LD-PRC: WBC <1 x 106 per unit by count or <5 X 106 per unit (USA)

•LPB or LPRC: WBC < <5x108 per unit by count

Indication for red cells : Leukocyte reduced• Prevention of allo-immunization to leukocytes and

platelets ( 5x106 leukocytes)

– Platelet Refractoriness

– NHFTR

• Prevention of transmission of CMV ( 5x106

leukocytes)

• Treatment( Not prevention) of patients with multiple febrile transfusion reactions ( 5x108

leukocytes)

• Prevention of immunomodulatory effects of transfusion

LPB or LPRC

• Prepared by centrifugation• Wbc removal 70 – 80%, rbc recovery 80%• Volume 200 – 350 ml, reduced rbc, wbc,

platelet and plasma• Hematocrit < 80%, wbc <5x108 cells/bag• Shelf life same as WB, PRC

Triggers for transfusion of RBCs at our institution

• Hb < 7 g/dL >>>>non bleeding medical and surgical inpatints

• Hb <8 g/gL >>>>Inpatients with active acute coronary syndrome

• Hb < 10 g/dL >>>>Inpatients being treated for sepsis during the first 6 hours of resuscitation

LD-PRC

• Prepared by filtration• Wbc removal >99%, plt. Removal >95%, rbc

recovery >85% • Volume: LP–WB 450 ml, LP–PRC 200 – 350 ml.v Wbc <5x106 cells/bagv Shelf life: same as LPB

Platelet transfusion

• Random platelet: > 5.5x1010 cells/bag• LPPC ( Leukocyte pool platelet concentration) 1

unit from 4-5 donor, 150-250 mL/unit• SDP: >3x1011

• Indication: bleeding in thrombocytopenia, prophylaxis in thrombocytopenia undergoingsurgery and chemotherapy, platelet dysfunction with thrombocytopenia

• Contraindication: TTP, HIT

SDP

• Advantage– Reduce donor exposure

• Disadvantage– High cost

Platelet concentration (PC)

vPrepared by centrifugation volume vfew wbc, rbc, pH >6.2, > 5.5x1010 cells/bagvshelf life 5 days at 22+2oC platelet incubator

with gentle agitationvIndication: bleeding in thrombocytopenia,

prophylaxis in thrombocytopenia undergoingsurgery and chemotherapy, platelet dysfunction with thrombocytopenia

Single donor plateletpheresis (SDP)

• prepared by blood cell separator• volume 250 – 350 ml, platelet >3x1011

cells/bag, pH >6.2, shelf life same as random PC

• Indication: same as PC, patient with platelet antibodies, patient undergoing BMT

Relationship of Platelet Count to bleedingin Thrombocytopenia

due to Decreased Platelet Production

> 50,000 / ml Bleeding unlikely caused byplatelets

10,000 – 50,000 / ml Increased risks of bleedingduring trauma, surgery,ulceration in GI tract etc.

5,000 – 10,000 / ml Increased risks of spontaneousbleeding

< 5,000 / ml High risks of spontaneousbleedingSevere life–threatening bleeding

Indication for platelet treatment

• Platelet <50,000 + severe bleeding (hemoptysis, GI bleeding, hematuria, retinal hemorrhage, CNS or spinal hemorrhage)

• Bleeding per gum or severe epistaxis cause anemia

Platelet transfusionv ABO

§ group specific§ compatible

Ø PC “AB” to A / B patientsØ PC “O” to A / B patients

§ not considered (plasma volume 20 ml / bag)v Rh (D)

§ Rh negative patients should receiveRh negative PC

§ if Rh positive platelets are given to Rhnegative patients, RhIG should be given

§ a dose of 300 mg RhIG can protect rbcfrom 30 bags of PC, 3 bags of SDP

20

v no RhIG given when D-positive blood is givento D–negative patient(life – saving condition)

v crossmatching is not requiredEXCEPT :

HLA-Ab and / or Ab to HPA are developedHLA – Human Leukocyte AntigenHPA – Human Platelet Antigen

v DOSE 10 kg / bagv platelet increment 5,000 – 10,000 / ml / bag

21

v pooled PC should be transfused within 4 hrs.(kept at 20 – 24oC with gentle agitation inplatelet incubator)

v use fresh standard blood administration setspecial platelet infusion sets

v infuse over a period of about 30 mins.

v evaluation of platelet transfusion

§ clinical bleeding 30 – 60 mins.

§ PRE and POST platelet count... 1 hr, 24 hrs.

v No increment at 1 hr. ... platelet antibody?

Corrected count increment (CCI)

• CCx=<(Post-tx plt ct) – (pre-tx plt ct)> *BSAPlatelets transfused

• PC 6 X 1010 , SDP 3 X 1011

• If CCI > 7.5 to 10 X 109 /L from a sample drawn 10 minutes to 1 hr after transfusion or

• CCI > 4.5 X 109 /L from a sample drawn 18-24 hrs after transfusion

• >>>acceptable (not indicative of refractoriness)

Causes of platelet refractoriness

v platelet alloantibodies (HLA / HPA / ABO)v platelet autoantibodiesv active bleedingv fever / sepsis / DIC / splenomegalyv drug – dependent platelet antibodiesv immune complex : TTPv Allogeneic transplantation

FFPv volume 150 – 300 ml.due to preparation

method, all coagulation factors, Factor VIII :C > 0.7 IU/ml, no platelets

v shelf life at < -18oC, 1 year thawed FFP at 37oC, shelf life 24 hrs, NO REFROZEN

v Indication: abnormal PT, APTT, multiplecoagulation factors deficiencies ( liver disease, massive transfusion, DIC, etc.), Hemophilia?

• Dose 10-20 ml/kg, no cross matching, ABO identical / compatible (Rh – any), Ab screening in plasma

•

Fresh Frozen Plasma (FFP)

Coagulation FactorFibrinogenProthrombinFactor VFactor VIIFactor VIIIFactor IXFactor XFactor XIFactor XIIIvon Willebrand factors

Concentration Half–life (hrs.)

200 – 450 mg/dl~ 1 IU/ml“----------”“----------”“----------”“----------”“----------”“----------”“----------”“----------”

100 – 15050 – 8012 – 24

61224

30 – 6040 – 80

150 – 30024

Contraindication

vprophylactic use in cardiac surgery vvolume expansionv nutritional supportv formula treatmentv increased PT, PTT alone without bleedingv enhancement of wound healing

Triggers for transfusion of FFP

• INR > 1.5 Neurosurgical patients• INR > 2.0 Patients who will undergo

invasive procedure• Undefined Trauma patients who are

receiving trauma-associated transfusion algorithm

Cryoprecipitate• Factor VIII, Factor XIII, VWF, Fibrinogen,Fibronectin• volume 5 – 10 ml, Factor VIII : C > 80 IU/bag,

Fibrinogen 150 – 250 mg/bag, Factor XIII, vWFother protein

• shelf life at < -18oC 1 year, thawed and pooledcryo, kept at 20 –24oC for 4 hrs.

• Indication: source of Factor VIII ( Hemophilia A, vWD),source of Fibrinogen (obstetric cases, hypofibrinogenemia), source of vWF ( platelet dysfunction), fibrin glue ( cryo : fibrinogen, human thrombi)

CPP

vDosev Factor VIII-depends on severity,v Fibrinogen -10 bagsv vWF - 10 bags

v use immediately after thawing and poolingv kept at 20 – 24oC for 4 hoursv ABO group is not considered

Cryo-removed

• Plasma ทเหลอจากการแยกตะกอนโปรตน CPP ออกไปแลว• Indication: multiple coagulation factors

ทไมตองการ factor VIII, fibrinogen, V• ความเสยงตอโรคตดเชอ การเกบรกษา ขนาดและวธการให

เชนเดยวกบ FFP

Component

Whole Blood

Packed Red Cells

Leukocyte Reduced(filtration)

(centrifugation)

Platelet Concentrate

Cryoprecipitate

FFP

Volume(ml)

450 + 10%

45 – 65

Hematocrit(%)

< 80

Specifications

100% of unit tested

100% of unit tested

95% of unit tested– retained 85% of original rbc– wbc < 5 x 106 per bag

wbc < 5 x 108 per bag

90% of unit tested– platelet > 5.5 x 1010 per bag– pH > 6.2

100% of unit tested– Factor VIII > 80 IU / bag– Fibrinogen > 150 mg / bag

Factor VIII 0.7 – 1.0 IU / bag

Q.C. of Blood Component

Irradiated blood

• Prevent t-GVHD – Aim of irradiating blood components:

inactivate lymphocytes while causing little or no damage to other blood cells

– onset of TA–GVHD is typically 3 – 30 days after transfusion

– high mortarity rate: infection, hemorrhage– treatment is always ineffective

Compatibility test

Series of pre-transfusion tests• ABO grouping• Rh D typing• Antibody screening test• crossmatching

ABO grouping

• Do cell grouping and serum grouping• Verify ABO group: check previous record or test

cell grouping again

group cell grouping serum groupingAnti-A Anti-B A cells B cells O cells

A + - - + -B - + + - -AB + + - - -O - - + + -

Aag

BagAag Bag

Anti-BAnti-A

Anti-BAnti-A

Rh D typing

• Test for presence of D antigen

• D positive : Rh D positive • D negative : Rh D negative

Rh D antigen : potent immunogenicity•People who don’t have D antigen receive blood transfusion, or pregnancyà may produce anti-D which is importance for subsequence transfusion or pregnancy

99.7%0.3%

Antibody screening test

Group O red cellsserum

+ =Antibodydetection

Aim: Detect presence or absence of Ab to red cell Ag in serum (0.3 – 2 % of population have unexpected Ab), determine specificities and possible significance of Ab

IAT : indirect antiglobulin test

Sensitization

Visible clumption

Donor blood

• ABO• Rh (D) • Antibody screening test• Infectious screening test : HBsAg,

Anti-HCV, anti-HIV,HIV -1 p24 Ag, Syphilis screening test

Crossmatching

• To determine compatibility between Red cells of donor and pt’s serum

• Minor cross-matching donor’s serum + patient’s red cells

– Antibody screening :donor blood – Antibodies will dilute in pt’s body– Keep cross-matching simple to reduce error

Majorcross-matching

nottest

Complication• Immediate complication

– Acute hemolytic transfusion reaction– Transfusion associated circulatory overload

(TACO)– Acute non-hemolytic transfusion reaction:

urticarial reaction, anaphylaxis IgA deficiency,TRALI, FNHTR

• Delayed complication– Delayed hemolytic transfusion reaction– Post transfusion purpura– TaGVH– Iron overload– Transfusion-transmitted infections

Acute intravascular hemolysis• Incompatibility blood: plasma Ab recipient reaction with

RBC donor• ABO incompatible transfusion (common), others (Kidd, Kell

duffy: may be)• Cause: human error• S &S: Burning sensation at infusion site and along vein,

Facial flushing and feeling of discomfort, Chill and/or rigor with fever, Lumbar pain and/or chest tightness, Development of shock and/or diffuse bleeding DIC, hemoglobinurias

• Prevention: prevent human error, compatibility test, double checking, ชบงผปวยใหถกตองเมอนำโลหตไปใหผปวย มการทวนซำ และตดตามอาการอยางใกลชดใน 15 นาทแรก

• Transfusionist’s responsibilities– Stop reaction; Notify physician– Observe and document sign, symptom &

conditions– Check I.D. of patient and donor– ตรวจสอบเรองความถกตอง ของผปวยกบถงเลอด

– Collect samples for Blood Bank– Return product with all attached sets

• Tx– Record B.P., pulse, urine output– Insert CVP line if necessary– Catheteries if necessary– Force diuresis, load IV fluid– IV Furosemide or 20% manitol– Inotropic drugs: Dopamine

Bacterial contamination and septic shock

• Cause– Contaminate from skin (donor, ผเจาะเลอด),

Staphylococcus (common)– Bacteremia in donor– Contaminate in process e.g. ระหวางการละลาย CPP ใน water

bath, ถงรวซม• Incidence: 0.4% of red cell, 1-2 % of platelet conc.

(Pseudomonas growth 2-6 C, Stap growth 20-24 C)• S&S: sudden or graduate onset, high grade fever,

myalgia, chill, hypotension• Tx: ATB, supportive care• Prevention: sterile technique, diversion pouch bag

Fluid overload

• Heart failure• Occur in pt with underlying heart disease,

chronic anemia• Cause

– Large volume intravenous fluid– High rate of blood transfusion– Renal failure

FNHTR

• Unexplained rise in BT at least 1 C,with or without rigor

• Occur ~ 1%of RC transfusion, 30%of PLT transfusion

• not serious, fever response to antipyretic and rigor to meperidine

• Mechanism: release of inflammatory cytokine : IL-1 ,TNF which react with hypothalamus and stimulate PGE2production (reset the thermoregulatory center of brain)

Treatment

• Stop transfusion, maintain IV line• Evaluate as per hemolytic transfusion

reaction• Continue transfusion if no evidence of

Hemolysis • Pre-medication antipyretic drugs• Record evidence and consider leucocyte

removal blood products on next transfusion

Anaphylactic reaction

• Not uncommon, occur in red cell & plasma• Increase risk in high volume of plasma (e.g.

plasma exchange)– Cytokines in plasma >>>bronchial

constriction & vasoconstriction– In pt with IgA deficiency >>>severe

anaphylaxis• S&S

– Immediate onset, HF, RS failure, BP drop, no fever

Transfusion-related acute lung injury (TRAIL)

• Causes: plasma donor ม Ab ตอ WBC recipient• Target: lung tissue• S&S: acute RS failure in 1-4 hrs, CXR: diffuse

opacity• Tx: supportive tx (intensive RS care, general

support)

Delayed hemolytic transfusion reactions

• Cause: เกดจากการกระตนใหมแอนตบอดของหมโลหตระบบอน ๆ นอกเหนอจาก ABO system หลงไดรบเลอด ทำใหเกด hemolysis

• S&S: หลงไดรบเลอด 5-10 วน, fever, anemia with jaundice, hemoglobinuira (may be), DAT+, increase IB

• Tx: supportive tx• Prevention: ตองตรวจหาชนดของ Ab ในพลาสมาของผปวยและเลอก

ใหเลอดจากผบรจากทไมม Ag ตรงกน

Post-transfusion purpura

• Cause: Ab to platelet-specific Ag• Female, uncommon, life-threathening • Red cells and platelets • S&S: bleeding, severe thrombocytopenia (plt

<100,000, <20-50,000 อนตราย ), occur in 5-10 days• Tx: corticosteroid high dose, high dose IVIG 2 g/kg

or 0.4 g/kg * 5 days), plasma exchange, monitor platelet count, ถาจำเปนตองให plt ทไมม PSA ตรงกบ Ab ทพบในผปวย

และตองมหม ABO ตรงกน• Prevention: ใหเกลดเลอดทเขาไดกบผปวย

Graft versus host disease

• Cause: lymphocyte ในโลหตทไดรบ engraft อยในรางกายผปวยแลวแบงตวสรางภาวะอมมนตอตานผปวย

• มกพบในผปวยทมภาวะอมมนตำจากการปลกถายไขกระดก, รบเลอดทม HLA ใกลเคยงกน หรอจากญาต

• S&S: onset 10-12 days, fever, rash, diarrhea, hepatitis, pancytopenia

• Tx: supportive Tx• Prevention: irradiated blood (inh. lymphocytes )

Transfusion-transmitted infections

• HIV-1 and HIV-2• HTLV1 and HTLVII• HCV, HBV• Syphilis• Chagas disease• Malaria• CMV• Other rare: HPV-B19, brucellosis, EBV,

toxoplasma, infectious mononucleosis, Lymes dz, prions dz, Dengue, Chikungunya

Question 1

• ผปวยหญงไทยโสด อาย 30 ป มอาการเหนอยเพลย มคนทกมา

เหลองมา 3 สปดาห• ตรวจรางกาย pale, mild jaundice, spleen 3 cm• Hct 18%, MCV 110• PBS: autoagglutinations 3+, NCNC• DCT 3+, IDCT 1+• Need red cell transfusion ???

AIHA

• Indication– Life-threatening anemia: severe hemolysis– Co-morbidities (heart dz, old age)

• Most compatible blood• ใหเลอดทละนอย

Blood transfusionHb(g/dL) โอกาสทผปวยจะเกด

อาการจากภาวะซดการใหเลอด

≥10 ตำมาก หลกเลยงการใหเลอด

8-10 ตำ หลกเลยงการใหเลอด(พจารณาใหเลอดกรณทมโรคอนทอาจแยลงจาก

ภาวะซด)

6-8 ปานกลาง พกผอนและลดกจกรรมหนก ในกรณทมอาการรนแรงจากภาวะซดมากหรอม

โรคอนทอาจแยลงจากภาวะซดอาจพจารณาใหเลอด

≤6 สง สวนมากมกมอาการรนแรงจากภาวะซดและมกจะไดรบเลอด

Question 2

• ผปวยชายไทย อาย 18 ป ไดรบการวนจฉยวาเปน B-thalassemia ตงแตอาย 3 ขวบ ไดรบเลอดบอยทก 1-2 เดอน Hct baseline 20-22% 1 สปดาหกอนมารพ. รสกเพลย

ลง เหนอยงาย ปสสาวะสเขมขน ไมมไข

• ตรวจรางกาย thalassemic face, markedly pale, mod jaundice, liver 10 cm, spleen 20 cm

• CBC: Hct 14%• Management in this patient??

Thalassemia: transfusion program• Hypertransfusion program

– high transfusion (pre-transfusion Hb 9-10 g/dl, keep mean Hb 12 g/dl)

– low transfusion (pre-transfusion Hb 7 g/dl, keep mean Hb 8 g/dl)

• normal physical activity• improve growth• reduction of chronic hypoxemia, hypervolemia, GI

absorption of iron • retardation of development of splenomegaly and

hypersplenism• Symptomatic transfusion• Thalassemia post splenectomy with pul. HT: keep

Hct 25%

Allo-immunization• 3% of patients in Thailand• Antibody ตอ Rh, Duffy, Kell, Kidd blood

group• X Leucodepleted blood products

Autoimmune hemolytic anemia

• สงสยเมอผปวยซดลงอยางรวดเรว

• พบในผปวย thalassemia มากกวาคนปกต

• Treatment– Steroid– IVIG– Splenectomy

Post transfusion hypertension

• Not common• High mortality rate (> 30%) ถาม cerebral

hemorrhage• Occur when receive 3-7 blood units• Onset: since 1-15 days after

transfusion

Complication of transfusion

• Infection• Iron overload, hemochromatosis

– 1 unit of PRC = 200 mg of iron– Blood products (5-10 gm/ year),Fe in food

(1-2 gm/ year)– Gold standard diagnosis: liver biopsy– Non-invasive investigation: serum ferritin

(>1,000)

Question 3

• ผปวยหญงไทยค อาย 52 วนจฉยวาเปน AML, M1 ได

induction chemotherapy 7+3 regimensหลงไดยาเคมบำบดวนท 10 มปญหา FN มจดเลอดออกตามตว

• CBC: Hct 19%, platelet 5,000, WBC 200• Management in this patients ???

Prophylactic plt transfusion

• Platelet < 5,000 ( incidence severe bleeding 10-30%)• Platelet 5,000-10,000 ในกรณทเกลดเลอดลดลงอยางรวดเรว หรอเปนมะเรง

เมดเลอดขาว (incidence severe bleeding 4.4%)• Platelet 10,000-20,000 ควรใหกรณ

– Abnormal coagulation or plt dysfunction– Bleeding : wet purpura or dimeter > 1 cm or large

ecchymosis– Procedure (กดเพอหามเลอดใหหยดไดลำบาก): CVP, abdominal

paracentesis, thoracocentesis, bronchial Bx, liver Bx, LP, ETT, dentral extraction ตองเพมเกลดเลอดอยางนอย

40,000-50,000, fiberoptic bronchoscope & GI scope without Bx (มความชำนาญสง สามารถทำไดแมเกลดเลอด

<20,000)

Prophylactic plt transfusion

– Procedure ทคาดวาจะมเลอดออกไมมากหรอการคลอดทางชองคลอด สามารถทำ

ไดถาเกลดเลอดมากกวา 50,000– Procedure บรเวณทเลอดมาเลยงมาก e.g. percutaneous liver

Bx, percutaneous kidney Bx, keep plt 60,000-100,000

– Abdominal Sx: plt 60,000-100,000– Brain, spinal, eye, heart Sx: plt >100,000– Spinal epidural block: plt ≥80,000

• Plt >20,000 ไมตองใหเกลดเลอด ยกเวนกรณ

– Local bleeding: gastric ulcer, นวในทางเดนปสสาวะ– Procedure or Sx พจารณาใหเกลดเลอดในกรณผาตดอวยวะทคาดวาจะเกด

การเสยเลอดมากหรอควบคมการหามเลอดไดยาก

Question 4• ผปวยหญงไทยค อาย 26ป ปวดทอง 1 วน และมอาการหนามดคลายจะเปน

ลม 2 ชม. กอนมารพ. ไมมเลอดออกทใด ผปวยไมมประจำเดอนมา 2 เดอน• ตรวจรางกาย

• BP 90/60, PR 120 bpm• GA: drowsiness, markedly pale, no jaundice, no

petechiae or ecchymosis, no cyanosis• Abdomen: soft, mild generalized tenderness,

no guarding• PR: no melena• CBC: Hb 7 g/dL, Hct 21%, WBC 13,000/mm3,

Platelet 260,000/mm3; polychromasia 2+• Diagnosis and management ???

Internal Bleeding

• Abdominal Trauma– Tearing or rupture of liver, spleen

• Local Intraabdominal pathology– Ruptured ectopic pregnancy– Ruptured hepatoma– GI bleeding

• Underlying bleeding disorders– Retroperitoneal hemorrhage

Volume lossML % of Total

blood volumeClinical signs

500 10 None, occasionally vasovagal syncope in blood donors

1000 20 Slight postural drop in BP, tachycardia with exercise

1500 30 Postural hypotension, flat supine neck vein

2000 40 Supine hypotension, cold clammy skin, tachycardia

2500 50 Signs of shock, tachycardia, oliguria, drowsiness or coma

Transfusion management guideline for major hemorrhage

• Control the bleeding: may need surgical intervention• Fluid resuscitation: crystalloid or colloids• Avoid exacerbating coagulation problems: keep warm• Use laboratory data to guide management

– CBC, PT, APTT, fibrinogen, blood bank sample, biochemical profile, blood gases

– Repeat CBC, PT, APTT, fibrinogen every 4 hrs, or after 1/3 blood volume replacement, or after infusion of FFP

PRC:FFP:platelet = 1:1:1, 3:1:1, 5:1:1

Handbook of transfusion medicine: Editor D B L McClelland, UK 2007

Have blood components available when needed

• Request red cells– PRC (universal donor=gr. O Rh-negative blood)– Rh-positive may be used for male or post-menopausal

female in emergency– Dose of 4 ml/kg (one pack to 70 kg adult) typically

raises venous Hb concentration by about 10 g/l– Use blood warmer– Depend on host status (age, heart disease, peripheral

vascular disease, previous Hb level), volume loss


• Platelets needed? (anticipate plt < 50,000 after 1-1.5Xblood volume replacement)– Dose: 10 ml/kg body weight for a neonate or small

child– One adult therapeutic dose’ (one pack)= 2.5–3X1011

(SDP 1 unit, platelet con 4-6 units)– Target plt >100,000 CNS/multiple trauma,

plt>75,000 others condition


• FFP needed? (anticipate coagulation factor deficiency after blood loss of 1–1.5Xblood volume)– Aim for PT and APTT < 1.5 X mean control,

fibrinogen > 1.0 g/l – Dose: 10–20 ml/kg body weight = 1 litre or 4 units for

an adult– Note PT and APTT > 1.5Xmean control correlates with

increased surgical bleeding, may need to use FFP before laboratory results are available

Handbook oftransfusionmedicine:EditorDBLMcClelland, UK2007

• Cryoprecipitate needed?(replace fibrinogen,FVIII)– Aim for fibrinogen > 1.0 g/l– Dose: 2-5 donation pools for mid-sized adult

(equivalent to 10 single donor units) containing 3–6 g fibrinogen in a volume of 200 to 500 ml.

– Fibrinogen < 0.5 strongly associated with microvascular bleeding, Low fibrinogen prolongs all clotting times (PT and APTT)


An example of a major haemorrhage protocolIf there is a local protocol for your hospital, that should be used


Use of blood components in the patient who is bleeding

Recombinant F VIIa (Novoseven) in hemorrhage: RCT have not yet established clear indications in haemorrhage


Blood components and hemorrhage


Question 5

• ผชายอาย 19 ป สบลอทบมอเตอรไซด ม fracture pelvis ได packed red cell 20 units ตอมามเลอดไหลไมหยดจากบรเวณทเจาะเลอด

• Platelet 50,000• APTT 60.5 sec (25-35)• PT 25.0 sec (11-14)• Fibrinogen 1.02 g/L (2-4 g/L)

Prolonged APTT, PT and thrombocytopenia

• DIC• Liver disease*• Massive transfusion**• Coagulopathy of trauma***

*Liver disease อาจพบรวมกบ DIC ได **blood transfusion > 10 unit in 24 hrs รวมกบ crystalloid ทาใหม

dilutional coagulopathy***มกม acidosis + hypothermia ทาใหการแขงตวของเลอดไมด

Massive transfusion

• Blood transfusion ≥ total blood volume within 24 hrs ( 70 ml/kg in adult, 80-90 ml/kg in infant & child)

• Problems– Dilution: dilutional coagulopathy, microvascular

bleeding– Consumption: DIC, microvascular bleeding– Decreased production

• FFP, platelets, and red cells in trauma patients, rupture aortic aneurysm (often to develop DIC)– Red cell : FFP : platelet = 1:1:1

Others complication of large volume transfusion


Question 6

• ผปวยชายอาย 19 ป ไดรบการวนจฉยเปน hemophilia A มาพบแพทยเนองจากขมอเตอรไซดลม มปวดบวมทขอสะโพกดานซาย

• ตรวจรางกาย swelling with tenderness around left hip joint, warm limited ROM

• Management ????

Factor VIII replacement• Cryoprecipitate: F VIII, F XIII, vWF,

fibrinogen, fibronectin• FFP• Factor VIII concentration• สตรคำนวณ 1 U/Kg raise F VIII 2 %• Half life 12 hr (repeated dose q 8-12 hr)

• ***F IX def: 1 U/Kg raise F IX 1 % (use FFP, F IX concentration), half life 24 hr

Recommended plasma factor

level and duration of

administration

จงใหการรกษาในผปวยรายนB

• BW 50 kg

Question 7

• ผปวยหญงอาย 45 ป มาดวยเลอดออกตามไรฟน มเลอดออกตามตว

• ตรวจรางกายพบ petechiae and ecchymosis • PBS: AML (M3)• Platelet 48,000 • APTT 37.3 sec (25-35)• PT 19.1 sec (11-14)• TT 17.0 sec (11-14)

Prolonged APTT, PT and thrombocytopenia

• DIC• Liver disease*• Massive transfusion**• Coagulopathy of trauma***

*Liver disease อาจพบรวมกบ DIC ได**blood transfusion > 10 unit in 24 hrs รวมกบ crystalloid ทำใหม dilutional coagulopathy***มกม acidosis + hypothermia ทำใหการแขงตวของเลอดไมด

DIC• Diagnosis• 1. Clinical

– ตองมสาเหตของ DIC เสมอ– Bleeding and/or thrombosis

• 2. Lab– Prolonged coagulation ( prolonged PT, low fibrinogen)– Thrombocytopenia– FDP or D-dimer rising

• ***fibrinogen: acute phase protein ซงจะสงในภาวะ

sepsis ดงนนถาพบ fibrinogen ปกตในผปวยตดเชอ อาจบงวาเรมม DIC• ***chronic DIC อาจม plt, clotting time ปกต

Treatment• Correct cause• keep plt > 20,000• Fibrinogen: keep 1-1.5 g/L, (Cryoprecipitate 10

bag q 12-24 hrs)• Bleeding or need surgery

– FFP 10-20 ml/kg; keep PT, PTT > 1.5 – Platelet transfusion keep 50,000-100,000

• Thrombosis + no bleeding: Low dose heparin• In APL: keep platelet 30,000-50,000,

fibrinogen > 100-150 g/dL

Question 8

• ผปวยชายไทยค ไดรบการวนจฉยเปน UGIB หลงจากไดรบเลอดไป

30 นาท มอาการไข หนาวสน ปวดเอว ปสสาวะสโคก

• Diagnosis and management

Transfusion and complication - Srinakharinwirot University · 2019-01-15 · Transfusion and...

Documents

Transcript of Transfusion and complication - Srinakharinwirot University · 2019-01-15 · Transfusion and...