Blood Transfusion 276m3e
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Pedaitric: 55
Anemia: Bleeding: Malignancy: Polycythemia: Hypercoagulable: Blood transfusion Stem Cell:
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Public Health
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Anemia: Bleeding: Malignancy: Polycythemia: Hypercoagulable : Blood transfusion: Stem Cell:
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BLOOD TRANSFUSION AND TRANSFUSION REACTION
BLOOD SELECTION
Blood Groups Phenotype Genotyp e (blood Type)
Antibodies present in the blood serum
A
IA IA Or IA I
Anti B
B
IB IB Or IB I
Anti A
AB
IA IB
-
O
ii
Anti A and B
Blood Groups Rh group
Rh antigen
Rh antibody
Rh positive
None
Rh negative
Anti- D
Selection of Blood
Red cell transfusion ◦ There must be ABO and Rh D compatibility between the donor’s red cells and the recipient’s plasma. Group A individuals can receive blood from Group A and O donors Group B individuals can receive blood from Group B and O donors
World Health Organization: Blood Transfusion Safety
Selection of Blood
Red cell transfusion ◦ There must be ABO and Rh D compatibility between the donor’s red cells and the recipient’s plasma. Group O individuals can receive blood from Group O donors only Group AB individuals can receive blood from Group AB donors, and also from Group A, B and O donors
World Health Organization: Blood Transfusion Safety
Selection of Blood
Plasma and Components containing Plasma ◦ In plasma transfusion, group AB plasma can be given to a patient of any ABO group because it contains neither anti-A nor anti-B antibody Group AB plasma (no antibodies) can be given to any ABO group patients Group O plasma (anti-A + anti-B) can be given to Group O patients only World Health Organization: Blood Transfusion Safety
Selection of Blood
Plasma and Components containing Plasma ◦ In plasma transfusion, group AB plasma can be given to a patient of any ABO group because it contains neither anti-A nor anti-B antibody Group A plasma (anti-B) can be given to Group O and A patients Group B plasma (anti-A) can be given to Group O and B patients World Health Organization: Blood Transfusion Safety
BLOOD TRANSFUSION
Blood Transfusion Practice THE DECISION to transfuse, like any other therapeutic decision, should be based on the risks, benefits, and alternatives of treatment.
PRINCIPLES OF CLINICAL TRANSFUSION PRACTICE
Transfusion is only one
part of the patient’s
blood loss should receive
management.
effective resuscitation (intravenous replacement
Prescribing should be
fluids, oxygen, etc.) while
based on national
the need for transfusion is
guidelines on the clinical use of blood, taking individual patient needs into .
The patient with acute
Blood loss should be minimized to reduce the
being assessed
Transfusion should be prescribed only when the benefits to the patient are likely to outweigh the risks.
PRINCIPLES OF CLINICAL TRANSFUSION PRACTICE
The patient’s haemoglobin
The clinician should be
value, although important,
aware of the risks of
should not be the sole
transfusion-transmissible
deciding factor in starting
infections in the blood
transfusion. This decision
products that are available
should be ed by the
for the individual patient.
need to relieve clinical
The clinician should record
signs and symptoms and
the reason for transfusion
prevent significant
clearly.
morbidity or mortality
Blood Products (Definition of )
Blood product
Any therapeutic substance prepared from human blood
Whole blood
Unseparated blood collected into an approved container containing an anticoagulantpreservative solution
Blood Products (Definition of )
Blood component
A constituent of blood, separated from whole blood, such as: ◦ Red cell concentrate ◦ Red cell suspension ◦ Plasma ◦ Platelet concentrates Plasma or platelets collected by apheresis Cryoprecipitate, prepared from fresh frozen plasma: rich in Factor VIII and fibrinogen
Blood Products (Definition of )
Plasma derivative
Human plasma proteins prepared under pharmaceutical manufacturing conditions, such as: ◦ Albumin ◦ Coagulation factor concentrates ◦ Immunoglobulins
RED CELL TRANSFUSION
WHOLE BLOOD (450 ml whole blood donation contains:)
Description
Up to 510 ml total volume (volume may vary in accordance with local policies) ◦ 450 ml donor blood ◦ 63 ml anticoagulantpreservative solution
Hgb approximately: 12 g/ml Haematocrit: 35%–45% No functional platelets No labile coagulation factors (V and VIII)
WHOLE BLOOD (450 ml whole blood donation contains:)
Infection risk
Not sterilized, so capable of transmitting any agent present in cells or plasma which has not been detected by routine screening for transfusiontransmissible infections, including HIV-1 and HIV-2, Hepatitis B and C, other hepatitis viruses, syphilis, malaria and Chagas disease
WHOLE BLOOD (450 ml whole blood donation contains:)
Indications
Contraindication s
Red cell replacement in Acute Blood Loss with Hypovolaemia Exchange transfusion Patients needing red cell transfusions where red cell concentrates or suspensions are not available Risk of volume overload in patients with: ◦ Chronic anaemia
◦ Incipient cardiac failure
Ideal component for patients who have sustained acute hemorrhage of 25% total blood volume loss ◦ Provides both oxygen-carrying capacity and volume expansion.
WHOLE BLOOD (450 ml whole blood donation contains:)
istration
Must be ABO and RhD compatible with the recipient Never add medication to a unit of blood Complete transfusion within 4 hours of commencement Transfusion should be started within 30 minutes of removal from refrigerator
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’)
Description
150–200 ml red cells from which most of the plasma has been removed Hgb approximately: 20 g/100 ml (not less than 45 g per unit) Haematocrit: 55%–75%
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’)
Infection risk
Same as whole blood
Storage
Same as whole blood
Indications
Replacement of red cells in anaemic patients Use with crystalloid replacement fluids or colloid solution in acute blood loss
Same as whole blood
istration
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’) 3 mL PRBC/kg will raise ◦ Hb by approximately 1 gm/dl ◦ Hct by approximately 3%
In normal sized adult (70 kg) 1 unit PRBC will raise the ◦ Hct by 3 - 4% or 1 gm/dl
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’) Exchange transfusion
◦ Term infants
--
80-160ml/kg
◦ Preterm infants
--
100-200ml/kg
Routine (neonates and children) ◦ 10-20 ml/kg Desired Hct – actual Hct x weight (kg)
Desired Hb – actual Hb x weight (kg) x 3
Red Cell Transfusion
Increases oxygen-carrying capacity in the anemic patient. Adequate oxygenation can be maintained with a Hemoglobin content of 70 g/L in the normo-volemic patient without cardiac disease; ◦ Co-morbid factors often necessitate transfusion at a higher threshold
Red Cell Transfusion
The decision to transfuse should be guided by the clinical situation and not by an arbitrary laboratory value. In the critical care setting, ◦ Liberal use of transfusions to maintain nearnormal levels of hemoglobin may have unexpected negative effects on survival.
In most patients requiring transfusion ◦ Levels of hemoglobin of 100 g/L are sufficient to keep oxygen supply from being critically low.
Red Cell Transfusion (Pediatric)
Transfusions may be given more stringently to children because: ◦ Normal hemoglobin levels are lower in healthy children than in adults ◦ Children do not have the underlying cardiorespiratory and vascular diseases that develop with aging in adults.
Red Cell Transfusion (Pediatric)
Children should be better able to compensate for RBC loss. ◦ In the peri-operative period, for example, it is unnecessary for most children to maintain hemoglobin levels of 80 g/L or greater, a level frequently desired for adults.
CHILDREN AND ADOLESCENTS
INFANTS WITHIN THE FIRST 4 MO OF LIFE
Acute loss of >25% at Hemoglobin of <13.0 circulating blood g/dL and severe volume pulmonary disease Hemoglobin of <8.0 g/dL Hemoglobin of <10.0 in the perioperative g/dL and moderate period pulmonary disease Hemoglobin of <13.0 Hemoglobin of <13.0 g/dL and severe g/dL and severe cardiac cardiopulmonary disease disease Hemoglobin of <10.0 Hemoglobin of <8.0 g/dL g/dL and major surgery and symptomatic chronic Hemoglobin of <8.0 g/dL anemia and symptomatic anemia Guidelines for Pediatric Red Blood Cell Hemoglobin of <8.0 g/dL and marrow failureTransfusions
THE DECISION TO TRANSFUSE
SHOULD NOT BE BASED ON THE HAEMOGLOBIN LEVEL ALONE, BUT ALSO ON A CAREFUL ASSESSMENT OF THE PATIENT’S CLINICAL CONDITION.
PLATELET CONCENTRATES
PLATELET CONCENTRATES (prepared from whole blood donations
Description
Single donor unit in a volume of 50–60 ml of plasma should contain: ◦ At least 55 x 109 platelets ◦ <1.2 x 109 red cells ◦ <0.12 x 109 leucocytes
Unit of issue
May be supplied as either: ◦ Single donor unit: platelets prepared from one donation ◦ Pooled unit: platelets prepared from 4 to 6 donor units ‘pooled’ into one pack to contain an adult dose of at least 240 x 109 platelets
PLATELET CONCENTRATES (prepared from whole blood donations
Infection risk
Same as whole blood, but a normal adult dose involves between 4 and 6 donor exposures Bacterial contamination affects about 1% of pooled units
Storage
Up to 72 hours at 20°C to 24°C (with agitation) Longer storage increases the risk of bacterial proliferation and septicaemia in the recipient
PLATELET CONCENTRATES (prepared from whole blood donations
Indications
Treatment of bleeding due to: ◦ Thrombocytopenia ◦ Platelet function defects Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure
Thrombocytopenia is a risk factor for hemorrhage, and platelet transfusion reduces the incidence of bleeding. ◦ The threshold for prophylactic platelet transfusion is 10,000/L. ◦ In patients without fever or infections, a threshold of 5000/L may be sufficient to prevent spontaneous hemorrhage.
For invasive procedures, 50,000/L platelets is the usual target level.
CHILDREN AND ADOLESCENTS
INFANTS WITHIN THE FIRST 4 MO OF LIFE
PLTs < 50 × 109/L and bleeding
PLTs < 50 × 109/L and an invasive procedure
PLTs < 20 × 109/L and marrow failure with hemorrhagic risk factors
PLTs < 10 × 109/L and marrow failure without hemorrhagic risk factors
PLTs at any count, but with PLT dysfunction plus bleeding or an invasive procedure
PLTs < 100 × 109/L and bleeding PLTs < 50 × 109/L and an invasive procedure PLTs < 20 × 109/L and clinically stable PLTs < 100 × 109/L and clinically unstable PLTs at any count, but with PLT dysfunction plus bleeding or an invasive procedure
Guidelines for Pediatric Platelet Transfusions
PLATELET CONCENTRATES (prepared from whole blood donations
Contraindication s
Not generally indicated for prophylaxis of bleeding in surgical patients, unless known to have significant pre-operative platelet deficiency
Not indicated in: ◦ Idiopathic autoimmune thrombocytopenic purpura (ITP) ◦ Thrombotic thrombocytopenic purpura (TTP)
◦ Untreated disseminated intravascular coagulation (DIC) ◦ Thrombocytopenia associated with septicaemia, until treatment has commenced or in cases of hypersplenism
PLATELET CONCENTRATES (prepared from whole blood donations
Dosage
1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult, 4–6 single donor units containing at least 240 x 109 platelets should raise the platelet count by 20–40 x 109/L Increment will be less if there is: ◦ Splenomegaly ◦ Disseminated intravascular coagulation ◦ Septicaemia
TRANSFUSION OF PLATELET CONCENTRATES Dose units: Platelet concentrate from 1 donor unit (450 ml) of whole blood contains about 60 x 109/L Dosage Volume Platelet concentrate •Up to 15 kg •15–30 kg • >30 kg
1 platelet conc. 30–50 ml* 60 x 109 /L 2 platelet conc. 60–100 ml 120 x 109 /L 4 platelet conc. 120–400 ml 240 x 109 /L
* For small infants, the blood bank may remove part of the plasma before transfusion
PLATELET CONCENTRATES (prepared from whole blood donations
istration
After pooling, platelet concentrates should be infused as soon as possible, generally within 4 hours, because of the risk of bacterial proliferation Must not be refrigerated before infusion as this reduces platelet function Should be infused over a period of about 30 minutes Do not give platelet concentrates prepared from RhD positive donors to an RhD negative female with childbearing potential
PLATELET CONCENTRATES (prepared from whole blood donations
Complications
Febrile non-haemolytic and allergic urticarial reactions are not uncommon, especially in patients receiving multiple transfusions
PLATELET CONCENTRATES
The goal of platelet therapy is to
control or stop the bleeding. The clinical response is more important
than the platelet count.
FRESH FROZEN PLASMA
FRESH FROZEN PLASMA
Description
Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin fibrinogen, Antithrombin, Proteins C and S. ◦ Factor VIII level at least 70% of normal fresh plasma level
FRESH FROZEN PLASMA
Unit of issue
Infection risk
Usual volume of pack is 200–300 ml Smaller volume packs may be available for children
If untreated, same as whole blood Very low risk if treated with methylene blue/ultraviolet light inactivation
FRESH FROZEN PLASMA
Storage
At –25°C or colder for up to 1 year Before use, should be thawed in the blood bank in water which is between 30°C to 37°C. Higher temperatures will destroy clotting factors and proteins Once thawed, should be stored in a refrigerator at +2°C to +6°C
FRESH FROZEN PLASMA
Indications
Replacement of multiple coagulation factor deficiencies: ◦ Liver disease ◦ Warfarin (anticoagulant) overdose ◦ Depletion of coagulation factors in patients receiving large volume transfusions
Disseminated intravascular coagulation (DIC) Thrombotic thrombocytopenic purpura (TTP)
INFANTS, CHILDREN AND ADOLESCENTS
Severe clotting factor deficiency and bleeding Severe clotting factor deficiency and an invasive procedure Emergency reversal of warfarin effects Dilutional coagulopathy and bleeding Anticoagulant protein (antithrombin III, proteins C and S) replacement Plasma exchange replacement fluid for thrombotic thrombocytopenic purpura
Guidelines for Pediatric Plasma Transfusions
FRESH FROZEN PLASMA
Precautions
Acute allergic reactions are not uncommon, especially with rapid infusions Severe life-threatening anaphylactic reactions occasionally occur Hypovolaemia alone is not an indication for use
FRESH FROZEN PLASMA
Dosage
Initial dose of 15 ml/kg
istration
Must normally be ABO compatible to avoid risk of haemolysis in recipient No compatibility testing required Infuse using a standard blood istration set as soon as possible after thawing Labile coagulation factors rapidly degrade; use within 6 hours of thawing
CRYOPRECIPITATE
CRYOPRECIPITATE
Description
Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C and resuspending it in 10–20 ml plasma Contains about half of the Factor VIII and fibrinogen in the donated whole blood: e.g. ◦ Factor VIII: 80–100 iu/ pack; ◦ Fibrinogen: 150–300 mg/pack
CRYOPRECIPITATE
Infection risk
As for plasma, but a normal adult dose involves at least 6 donor exposures
Storage
At –25°C or colder for up to 1 year
CRYOPRECIPITATE
Indications
As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of: ◦ von Willebrand Factor (von Willebrand’s disease) ◦ Factor VIII (haemophilia A) ◦ Factor XIII
As a source of fibrinogen in acquired coagulopathies: e.g. disseminated intravascular coagulation (DIC)
CRYOPRECIPITATE
istration
If possible, use ABOcompatible product No compatibility testing required After thawing, infuse as soon as possible through a standard blood istration set Must be infused within 6 hours of thawing
CRYOPRECIPITATEDEPLETED PLASMA
CRYOPRECIPITATE-DEPLETED PLASMA
Description
Plasma from which approximately half the fibrinogen and Factor VIII has been removed a cryoprecipitate, butwhich contains all the other plasma constituents
Transfusion Reactions
Immediate effects ◦ ◦ ◦ ◦ ◦ ◦
Hemolytic reactions Febrile reactions Allergic reaction Hyperkalemia Circulatory overload Reactions due to Contaminated bld
Delayed Effects
Hemolytic reaction
Alloimmunization
Infectious complications
Hemosiderosis
Transfusion Reactions
Manifestations of Adverse reaction ◦ Fever with or without chills most common symptom of Hemolytic transfusion reaction
◦ Chills with or with out fever ◦ Pain at the transfusion site or in the chest, abdomen or flanks ◦ Blood pressure changes
Transfusion Reactions
Manifestations of Adverse reaction ◦ Blood pressure changes
Acute Hypertension Hypotension Circulatory shock in combination with fever, severe chills and high-cardiac-output suggest -Sepsis or HTR
Guidelines for the recognition acute transfusion reactions Category 1: MILD REACTIONS
Signs ◦ Localized Cutaneous reactions Urticaria Rash
Symptoms ◦ Pruritus (itching)
Possible Cause ◦ Hypersensitivity (mild)
Guidelines for the recognition of acute transfusion reactions Category 2: MODERATELY - SEVERE REACTIONS
Signs ◦ Flushing ◦ Urticaria ◦ Rigors ◦ Fever ◦ Restlessness ◦ tachycardia
Symptoms ◦ Anxiety ◦ Pruritus ◦ Palpatations ◦ Mild Dyspnea ◦ Headache
Possible Cause Hypersensitivity (mod-severe) Febrile NH Ab to WBC Ab to proteins such as IgA Contamination with pyrogens and/or bacteria
Guidelines for the recognition of acute transfusion reactions Category 3: LIFE-THREATENING REACTIONS
Signs ◦ Rigors ◦ Fever ◦ Restlessness ◦ Tachycardia (rise of >20% in heart rate ◦ Hypotension (fall of >20% in systolic BP) ◦ Haemoglobuniria (red urine) ◦ Unexplained bleeding (DIC)
Symptoms ◦ Anxiety
Possible Cause
Acute intravascular haemolysis
◦ Respiratory distress/ shortness of breath
Bacterial contamination and septic shock
Fluid overload
Anaphylaxis
◦ Loin/ back pain
Transfusion associated acute lung injury
◦ Chest pain
◦ Pain near infusion site
◦ Dyspnea ◦ Headache
Hemolytic reactions
Non-immune mediated (physical destruction) ◦ Overheating-use of improvised blood warmers ◦ Forceful transfusion-pressure cuffs ◦ Small bore needles(?) ◦ Using same line for hypotonic solutions or drugs ◦ Bacterial growth in blood units
Hemolytic reactions
Non-immune mediated (physical destruction) ◦ Treatment Depends upon the severity of reaction Severe reaction, hypotension, shock and renal dysfunction -- Intensive management Hemoglobinuria or Hemoglobinemia --
ive therapy
Hemolytic reactions
Immune mediated ◦ Patient Ab reacting with donor Ag ◦ Wrong blood given ◦ Due to rxn with ABO, Rh, Lewis, Kelly ◦ Severity depends upon the amount transfused (as small as 10-15ml)
Hemolytic reactions
Immune mediated ◦ The most dramatic and challenging adverse event of blood transfusion. ◦ There is rapid destruction of blood cells. Most commonly occurs Whole blood Packed red cell
Hemolytic reactions
Immune mediated Can also occur in Fresh frozen plasma Platelet concentrate Other plasma derived
Hemolytic reactions
Immune mediated ◦ Acute Hemolytic Transfusion Reaction Immediately after or with in 24 hours of a transfusion Incidence: 1 in 12000 to 1 in 35000 transfusion Mortality: 1 in 100000 to 1 in 600000 transfusion
Hemolytic reactions
Immune mediated ◦ Delayed Hemolytic Transfusion Reaction Recognized 3 to 10 days after transfusion
Hemolytic reactions
Immune Mediated
Signs and Symptoms of Acute Immune Mediated Fever Dyspnea Chills and rigors Diarrhea Anxiety Hypotension Feeling of dread Hemoglobinuria Facial flushing Pallor Oliguria Icterus
Hemolytic reactions
Immune Mediated
Signs and Symptoms of Acute Immune Mediated Back pain Anuria Flank pain Pain on the Nausea transfusion site Vomiting Diffuse bleeding Chest pain Jaundice Abdominal pain
Hemolytic reactions
Immune Mediated
Signs and Symptoms of Chronic Immune Mediated Fever Jaundice Chills and rigors Oliguria Pallor Anuria Diffuse bleeding
Hemolytic reactions
Stop Transfusion
Severity depends on amount (as small as 30ml)
Maintain adequate systemic arterial blood
Pressure and tissue perfusion by hydration Normal saline solution Prevent renal failure (100ml/hr urine
Hemolytic reactions
Vaso-active agents (dopamine)
DIC – cryoprecipitate, platelet Investigate
◦ Blood typing ◦ Coomb’s test If positive identify antibody responsible
◦ Urine hemoglobin ◦ Culture of the remaining blood
Febrile Non-Hemolytic Reaction
Due to anti-leukocyte Antibody against
White cell and platelet of donor
Mild reaction
rule out Hemolytic Transfusion reaction
bacterial contamination
Febrile Non-Hemolytic Reaction
43% - 75% of all transfusion reaction
0.5% - 1.4% on non-leukocyte reduced red blood cell
15% recurrence rate
Febrile Non-Hemolytic Reaction
Fever
Chills with no reason ◦ Temperature increase of >1C associated with transfusion and without any other explanation
Febrile Non-Hemolytic Reaction
Treatment ◦ Antipyretics/steroids ◦ Antihistamines not indicated -- not involve histamine release ◦ if frequent -- washed Rbc
Allergic Transfusion Reaction
A rare complication of transfusion of blood components or plasma derivatives Can occur in (most common): ◦
Plasma rich blood component like Platelet concentrate
◦
FFP/Cryoprecipitate
Can also occur: ◦
Packed red cells
Allergic Transfusion Reaction
The risk is increased by rapid infusion, typically when fresh frozen plasma is used as an exchange fluid in therapeutic
plasma exchange.
Cytokines in the plasma may be one
cause of bronchoconstriction and vasoconstriction in occasional recipients.
Allergic Transfusion Reaction
Allergic transfusion reaction ◦
Due to binding of soluble substance in donor plasma with IgE antibodies
release of histamine
Allergic Transfusion Reaction
Uncomplicated allergic transfusion
reaction ◦
Anaphylactoid reaction
◦
45% of all transfusion Reaction
1%-3% of transfusion
Anaphylaxis ◦
0.002%-0.005% per transfused product
Allergic Transfusion Reaction
Allergic transfusion reaction ◦
Urticaria (diffuse or local)
◦
Discontinue temporarily but need not be stopped
◦
Stopped if with other systemic manifestation such as hypotension, GI manifestation
◦
Anti histamines
Allergic Transfusion Reaction
Anaphylactoid reaction ◦
Mild form of: Fever Chills Nausea Vomiting Diarrhea And/or Urticaria
Anaphylaxis
◦ ◦ ◦ ◦ ◦ ◦ ◦
Severe form (life threatening Fever Chills Nausea Vomiting Diarrhea And/or Urticaria
Allergic Transfusion Reaction
Anaphylaxis (life threatening) May include several systems ◦
Respiratory (cough, wheezing, chest tightness)
◦
GI (vomiting, diarrheas, nausea)
◦
Circulatory (arrhythmias)
Ig A deficiency
Allergic Transfusion Reaction
Treatment ◦
Stop transfusion
◦
Depends upon severity
Hypotension fluids, epinephrine
Bronchospasm B2 agonist, Theophyline
Post transfusion purpura
Thrombocytopenia 5 to 21 days
Patient makes an alloantibody in response to platelet antigens in the transfused blood that for a period of time (7-48days) causes destruction of autologous antigen-negative platelets.
Sign/Symptoms: Thrombocytopenia that is frequently profound, purpura, or bleeding
Post transfusion purpura
Treatment ◦
Platelet transfusion is of very little value - should be reserved for patients with active bleeding.
◦
Therapeutic plasma exchange may be beneficial.
Transfusion related Acute Lung Injury
Rare
Mortality: 10%
Abrupt onset of non cardiogenic pulmonary edema ◦ Rapid failure of pulmonary function usually presents within 1 to 4 hours of starting transfusion, with diffuse opacity on the chest X-ray.
Transfusion related Acute Lung Injury
Presence of antibodies in the donor plasma reactive to recipient leukocyte antigens
Production of inflammatory mediators
during storage of cellular blood components
Transfusion related Acute Lung Injury
Symptoms ◦ ◦ ◦ ◦ ◦ ◦
Respiratory distress Fever Chills Increased respiratory rate Cough Tachycardia
Transfusion related Acute Lung Injury
Most resolve within 72 hours
Treatment ◦
(O2, ventilation)
◦
Severe cases may require assisted ventilation with high FIO2.
Circulatory overload Fluid overload can result in heart failure and pulmonary edema. May occur when:
◦ Too much fluid is transfused ◦ The transfusion is too rapid ◦ Renal function is impaired.
Fluid overload is particularly likely to happen in patients with: ◦ Chronic severe anaemia ◦ Underlying cardiovascular disease.
Circulatory overload
May complicate up to 1 in 100 transfusion Symptoms ◦ ◦ ◦ ◦ ◦
Dyspnea Orthopnea Cough Tachycardia Hypertension
Infectious
Bacterial /Viral ◦ Can occur in: Packed red cells Plasma rich blood component (most common) Platelet concentrate FFP/Cryoprecipitate
Bacterial Infections
Packed red cells ◦ 2.6 per 100000 transfusions
Symptoms
Temperature higher than 38.5 Rigors Hypotension Nausea Vomiting
Dyspnea Diarrhea Shock Oliguria DIC
Bacterial Infections
Platelet concentrate (common)
8-80 per 100000 units transfused (random)
Symptoms ◦ Symptoms may begin during or shortly after transfusion or begin up to 2 weeks after transfusion: Fever, Chills, Hypotension
Viral Infections
Hepatitis ◦
Hepatitis A
◦
Hepatitis B
◦ ◦
Rare 1:1million 1:63000
Hepatitis C Hepatitis D
Viral Infections
Human Herpes Infection ◦
CMV
◦
EBV
Pedaitric: 55
Anemia: Bleeding: Malignancy: Polycythemia: Hypercoagulable: Blood transfusion Stem Cell:
8 items 8 items 8 items 2 Items 6 items 6 items 3 items
Public Health
6 items
Anemia: Bleeding: Malignancy: Polycythemia: Hypercoagulable : Blood transfusion: Stem Cell:
12 items 12 items 12 items 3 items 4 items 7 items 3 items
BLOOD TRANSFUSION AND TRANSFUSION REACTION
BLOOD SELECTION
Blood Groups Phenotype Genotyp e (blood Type)
Antibodies present in the blood serum
A
IA IA Or IA I
Anti B
B
IB IB Or IB I
Anti A
AB
IA IB
-
O
ii
Anti A and B
Blood Groups Rh group
Rh antigen
Rh antibody
Rh positive
None
Rh negative
Anti- D
Selection of Blood
Red cell transfusion ◦ There must be ABO and Rh D compatibility between the donor’s red cells and the recipient’s plasma. Group A individuals can receive blood from Group A and O donors Group B individuals can receive blood from Group B and O donors
World Health Organization: Blood Transfusion Safety
Selection of Blood
Red cell transfusion ◦ There must be ABO and Rh D compatibility between the donor’s red cells and the recipient’s plasma. Group O individuals can receive blood from Group O donors only Group AB individuals can receive blood from Group AB donors, and also from Group A, B and O donors
World Health Organization: Blood Transfusion Safety
Selection of Blood
Plasma and Components containing Plasma ◦ In plasma transfusion, group AB plasma can be given to a patient of any ABO group because it contains neither anti-A nor anti-B antibody Group AB plasma (no antibodies) can be given to any ABO group patients Group O plasma (anti-A + anti-B) can be given to Group O patients only World Health Organization: Blood Transfusion Safety
Selection of Blood
Plasma and Components containing Plasma ◦ In plasma transfusion, group AB plasma can be given to a patient of any ABO group because it contains neither anti-A nor anti-B antibody Group A plasma (anti-B) can be given to Group O and A patients Group B plasma (anti-A) can be given to Group O and B patients World Health Organization: Blood Transfusion Safety
BLOOD TRANSFUSION
Blood Transfusion Practice THE DECISION to transfuse, like any other therapeutic decision, should be based on the risks, benefits, and alternatives of treatment.
PRINCIPLES OF CLINICAL TRANSFUSION PRACTICE
Transfusion is only one
part of the patient’s
blood loss should receive
management.
effective resuscitation (intravenous replacement
Prescribing should be
fluids, oxygen, etc.) while
based on national
the need for transfusion is
guidelines on the clinical use of blood, taking individual patient needs into .
The patient with acute
Blood loss should be minimized to reduce the
being assessed
Transfusion should be prescribed only when the benefits to the patient are likely to outweigh the risks.
PRINCIPLES OF CLINICAL TRANSFUSION PRACTICE
The patient’s haemoglobin
The clinician should be
value, although important,
aware of the risks of
should not be the sole
transfusion-transmissible
deciding factor in starting
infections in the blood
transfusion. This decision
products that are available
should be ed by the
for the individual patient.
need to relieve clinical
The clinician should record
signs and symptoms and
the reason for transfusion
prevent significant
clearly.
morbidity or mortality
Blood Products (Definition of )
Blood product
Any therapeutic substance prepared from human blood
Whole blood
Unseparated blood collected into an approved container containing an anticoagulantpreservative solution
Blood Products (Definition of )
Blood component
A constituent of blood, separated from whole blood, such as: ◦ Red cell concentrate ◦ Red cell suspension ◦ Plasma ◦ Platelet concentrates Plasma or platelets collected by apheresis Cryoprecipitate, prepared from fresh frozen plasma: rich in Factor VIII and fibrinogen
Blood Products (Definition of )
Plasma derivative
Human plasma proteins prepared under pharmaceutical manufacturing conditions, such as: ◦ Albumin ◦ Coagulation factor concentrates ◦ Immunoglobulins
RED CELL TRANSFUSION
WHOLE BLOOD (450 ml whole blood donation contains:)
Description
Up to 510 ml total volume (volume may vary in accordance with local policies) ◦ 450 ml donor blood ◦ 63 ml anticoagulantpreservative solution
Hgb approximately: 12 g/ml Haematocrit: 35%–45% No functional platelets No labile coagulation factors (V and VIII)
WHOLE BLOOD (450 ml whole blood donation contains:)
Infection risk
Not sterilized, so capable of transmitting any agent present in cells or plasma which has not been detected by routine screening for transfusiontransmissible infections, including HIV-1 and HIV-2, Hepatitis B and C, other hepatitis viruses, syphilis, malaria and Chagas disease
WHOLE BLOOD (450 ml whole blood donation contains:)
Indications
Contraindication s
Red cell replacement in Acute Blood Loss with Hypovolaemia Exchange transfusion Patients needing red cell transfusions where red cell concentrates or suspensions are not available Risk of volume overload in patients with: ◦ Chronic anaemia
◦ Incipient cardiac failure
Ideal component for patients who have sustained acute hemorrhage of 25% total blood volume loss ◦ Provides both oxygen-carrying capacity and volume expansion.
WHOLE BLOOD (450 ml whole blood donation contains:)
istration
Must be ABO and RhD compatible with the recipient Never add medication to a unit of blood Complete transfusion within 4 hours of commencement Transfusion should be started within 30 minutes of removal from refrigerator
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’)
Description
150–200 ml red cells from which most of the plasma has been removed Hgb approximately: 20 g/100 ml (not less than 45 g per unit) Haematocrit: 55%–75%
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’)
Infection risk
Same as whole blood
Storage
Same as whole blood
Indications
Replacement of red cells in anaemic patients Use with crystalloid replacement fluids or colloid solution in acute blood loss
Same as whole blood
istration
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’) 3 mL PRBC/kg will raise ◦ Hb by approximately 1 gm/dl ◦ Hct by approximately 3%
In normal sized adult (70 kg) 1 unit PRBC will raise the ◦ Hct by 3 - 4% or 1 gm/dl
RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’) Exchange transfusion
◦ Term infants
--
80-160ml/kg
◦ Preterm infants
--
100-200ml/kg
Routine (neonates and children) ◦ 10-20 ml/kg Desired Hct – actual Hct x weight (kg)
Desired Hb – actual Hb x weight (kg) x 3
Red Cell Transfusion
Increases oxygen-carrying capacity in the anemic patient. Adequate oxygenation can be maintained with a Hemoglobin content of 70 g/L in the normo-volemic patient without cardiac disease; ◦ Co-morbid factors often necessitate transfusion at a higher threshold
Red Cell Transfusion
The decision to transfuse should be guided by the clinical situation and not by an arbitrary laboratory value. In the critical care setting, ◦ Liberal use of transfusions to maintain nearnormal levels of hemoglobin may have unexpected negative effects on survival.
In most patients requiring transfusion ◦ Levels of hemoglobin of 100 g/L are sufficient to keep oxygen supply from being critically low.
Red Cell Transfusion (Pediatric)
Transfusions may be given more stringently to children because: ◦ Normal hemoglobin levels are lower in healthy children than in adults ◦ Children do not have the underlying cardiorespiratory and vascular diseases that develop with aging in adults.
Red Cell Transfusion (Pediatric)
Children should be better able to compensate for RBC loss. ◦ In the peri-operative period, for example, it is unnecessary for most children to maintain hemoglobin levels of 80 g/L or greater, a level frequently desired for adults.
CHILDREN AND ADOLESCENTS
INFANTS WITHIN THE FIRST 4 MO OF LIFE
Acute loss of >25% at Hemoglobin of <13.0 circulating blood g/dL and severe volume pulmonary disease Hemoglobin of <8.0 g/dL Hemoglobin of <10.0 in the perioperative g/dL and moderate period pulmonary disease Hemoglobin of <13.0 Hemoglobin of <13.0 g/dL and severe g/dL and severe cardiac cardiopulmonary disease disease Hemoglobin of <10.0 Hemoglobin of <8.0 g/dL g/dL and major surgery and symptomatic chronic Hemoglobin of <8.0 g/dL anemia and symptomatic anemia Guidelines for Pediatric Red Blood Cell Hemoglobin of <8.0 g/dL and marrow failureTransfusions
THE DECISION TO TRANSFUSE
SHOULD NOT BE BASED ON THE HAEMOGLOBIN LEVEL ALONE, BUT ALSO ON A CAREFUL ASSESSMENT OF THE PATIENT’S CLINICAL CONDITION.
PLATELET CONCENTRATES
PLATELET CONCENTRATES (prepared from whole blood donations
Description
Single donor unit in a volume of 50–60 ml of plasma should contain: ◦ At least 55 x 109 platelets ◦ <1.2 x 109 red cells ◦ <0.12 x 109 leucocytes
Unit of issue
May be supplied as either: ◦ Single donor unit: platelets prepared from one donation ◦ Pooled unit: platelets prepared from 4 to 6 donor units ‘pooled’ into one pack to contain an adult dose of at least 240 x 109 platelets
PLATELET CONCENTRATES (prepared from whole blood donations
Infection risk
Same as whole blood, but a normal adult dose involves between 4 and 6 donor exposures Bacterial contamination affects about 1% of pooled units
Storage
Up to 72 hours at 20°C to 24°C (with agitation) Longer storage increases the risk of bacterial proliferation and septicaemia in the recipient
PLATELET CONCENTRATES (prepared from whole blood donations
Indications
Treatment of bleeding due to: ◦ Thrombocytopenia ◦ Platelet function defects Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure
Thrombocytopenia is a risk factor for hemorrhage, and platelet transfusion reduces the incidence of bleeding. ◦ The threshold for prophylactic platelet transfusion is 10,000/L. ◦ In patients without fever or infections, a threshold of 5000/L may be sufficient to prevent spontaneous hemorrhage.
For invasive procedures, 50,000/L platelets is the usual target level.
CHILDREN AND ADOLESCENTS
INFANTS WITHIN THE FIRST 4 MO OF LIFE
PLTs < 50 × 109/L and bleeding
PLTs < 50 × 109/L and an invasive procedure
PLTs < 20 × 109/L and marrow failure with hemorrhagic risk factors
PLTs < 10 × 109/L and marrow failure without hemorrhagic risk factors
PLTs at any count, but with PLT dysfunction plus bleeding or an invasive procedure
PLTs < 100 × 109/L and bleeding PLTs < 50 × 109/L and an invasive procedure PLTs < 20 × 109/L and clinically stable PLTs < 100 × 109/L and clinically unstable PLTs at any count, but with PLT dysfunction plus bleeding or an invasive procedure
Guidelines for Pediatric Platelet Transfusions
PLATELET CONCENTRATES (prepared from whole blood donations
Contraindication s
Not generally indicated for prophylaxis of bleeding in surgical patients, unless known to have significant pre-operative platelet deficiency
Not indicated in: ◦ Idiopathic autoimmune thrombocytopenic purpura (ITP) ◦ Thrombotic thrombocytopenic purpura (TTP)
◦ Untreated disseminated intravascular coagulation (DIC) ◦ Thrombocytopenia associated with septicaemia, until treatment has commenced or in cases of hypersplenism
PLATELET CONCENTRATES (prepared from whole blood donations
Dosage
1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult, 4–6 single donor units containing at least 240 x 109 platelets should raise the platelet count by 20–40 x 109/L Increment will be less if there is: ◦ Splenomegaly ◦ Disseminated intravascular coagulation ◦ Septicaemia
TRANSFUSION OF PLATELET CONCENTRATES Dose units: Platelet concentrate from 1 donor unit (450 ml) of whole blood contains about 60 x 109/L Dosage Volume Platelet concentrate •Up to 15 kg •15–30 kg • >30 kg
1 platelet conc. 30–50 ml* 60 x 109 /L 2 platelet conc. 60–100 ml 120 x 109 /L 4 platelet conc. 120–400 ml 240 x 109 /L
* For small infants, the blood bank may remove part of the plasma before transfusion
PLATELET CONCENTRATES (prepared from whole blood donations
istration
After pooling, platelet concentrates should be infused as soon as possible, generally within 4 hours, because of the risk of bacterial proliferation Must not be refrigerated before infusion as this reduces platelet function Should be infused over a period of about 30 minutes Do not give platelet concentrates prepared from RhD positive donors to an RhD negative female with childbearing potential
PLATELET CONCENTRATES (prepared from whole blood donations
Complications
Febrile non-haemolytic and allergic urticarial reactions are not uncommon, especially in patients receiving multiple transfusions
PLATELET CONCENTRATES
The goal of platelet therapy is to
control or stop the bleeding. The clinical response is more important
than the platelet count.
FRESH FROZEN PLASMA
FRESH FROZEN PLASMA
Description
Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin fibrinogen, Antithrombin, Proteins C and S. ◦ Factor VIII level at least 70% of normal fresh plasma level
FRESH FROZEN PLASMA
Unit of issue
Infection risk
Usual volume of pack is 200–300 ml Smaller volume packs may be available for children
If untreated, same as whole blood Very low risk if treated with methylene blue/ultraviolet light inactivation
FRESH FROZEN PLASMA
Storage
At –25°C or colder for up to 1 year Before use, should be thawed in the blood bank in water which is between 30°C to 37°C. Higher temperatures will destroy clotting factors and proteins Once thawed, should be stored in a refrigerator at +2°C to +6°C
FRESH FROZEN PLASMA
Indications
Replacement of multiple coagulation factor deficiencies: ◦ Liver disease ◦ Warfarin (anticoagulant) overdose ◦ Depletion of coagulation factors in patients receiving large volume transfusions
Disseminated intravascular coagulation (DIC) Thrombotic thrombocytopenic purpura (TTP)
INFANTS, CHILDREN AND ADOLESCENTS
Severe clotting factor deficiency and bleeding Severe clotting factor deficiency and an invasive procedure Emergency reversal of warfarin effects Dilutional coagulopathy and bleeding Anticoagulant protein (antithrombin III, proteins C and S) replacement Plasma exchange replacement fluid for thrombotic thrombocytopenic purpura
Guidelines for Pediatric Plasma Transfusions
FRESH FROZEN PLASMA
Precautions
Acute allergic reactions are not uncommon, especially with rapid infusions Severe life-threatening anaphylactic reactions occasionally occur Hypovolaemia alone is not an indication for use
FRESH FROZEN PLASMA
Dosage
Initial dose of 15 ml/kg
istration
Must normally be ABO compatible to avoid risk of haemolysis in recipient No compatibility testing required Infuse using a standard blood istration set as soon as possible after thawing Labile coagulation factors rapidly degrade; use within 6 hours of thawing
CRYOPRECIPITATE
CRYOPRECIPITATE
Description
Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C and resuspending it in 10–20 ml plasma Contains about half of the Factor VIII and fibrinogen in the donated whole blood: e.g. ◦ Factor VIII: 80–100 iu/ pack; ◦ Fibrinogen: 150–300 mg/pack
CRYOPRECIPITATE
Infection risk
As for plasma, but a normal adult dose involves at least 6 donor exposures
Storage
At –25°C or colder for up to 1 year
CRYOPRECIPITATE
Indications
As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of: ◦ von Willebrand Factor (von Willebrand’s disease) ◦ Factor VIII (haemophilia A) ◦ Factor XIII
As a source of fibrinogen in acquired coagulopathies: e.g. disseminated intravascular coagulation (DIC)
CRYOPRECIPITATE
istration
If possible, use ABOcompatible product No compatibility testing required After thawing, infuse as soon as possible through a standard blood istration set Must be infused within 6 hours of thawing
CRYOPRECIPITATEDEPLETED PLASMA
CRYOPRECIPITATE-DEPLETED PLASMA
Description
Plasma from which approximately half the fibrinogen and Factor VIII has been removed a cryoprecipitate, butwhich contains all the other plasma constituents
Transfusion Reactions
Immediate effects ◦ ◦ ◦ ◦ ◦ ◦
Hemolytic reactions Febrile reactions Allergic reaction Hyperkalemia Circulatory overload Reactions due to Contaminated bld
Delayed Effects
Hemolytic reaction
Alloimmunization
Infectious complications
Hemosiderosis
Transfusion Reactions
Manifestations of Adverse reaction ◦ Fever with or without chills most common symptom of Hemolytic transfusion reaction
◦ Chills with or with out fever ◦ Pain at the transfusion site or in the chest, abdomen or flanks ◦ Blood pressure changes
Transfusion Reactions
Manifestations of Adverse reaction ◦ Blood pressure changes
Acute Hypertension Hypotension Circulatory shock in combination with fever, severe chills and high-cardiac-output suggest -Sepsis or HTR
Guidelines for the recognition acute transfusion reactions Category 1: MILD REACTIONS
Signs ◦ Localized Cutaneous reactions Urticaria Rash
Symptoms ◦ Pruritus (itching)
Possible Cause ◦ Hypersensitivity (mild)
Guidelines for the recognition of acute transfusion reactions Category 2: MODERATELY - SEVERE REACTIONS
Signs ◦ Flushing ◦ Urticaria ◦ Rigors ◦ Fever ◦ Restlessness ◦ tachycardia
Symptoms ◦ Anxiety ◦ Pruritus ◦ Palpatations ◦ Mild Dyspnea ◦ Headache
Possible Cause Hypersensitivity (mod-severe) Febrile NH Ab to WBC Ab to proteins such as IgA Contamination with pyrogens and/or bacteria
Guidelines for the recognition of acute transfusion reactions Category 3: LIFE-THREATENING REACTIONS
Signs ◦ Rigors ◦ Fever ◦ Restlessness ◦ Tachycardia (rise of >20% in heart rate ◦ Hypotension (fall of >20% in systolic BP) ◦ Haemoglobuniria (red urine) ◦ Unexplained bleeding (DIC)
Symptoms ◦ Anxiety
Possible Cause
Acute intravascular haemolysis
◦ Respiratory distress/ shortness of breath
Bacterial contamination and septic shock
Fluid overload
Anaphylaxis
◦ Loin/ back pain
Transfusion associated acute lung injury
◦ Chest pain
◦ Pain near infusion site
◦ Dyspnea ◦ Headache
Hemolytic reactions
Non-immune mediated (physical destruction) ◦ Overheating-use of improvised blood warmers ◦ Forceful transfusion-pressure cuffs ◦ Small bore needles(?) ◦ Using same line for hypotonic solutions or drugs ◦ Bacterial growth in blood units
Hemolytic reactions
Non-immune mediated (physical destruction) ◦ Treatment Depends upon the severity of reaction Severe reaction, hypotension, shock and renal dysfunction -- Intensive management Hemoglobinuria or Hemoglobinemia --
ive therapy
Hemolytic reactions
Immune mediated ◦ Patient Ab reacting with donor Ag ◦ Wrong blood given ◦ Due to rxn with ABO, Rh, Lewis, Kelly ◦ Severity depends upon the amount transfused (as small as 10-15ml)
Hemolytic reactions
Immune mediated ◦ The most dramatic and challenging adverse event of blood transfusion. ◦ There is rapid destruction of blood cells. Most commonly occurs Whole blood Packed red cell
Hemolytic reactions
Immune mediated Can also occur in Fresh frozen plasma Platelet concentrate Other plasma derived
Hemolytic reactions
Immune mediated ◦ Acute Hemolytic Transfusion Reaction Immediately after or with in 24 hours of a transfusion Incidence: 1 in 12000 to 1 in 35000 transfusion Mortality: 1 in 100000 to 1 in 600000 transfusion
Hemolytic reactions
Immune mediated ◦ Delayed Hemolytic Transfusion Reaction Recognized 3 to 10 days after transfusion
Hemolytic reactions
Immune Mediated
Signs and Symptoms of Acute Immune Mediated Fever Dyspnea Chills and rigors Diarrhea Anxiety Hypotension Feeling of dread Hemoglobinuria Facial flushing Pallor Oliguria Icterus
Hemolytic reactions
Immune Mediated
Signs and Symptoms of Acute Immune Mediated Back pain Anuria Flank pain Pain on the Nausea transfusion site Vomiting Diffuse bleeding Chest pain Jaundice Abdominal pain
Hemolytic reactions
Immune Mediated
Signs and Symptoms of Chronic Immune Mediated Fever Jaundice Chills and rigors Oliguria Pallor Anuria Diffuse bleeding
Hemolytic reactions
Stop Transfusion
Severity depends on amount (as small as 30ml)
Maintain adequate systemic arterial blood
Pressure and tissue perfusion by hydration Normal saline solution Prevent renal failure (100ml/hr urine
Hemolytic reactions
Vaso-active agents (dopamine)
DIC – cryoprecipitate, platelet Investigate
◦ Blood typing ◦ Coomb’s test If positive identify antibody responsible
◦ Urine hemoglobin ◦ Culture of the remaining blood
Febrile Non-Hemolytic Reaction
Due to anti-leukocyte Antibody against
White cell and platelet of donor
Mild reaction
rule out Hemolytic Transfusion reaction
bacterial contamination
Febrile Non-Hemolytic Reaction
43% - 75% of all transfusion reaction
0.5% - 1.4% on non-leukocyte reduced red blood cell
15% recurrence rate
Febrile Non-Hemolytic Reaction
Fever
Chills with no reason ◦ Temperature increase of >1C associated with transfusion and without any other explanation
Febrile Non-Hemolytic Reaction
Treatment ◦ Antipyretics/steroids ◦ Antihistamines not indicated -- not involve histamine release ◦ if frequent -- washed Rbc
Allergic Transfusion Reaction
A rare complication of transfusion of blood components or plasma derivatives Can occur in (most common): ◦
Plasma rich blood component like Platelet concentrate
◦
FFP/Cryoprecipitate
Can also occur: ◦
Packed red cells
Allergic Transfusion Reaction
The risk is increased by rapid infusion, typically when fresh frozen plasma is used as an exchange fluid in therapeutic
plasma exchange.
Cytokines in the plasma may be one
cause of bronchoconstriction and vasoconstriction in occasional recipients.
Allergic Transfusion Reaction
Allergic transfusion reaction ◦
Due to binding of soluble substance in donor plasma with IgE antibodies
release of histamine
Allergic Transfusion Reaction
Uncomplicated allergic transfusion
reaction ◦
Anaphylactoid reaction
◦
45% of all transfusion Reaction
1%-3% of transfusion
Anaphylaxis ◦
0.002%-0.005% per transfused product
Allergic Transfusion Reaction
Allergic transfusion reaction ◦
Urticaria (diffuse or local)
◦
Discontinue temporarily but need not be stopped
◦
Stopped if with other systemic manifestation such as hypotension, GI manifestation
◦
Anti histamines
Allergic Transfusion Reaction
Anaphylactoid reaction ◦
Mild form of: Fever Chills Nausea Vomiting Diarrhea And/or Urticaria
Anaphylaxis
◦ ◦ ◦ ◦ ◦ ◦ ◦
Severe form (life threatening Fever Chills Nausea Vomiting Diarrhea And/or Urticaria
Allergic Transfusion Reaction
Anaphylaxis (life threatening) May include several systems ◦
Respiratory (cough, wheezing, chest tightness)
◦
GI (vomiting, diarrheas, nausea)
◦
Circulatory (arrhythmias)
Ig A deficiency
Allergic Transfusion Reaction
Treatment ◦
Stop transfusion
◦
Depends upon severity
Hypotension fluids, epinephrine
Bronchospasm B2 agonist, Theophyline
Post transfusion purpura
Thrombocytopenia 5 to 21 days
Patient makes an alloantibody in response to platelet antigens in the transfused blood that for a period of time (7-48days) causes destruction of autologous antigen-negative platelets.
Sign/Symptoms: Thrombocytopenia that is frequently profound, purpura, or bleeding
Post transfusion purpura
Treatment ◦
Platelet transfusion is of very little value - should be reserved for patients with active bleeding.
◦
Therapeutic plasma exchange may be beneficial.
Transfusion related Acute Lung Injury
Rare
Mortality: 10%
Abrupt onset of non cardiogenic pulmonary edema ◦ Rapid failure of pulmonary function usually presents within 1 to 4 hours of starting transfusion, with diffuse opacity on the chest X-ray.
Transfusion related Acute Lung Injury
Presence of antibodies in the donor plasma reactive to recipient leukocyte antigens
Production of inflammatory mediators
during storage of cellular blood components
Transfusion related Acute Lung Injury
Symptoms ◦ ◦ ◦ ◦ ◦ ◦
Respiratory distress Fever Chills Increased respiratory rate Cough Tachycardia
Transfusion related Acute Lung Injury
Most resolve within 72 hours
Treatment ◦
(O2, ventilation)
◦
Severe cases may require assisted ventilation with high FIO2.
Circulatory overload Fluid overload can result in heart failure and pulmonary edema. May occur when:
◦ Too much fluid is transfused ◦ The transfusion is too rapid ◦ Renal function is impaired.
Fluid overload is particularly likely to happen in patients with: ◦ Chronic severe anaemia ◦ Underlying cardiovascular disease.
Circulatory overload
May complicate up to 1 in 100 transfusion Symptoms ◦ ◦ ◦ ◦ ◦
Dyspnea Orthopnea Cough Tachycardia Hypertension
Infectious
Bacterial /Viral ◦ Can occur in: Packed red cells Plasma rich blood component (most common) Platelet concentrate FFP/Cryoprecipitate
Bacterial Infections
Packed red cells ◦ 2.6 per 100000 transfusions
Symptoms
Temperature higher than 38.5 Rigors Hypotension Nausea Vomiting
Dyspnea Diarrhea Shock Oliguria DIC
Bacterial Infections
Platelet concentrate (common)
8-80 per 100000 units transfused (random)
Symptoms ◦ Symptoms may begin during or shortly after transfusion or begin up to 2 weeks after transfusion: Fever, Chills, Hypotension
Viral Infections
Hepatitis ◦
Hepatitis A
◦
Hepatitis B
◦ ◦
Rare 1:1million 1:63000
Hepatitis C Hepatitis D
Viral Infections
Human Herpes Infection ◦
CMV
◦
EBV
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