Transfusion Medicine: Types, Indications and Complications
D.MAHAMED HUSSEN GENERAL SURGEONHistory of Transfusions
Blood transfused in humans since mid-1600’s1828 – First successful transfusion1900 – Landsteiner described ABO groups1916 – First use of blood storage1939 – Levine described the Rh factorTransfusion Overview
Integral part of medical treatment Most often used in Hematology/Oncology, but other specialties as well (surgery, ICU, etc) Objectives Blood components Indications for transfusion ComplicationsBlood Components
Prepared from Whole blood collection or apheresisWhole blood is separated by differential centrifugationRed Blood Cells (RBC’s)PlateletsPlasmaCryoprecipitateOthersOthers include Plasma proteins— Coagulation Factors, albumin, Anti-D, Growth Factors, Colloid volume expandersApheresis may also used to collect blood componentsDifferential Centrifugation First Centrifugation
Whole Blood Main BagSatellite Bag 1
Satellite Bag 2
RBC’s Platelet-rich Plasma
First
Closed System
Differential Centrifugation Second Centrifugation
Platelet-rich PlasmaRBC’s Platelet Concentrate
RBC’s Plasma
Second
1- Whole Blood
2- RBC ConcentrateStorage4° for up to 42 days, can be frozenIndicationsMany indications—ie anemia, hypoxia, etc.ConsiderationsRecipient 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
3- Platelets
4- Plasma and FFPContents—Coagulation Factors (1 unit/ml)StorageFFP--12 months at –18 degrees or colderIndicationsCoagulation Factor deficiency, fibrinogen replacement, DIC, liver disease, exchange transfusion, massive transfusionConsiderationsPlasma should be recipient RBC ABO compatibleIn children, should also be Rh compatibleAccount for time to thawUsual dose is 20 cc/kg to raise coagulation factors approx 20%
5- Cryoprecipitate
6- Granulocyte TransfusionsPrepared 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 expectedComplicationsSevere allergic reactions
Leukocyte Reduction Filters
Used for prevention of transfusion reactionsFilter used with RBC’s, Platelets, FFP, CryoprecipitateOther plasma proteins (albumin, colloid expanders, factors, etc.) do not need filters—NEVER use filters with stem cell/bone marrow infusionsMay reduce RBC’s by 5-10%
(1) RBC Transfusions Preparations
TypeTyping of RBC’s for ABO and Rh are determined for both donor and recipientScreenScreen RBC’s for atypical antibodiesApprox 1-2% of patients have antibodiesCrossmatchDonor cells and recipient serum are mixed and evaluated for agglutinationRBC Transfusions Administration
DoseUsual dose of 10 cc/kg infused over 2-4 hoursMaximum dose 15-20 cc/kg can be given to hemodynamically stable patient ProcedureMay need Premedication (Tylenol and/or Benadryl)Filter use—routinely leukodepletedMonitoring—VS q 15 minutes, clinical statusDo NOT mix with medicationsComplicationsRapid infusion may result in Pulmonary edemaTransfusion Reaction(2) Platelet Transfusions Preparations
ABO antigens are present on plateletsABO compatible platelets are idealRh antigens are not present on plateletsNote: a few RBC’s in Platelet unit may sensitize the Rh- patientPlatelet Transfusions Administration
DoseMay be given as single units or as apheresis unitsUsual dose is approx 4 units/m2—in children using 1-2 apheresis units is ideal1 apheresis unit contains 6-8 Plt units (packs) from a single donorProcedureShould be administered over 20-40 minutesFilter usePremedicate if hx of Transfusion ReactionComplications—Transfusion ReactionTransfusion Complications
Acute Transfusion Reactions (ATR’s)Chronic Transfusion ReactionsTransfusion related infectionsAcute Transfusion Reactions
Hemolytic Reactions (AHTR) Febrile Reactions (FNHTR) Allergic Reactions Transfusion Related Acute Lung Injury (TRALI) Coagulopathy with Massive transfusions Bacteremia1) Acute Hemolytic Transfusion Reactions (AHTR)
Occurs when incompatible RBC’s are transfused into a recipient who has pre-formed antibodies (usually ABO or Rh)Antibodies activate the complement system, causing intravascular hemolysisSymptoms occur within minutes of starting the transfusionThis hemolytic reaction can occur with as little as 1-2 cc of RBC’sLabeling error is most common problemCan be fatalSymptoms of AHTR
High fever/chills Hypotension Back/abdominal pain Oliguria Dyspnea Dark urine Pallor2) Febrile Non-hemolytic Transfusion Reactions (FNHTR)
Washed Blood ProductsPRBC’s or platelets washed with salineRemoves all but traces of plasma (>98%)Indicated to prevent recurrent or severe reactionsWashed RBC’s must be used within 24 hoursRBC dose may be decreased by 10-20% by washing
3) Allergic Non-hemolytic Transfusion Reactions
EtiologyMay be due to plasma proteins or blood preservative/anticoagulantBest characterized with IgA given to an IgA deficient patients with anti-IgA antibodies Presents with urticaria and wheezingTreatmentMild reactions—Can be continued after BenadrylSevere reactions—Must STOP transfusion and may require steroids or epinephrinePrevention—Premedication (Antihistamines)4) 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 pulmonary leukostasis Treatment is supportive High mortality5) Massive Transfusions
Coagulopathy may occur after transfusion of massive amounts of blood (trauma/surgery)Coagulopathy is caused by failure to replace plasmaSee electrolyte abnormalitiesDue to citrate binding of CalciumAlso due to breakdown of stored RBC’s6) Bacterial Contamination
More common and more severe with platelet transfusion (platelets are stored at room temperature)OrganismsPlatelets—Gram (+) organisms, ie Staph/StrepRBC’s—Yersinia, enterobacterRisk increases as blood products age (use fresh products for immunocompromised)