Components JLV
Components JLV
Components JLV
PRODUCTION
1
Components
Describe how differential centrifugation is utilized to
prepare components such as platelet concentrate &
cryoprecipitate.
Differentiate among the following components in terms of
preparation, storage temperature, shelf life, composition,
approximate volume, & quality control standards: whole
blood, packed RBC's, leukocyte reduced RBC's, frozen
RBC's, rejuvenated RBC's, fresh frozen plasma, single
donor plasma, cryoprecipitate, & platelet apheresis
products.
Given a component, diagram the appropriate method for
its preparation from a freshly drawn unit of whole blood.
2
Milestones in the Development of
Transfusion Practice
1665First transfusion (dog to dog)
1667 Dennis
first human transfusion (lamb’s blood)
1818 Blundell
first human transfusion with human blood
1900 Landsteiner
discovered ABO blood groups
1907 Ottenberg
introduced pretransfusion compatibility testing
3
Post World War II:
Expansion of Blood
Bank network
Use of plastic tubing
& bags for storage
4
Post World War II:
Development of
blood component
therapy
Testing of blood for
infectious agents
5
Plastic Bag
7
Plastic Bag
“Over Thanksgiving vacation in 1947, he
fashioned a primitive bag with diaphragm-sealed
tube and ports. And on the following Monday, he
drew up a patent claim. Commercial concerns
were at first unimpressed, and Walter instead
gathered his own experts to work on needed
improvements to the plastic.”
8
Plastic Bag
“His company became Fenwal, Incorporated (the
name was an amalgamation of his own and his
next-door neighbor’s, an investment counselor
named T. Legare Fenn, who helped with the
financing). Some of the initial clinical trials of the
polyvinyl resin blood bag, fittingly enough, took
place at the Brigham.”
9
Blood Volume
45% of blood volume is cellular
Red cells, white cells, platelets
55% of blood volume is liquid
plasma
10
11
Component Therapy
12
Advantages of
Component Therapy
14
15
16
Whole Blood
17
WHOLE BLOOD
Volume: 450 ml +- 10%
Anticoagulant: 63 ml
Expiration: 21 to 35 days
Storage Temp: 1 to 6 C
HCT increase: 3% in adult
18
Indications for WB
Provides oxygen carrying capacity, stable
coagulation factors and blood volume
Actively bleeding
Loss of > 25% blood volume
For massive blood loss, transfuse as fast as
patient can tolerate
Usually transfused over 1 ½ to 4 hours
19
Whole Blood
20
Whole Blood Must Be ABO
Identical
Recipient’s Donor’s
Blood Group Blood Group
A A
B B
AB AB
O O
21
Whole Blood Characteristics
After Storage in CPDA-1
Plasma dextrose
Plasma K
pH
Lactate
Plasma LDH
Whole-blood ammonia
Plasma hemoglobin
2,3 DPG
ATP
22
PACKED RED
BLOOD CELLS
LEUKOCYTE REDUCED BY
FILTRATION
23
Blood Products: PRBCs
Single Donor (1 unit= ~300cc) or Pheresis (2 units)
• Typical HCT 0.65-0.7
• Need to anticoagulate
• Citrate-phosphate-dextrose-adenine (CPDA)
• Extended storage, additive solutions (AS), Plasma
removed first
Adsol (AS-1)
Nutricel (AS-3)
Optisol (AS-5)
24
PACKED RED BLOOD
CELLS
Shelf life: 21-42 days
Storage Temp: 1- 6 C
Restore or maintain
O2-carrying capacity for
symptomatic patients who
are not treatable within a
reasonable amount of time
with iron, vitamin B12, folic
acid or erythropoietin
Demand for O2 varies
HCT increase
25
Blood Components
• Red Cells – CPDA-1
– prepared by removing ~ 80%
of plasma in Whole Blood -
avg. vol. ~ 250 to 300 mL
– hct cannot be greater than
80%
– by removing plasma - vol. is
reduced & still get the same
O2 carrying capacity
– 35 day expiration
26
Red Cells with
Adenine-saline-
preservative
remove an additional 50
mL of plasma that is
replaced with 150 ml
adenine-saline
increases shelf life of cells
to 42 days
AS1 Hematocrit of final product
is 55-65%
27
Red Cells Aliquots
most often transfused to
neonates 2nd to
fetomaternal bleed
hemorrhage
tests]
vol.is usually 10 to 25 mL
Sterile docking - life of unit
enter unit then 24 hours
28
Red Cells Irradiated
reduce risk of graft versus
host disease in
allogeneic bone
immunodeficiencies
Hodgkins
WBC’s
is not used for graft vs. host
30
LEUKOCYTE REDUCED
RED BLOOD CELLS
WBC < 5 x 10 6
Repeated febrile
transfusion reactions
Prophylaxis against
alloimmunization
Prevention of CMV
transmission
31
LEUKOCYTE REDUCED
RED BLOOD CELLS
Expiration: Depends
on anticoagulant
Storage Temp:
1 to 6 C
Transfuse in < 4
hours
32
Packed Red Blood Cells
Volume: ~ ½ of WB
Transfused as fast as patient can tolerate
but < 4 hours (1 ½ to 4 usual)
Must crossmatch
Very little plasma - does not have to be
group specific
Must be ABO compatible
O universal donor
AB universal recipient
33
Choice of Packed Cells
Recipient’s Donor’s
Blood Group Blood Group
A A, O
B B, O
AB AB, A, B, O
O O
34
PACKED RED BLOOD CELLS
Indications for:
Measurement of HCT/Hgb only cannot
accurately assess the need for
transfusion
Hemoglobin: 6 – 10 g/dL
Tachycardia
Hypotension
35
Packed Red Blood Cells
Symptoms of anemia
Generalized
weakness
Headache
Dizziness
Disorientation
Breathlessness
Palpitations or chest
pain
Tachycardia
36
WASHED RED BLOOD CELLS
To remove plasma
Suspend in normal saline
Removes 98% plasma
Reduces concentration of leukocytes
Removes platelets and cellular debris
37
Frozen Red blood
cells
38
Deglycerolization
39
Frozen Red Blood Cells -
Deglycerolized
Expiration:
10 years (while frozen)
store at -65C or colder
24 hours “after
thawing” stored at 1-
6C
Approximately 1 hour to
thaw and “deglycerolize”
40
Frozen PRBC
• 10% glycerol long term storage frozen
• Thaw and wash away glycerol
• WBC and CMV destroyed by this.
• For rare blood types or multiple
alloantibodies
41
Deglyerolization
Quality Control
Recovery of 80% rbcs
Sickle cell positive
70% viability after 24
units will not
survive routine
hours
freezing and
<1% residual glycerol
deglycerolization
Osmolarity
Simulate
transfusion
42
PLATELETS
43
Preparation of Platelets
Whole Blood
44
Preparation of Platelets
Separate into:
Packed red cells
Platelet rich plasma
Heavy spin – 5min/3600 RPMs
Following spin: “Rest” 1 to 2 hrs
46
concentrate from a single unit
is referred to as random-
donor platelets
when harvested by
plasmapheresis, called single
donor platelets
47
Pheresis
Apheresis (or just pheresis):
Greek: apo+hairien to take away
48
Pheresed single donor
platelets
contain at least 3.0 x 1011
platelets
have about 300 mLs
Reduces exposure to
donors
49
Collection & Storage
Whole blood derived Apheresis
50
PLATELETS
Platelet concentrates
Whole Blood Donation
5.5 x 10 10 platelets
50 – 70 ml plasma to
maintain pH of 6.2 or >
Platelet pheresis
Apheresis collection
3 x 10 11 platelets
51
Functionally Abnormal Platelets
Exposure of blood to the extra corporeal
circuit (ECMO) leads to impairment of the
hemostatic system and a predisposition to
excessive bleeding
Hypothermia (<95C)
52
Platelets
Indications:
Platelet count
<20,000/uL
<50,000/uL– scheduled for minor procedure
<100,000/uL – scheduled for major surgery
53
PLATELETS - CONTRAINDICATIONS
55
Platelet Refractoriness
Immune
HLA or platelet alloantibodies
Nonimmune
Bleeding
Splenomegaly
DIC
Fever
Sepsis
56
ABO Group Considerations for
Platelet Transfusions
Rh matters - Some rbc contamination
If Rh neg female gets Rh Pos - RHIG
Crossmatch if > 2 ml of rbcs
Plasma should be compatible
ABO-incompatible
Pos DAT
Rarely hemolysis
Leukoreduced
May be washed
57
Platelet Preparation for
Transfusion
A dose of random donor (WB) platelets is
usually 4-6 platelets that are pooled into a
single bag
Expiration is 4 hours at RT
A platelet pheresis may consist of one
single bag or two joined bags.
If
2 bags, pool together prior to transfusion
Expiration after pooling is 24 hours at RT
58
CRYOPRECIPITATE
59
Cryoprecipitate Preparation
FFP is frozen
Thawed slowly at 1-6 C
Cold insoluble portion
removed
Storage: -18 C or lower
Expiration: 12 months
60
Cryoprecipitate
predominately
factor VIII at least 80 (to
120) units of activity &
fibrinogen 150 to 250 mg
von Willebrand’s
prepared by freezing
plasma within ~ 4 to 6 hrs.
of collecting unit.
plasma is then thawed
slowly at 1 to 6C
61
remove all but about 10 to 15
mL’s of plasma
precipitate can then be frozen
up to 12 months
62
CRYOPRECIPITATE contains:
Factor VIII:C 80 to 120 units
Factor VIII:vWF
Fibrinogen
Onlyconcentrated product currently available
Contains approximately 250 mg (150mg)
Factor XIII
Fibronectin
63
Preparation of Cryo for Transfusion
65
GRANULOCYTE
CONCENTRATES
66
Granulocytes (Leukapheresis)
Indications
Neutropenia
Unresponsiveto antibiotics
Reasonable chance for recovery of marrow
function
67
Preparation
Cytapheresis of single donor (most
common method)
“Buffy coat” prep from single units of fresh
WB for neonates
68
Granulocytes
24 hour expiration
Stored at Room Temperature (20 to 24 C)
Red cell compatibility (crossmatch) must be
performed
Minimum transfusion of 1-2 x 10 10 granulocytes
given in four daily doses have been reported to
demonstrate clinical benefit
Blood administration set with 150-280 micron filter
Do not use leukocyte reduction filters
69
Granulocyte
Concentrates
collectedby
cytopheresis
should contain 1 x 1010
granulocytes
if steroid have been given
to donor 12 to 24 hrs.
before collection OR
hydroxyethyl starch
[HES] is used to enhance
separation
should
contain 200 to
600 mL of plasma
70
store at 20 to 24C &
use within 24 hrs [as soon
as possible]
mainly used for
neonatal sepsis
have had most success
with severe neutropenias,
fevers unresponsive to
antibiotics for 24 to 48
hrs. & myeloid hypoplasia
71
PLASMA
72
Single Donor Plasma Fresh Frozen
a by product of WB, Plasma
platelet concentrate, Frozen within 8 hrs.
or cryoprecipitate of collection at –18C
used as a source of or lower.
stable clotting factors Has both stabile &
only & 2ndarily vol. labile factors
expander
Used when there is
most used in prep of
active bleeding,
plasma protein multiple clotting
fraction, serum factor deficiencies
albumin, & immune
globulin
73
Preparation of Plasma
Whole Blood
74
FRESH FROZEN PLASMA
Volume approximately
250 ml
Expiration
1 year if frozen (-18C or
lower)
24 hours thawed (1 to 6
C)
75
FRESH FROZEN PLASMA
Expected Increase in 70kg adult
1 Unit increases most factors approx. 2.5%
4 Units increase most factors approx. 10%
Indications for use:
Clinically significant deficiencies of Factors II, V, X
and XI.
Multiple factor deficiencies
Liver disease
Warfarin treatment (Vitamin K antagonist)
Dilutional and consumption coagulopathy
Plasma exchange treatment for TTP or HUS
Replace deficient vWF processing protease in TTP
76
Transfusion of FFP
Recipient’s Donor’s
Blood Group Blood Group
A A, AB
B B, AB
AB AB
O O, A, B, AB
77
Note: Rh need not be considered for FFP
FFP Notes
Thaw at 30-38 C
Water bath –over wrap
Microwaves
Expiration :24 hours after
thawing to be called FFP
Does not need to be
crossmatched
Transfusion time usually
30 to 60 minutes
78
FFP Notes
Recovered Plasma
Up to 5 days after unit
expiration
Solvent/detergent-
treated plasma
Treated with a solvent
and a detergent to
eliminate lipid-enveloped
viruses
Used in Europe but
phased out in the U.S.
79
Factor VIII concentrate
For classic hemophilia A bleeding disorders
and at times for von Willebrand’s
Usually from large volumes of pooled
plasma which has high risk for transmission
of viral diseases. To avoid
Pasteurization
Monoclonal Purification
81
Porcine Factor VIII
Used when hemophiliac has developed inhibitors
Purification techniques have improved & reduced
side effects
Factor IX Concentrate
Frompooled plasma
Newer product is purified by immunoaffinity
Contains more Factor IX, less II, VII & X
Fewer problems with formation of thrombi
82
Blood Components Review
W h o le B lo od U n it
ce n trifu ge
83
Requirements for
Storage and Expiration
Component Storage Transport Expiration
85
Requirements for
Storage and Expiration
Component Storage Transport Expiration
86
Component Storage
Component temp Expiration transfusion
Transfusion Therapy
89
Blood longevity
RBC 120 days
WBC 7 hrs
Platelets 10 days
90
With Age of Stored RBC
K+ rises accelerated by irradiation
Free Hb rises
2,3 DPG falls (O2 dissociation curve shifts
to left, increasing affinity)
Intracellular Ph falls
91
PRBC: Storage Solutions
92
PRBC Options
• Leukoreduction:
Reduces leukocytes to ‹ 5x106 per unit-
Filtration
Febrile reactions
TA-GVHD
• Radiation:
• 25Gy, inactivate T cells. Applies only to fresh
components (PRBC, plt, grans)
• Immunocompromised: BMT, onc, heart, lung
transplant
93
CMV
• Lives in WBC
• Leukoreduced blood as safe as
seronegative blood
• Indication CMV negative blood
• All premies, sick neonates
• Immunodeficient patients
• Oncology
• Transplant recipients
94
PRBC Options, cont’d
• Washing: PRBC
• IgA deficient
• Persistent allergic reaction
• Removes proteins
• Use 1-2l Normal saline
• 20% RBC lost
• Use within 24hrs
• Washing: Platelets
• Use NS or buffered saline
• Retains 90% platelets
• Must be used within 4hrs
• Sickle negative
• Standard for all sickle cell patients
• Standard for ECMO, exchange 95
Transfusion Associated Graft
Versus Host Disease
• 90% fatality
• Immunodeficient host
• Interuterine transfusion. Exchange, ECMO
• Oncology Pt
• BMT
• HLA heterozygous who receives transfusion form HLA
homozygous relative- always irradiate relative’s blood
96
Irradiation
• 2500Gy
• Kills all dividing cells (T-cells)
• Increases K+ in stored RBC
• Shortens storage life to 28days
97
Platelets
98
Blood Products: Platelet
99
Platelet Options
Leukoreduced (Universal)
Concentrated
Allergic reaction
Volume reduction (must be severe restriction)
Washed
Moderate/persistent or Severe allergic reaction
IgA deficient
Note: Reduced plt number and function with
concentration/washing
Irradiated
100
Platelet Options
Platelet Concentration
From whole blood donation –random donor platelets –RDP 5-7
E10 plt 50-60ml
0.1u/kg increases platelets by 50,000
Apheresis single donor platelets SDP, 3-5E11, =5-8U of RDP or
150-400ml
Other information
Infection risk rises after day 5
ABO and RH specific (not always done)
101
Blood Products: Platelet
CCI Plt increment x BSA
1h >5000 # units transfused
24h >2500
Ex: 7,000-37,000 1h after 2 units:
30,000* 0.6m2 = 15,000
2
If bad increment
Consumption (fever, splenomegaly, DIC, infection)
HLA alloimunized: match HLA-A, HLA-B loci (check with
Quick Screen (screen for anti-HLA Ab)
Rarely HPA alloimmunized
Amphoteracin other antibiotics
IVIG if in a bind
102
Treatment of Platelet
Refractoriness
HLA antibodies
HLA matched
X-matched compatible platelets
Platelet allo-antibodies
Antigen match
X-matched compatible platelets
Auto antibodies
IVIG
Steroids
Splenectomy
103
Blood Products: FFP
Fresh frozen plasma (unit= ~300cc)
Prepared from plasma separated from whole blood
Frozen within 8 hours= FFP
Most “24h plasma”
Used for factor replacement
10cc/kg gives 20% factor activity
Except I, VIII, XIII (use cryo)
1 Unit ~300cc
NO OPTIONS
(Don’t ask for washed plasma)
104
Blood Products: Cryoprecipitate
-O- 105
Granulocytes
Indications
ANC <500 or qualitative defect
Documented bacterial/fungal infection not
responsive to Abx
Chance for neutrophil recovery
< 2weeks old, bacterial sepsis, neutrophils <300
Must be ABO/Rh compatible
Irradiated
Used ASAP <4h (some 6-10hr)
Donors get dex or G-CSF
Study to open at JHH
106
Transfusion and Transplant
Stem cells don’t express A,B
Can transplant across ABO
Minor (incompatible plasma for the recipient)
Donor has anti-A or anti-B in plasma
O donor into A recipient
Passenger lymphocyte
Major (incompatible cells for the recipient)
Recipient makes anti-A or anti-B
A donor into O recipient
Bonus: B into A?
Minor: donor has anti-A
Major: recipient makes anti-B
107
Acquired Bleeding Disorders
Liver Disease
Disseminated Intravascular Coagulation
Sepsis,
trauma, OB complications,
malignancy, intravascular hemolysis
108
Vitamin K Deficiency and
Antagonism
Fat soluble vitamin necessary for synthesis in liver of
Factors II, VII, IX, X, protein C and protein S
Deficiency can occur in patients in intensive care
unit, those with chronic disease and receiving
antibiotics and those with general fat malabsorption
states such as celiac disease or obstructive jaundice
Oral Anticoagulants (warfarin) interfere with Vitamin-
K dependent synthesis of Factors
109
Liver Disease
Coagulation factors are synthesized in the
liver
May have multiple coag problems
Coagulation factor deficiency
Impaired vitamin K utilization
110
Disseminated Intravascular
Coagulation (DIC)
Uncontrolled activation of coagulation and
secondary fibrinolysis
Thrombin is generated by pathologic
release of tissue factor into the blood or by
widespread endothelial damage
111
Disseminated Intravascular
Coagulation (DIC)
Treat underlying cause
Chief clinical manifestation
Bleeding due to consumption of platelets and
coag factors (fibrinogen)
Common clinical conditions predisposed
Sepsis, trauma, OB complications,
intravascular hemolysis, malignancy
112
PLASMA DERIVATIVES
Factor VIII (concentrates/recombinant)
Factor IX (concentrates/recombinant)
Immune Globulin
Antithrombin
Activated Protein C (recombinant)
Factor VIIa (recombinant)
113
Hemophilia A
X- linked congenital bleeding disorder
Gene deletion or point mutation
Factor VIII deficiency (Coagulant portion)
Hemophilic bleeding manifests several hours after
the trauma and occurs most frequently in deep
structures (joints, muscles)
Von Willebrand Factor Levels are normal
Mild or moderate hemophilia A can be treated with
DDAVP
Severe disease usually requires infusion of Factor
VIII concentrates
10-15% develop antibodies after repeated infusions
114
Hemophilia B
Clinically manifests like Hemophilia A
Factor IX Deficiency
Treated with Factor IX concentrates
DDAVP is not effective
115
Factor VIII concentrate
Human plasma or recombinant technology
Recombinant produced in established hamster
cell lines
stabilized with the addition of human albumin
Recombinant product of choice
Treatment or prevention
of bleeding episodes in
hemophilia A
Certain Factor VIII
concentrates have been
used to treat vWD
Humate-P
Alphanate
Koate DVI
117
Dose and Administration
Quantity of Factor VIII coagulant activity is stated
on the bottle in IU
Reconstitute with sterile diluent
1 IU is amount Factor VIII present in 1 ml of normal
plasma
Formula:
Desired units of Factor VIII =
Plasma Volume x {Desired level (%) – initial level (%)}
100
118
Factor IX Concentrate
Plasma derived
Highly purified preparation with trace amounts
of Factors II, VII, X
Recombinant (Chinese hamster ovary cell
line)
Treatment of choice for hemophilia B
119
Antithrombin Concentrate
Inhibitor of thrombin, activated Factors
IX,X,XI,XII
Used to treat patients with hereditary AT
deficiency who have thrombosis or require
prophylaxis when scheduled for surgery
Pooled human plasma - heat treated
120
Factor VIIa
Recently licensed to
treat bleeding in
hemophilia patients with
inhibitor
Probably works by
enhancing thrombin
generation through
direct activation of
Factor X leading to
thrombin activated
platelet surfaces
121
Factor VIIa
122
Factor VIIa (NovoSeven)
Binds with tissue factor to
activate factor X.
Binds directly to activated
platelets (no effect on
unactivated) promoting the
generation of factor Xa on
the platelet surface to
produce thrombin
Thrombin generated on
the platelet surface
promotes formation of a
stable fibrin clot
123
Protein C Concentrate
Inhibitor of coagulation
Vitamin K dependent
Inhibits activated Factors V and VIII in
presence of Protein S
Treatment of Protein C Deficiency
124
Fibrin Sealant
FDA has licensed a fibrin sealant kit
Uses lyophilized, virus inactivated pooled
human fibrinogen and thrombin with a bovine
albumin stabilizer
Applied to surgical site to generate a cross
linked fibrin clot to stem bleeding
125
Immune Globulin
Cold ethanol fractionation
Pools of human plasma
Gamma globulin preparation
Provide passive antibody prophylaxis
HBIG
IVIG
ITP
126
RHIG
IgG anti-D
IV or IM preparations
Rh negative
individuals
Within 72 hours
300 ug dose
15 ml rbcs
30 ml WB
127
History
negative blood to
deliver healthy Rh-
positive babies. Dr.
Freda also introduced
amniocentesis.
128
RHIG
ITP
FDA approved for
Rh positive, non-
splenectomized
IV administration
Advantages of IV-Ig
Lower cost
Lower volume
129
Urgent and Massive
Transfusions
Urgent Transfusion
Administration of blood before pretransfusion
testing is complete
Patient’s physician must sign stating nature of
emergency
130
Urgent and Massive
Transfusions
Massive Transfusion
Replacement of one or more blood volumes
within 24 hours (10 or > units)
Four stages in massive transfusion setting
Blood coagulation support
Potential for fibrinolysis
Metabolic complications
131
Why do surgical patients bleed?
Anatomic defects
Dilution or consumption of coagulation
factors and platelets
Hypothermia
Below 33 C the clotting becomes slower
Significant decrease in platelet adhesion as
temperature decreases
Acidosis
As pH decreases there is a decrease in
coag Factor activity
132
Historical Reasons to Limit
Transfusions
Risk of transfusion reaction
Disease transmission
Immunosuppression
133
Immunologic Effects
T-cell proliferation, Natural killer cell
activity, and CD3, CD4 and CD8 T cells
are decreased
Soluble cytokine receptors, serum
neopterin, cell-mediated lympholysis,
tumor necrosis factor alpha and
suppressor T-cell activity are increased
134
Transfusion Immunomodulation
(TRIM)
Rejection rates lower in transfused transplant patients
Survival rates lower and recurrence rate higher in
transfused cancer patients
Makino et al J Gastroenterology. 2000;95:1294-1300
Landers et al Anesth Anlg. 1996;83:197-204
Allogeneic transfusion
Decreased cell mediated immunity
Decreased macrophage migration
Decreased NK cell activity
All of above reduced with LR products
135
Transfusion is only blood replacement
therapy for acute blood loss
However, 85% of transfusions in non-
trauma settings
136
Current Reasons to Limit
Transfusions
Documented increased morbidity and mortality
directly related to transfusion
In trauma patients, transfusions are shown to be
independent markers of death, infection
Taylor et al CCM. 2002; 30:2249-2254
Transfused trauma patients (after stratification for age,
etc.) suffer:
10 fold increased risk for mortality and a 6 fold increase
in mean ICU LOS
Malone et al J Trauma. 2003; 54:898-907
137
Current Reasons to Limit Transfusions
138
Current Reasons to Limit Transfusions
139
Current Reasons to Limit Transfusions
Correlation between transfusion doses and rates
of infection and mortality
One study
Patients receiving up to two transfusion had an
infection incidence of 0.2 or less
Patients receiving 15 transfusions had incidence of
1.0
Another study
Infection odds ratio of 1.06 for patients receiving only
intraoperative transfusions and 9.28 for those
receiving more than 4 units
Mortality odds ratio was 1.08 and 2.84 respectively
140
Current Reasons to Limit
Transfusions
Critically ill patients can tolerate a low
hemoglobin
Restrictive transfusion strategies (7-9
gm/dl) and transfusion of 2.5 +- 3.8 units
carried about an 81% survival rate after 30
days, declining to 77% after 60
Similar results with liberal transfusion
strategies (10-12 gm/dl)
However, trend reversed with critically ill
patients with cardiovascular disease –
more liberally transfused fared better.
141
Current Reasons to Limit
Transfusions
Shortage of blood
Aging donors
Increasing exclusions
142
Transfusion Considerations
Corwin et al Chest 1995; 108-767
85% patients in ICU >1 week received PCs
Most receive 9.5 units
Average 2-3 u/week
Anemia not due to acute blood loss
Multifactorial anemia of critical illness
Chart review
Up to 40% transfused with no indication
Transfusion triggers arbitrary
Rarely based on physiologic parameters
143
Irradiation - Review
Indicated for cellular components that
contain viable lymphocytes for
immunosuppressed patients
Prevent proliferation of transfused T lymphs
Primary cause of TA-GVHD
Donor units from relatives
HLA matched platelets
144
Irradiation
Dosage: 2500cGY to center of bag
Lymphocytes: inhibits mitotic activity and blast
formation
Granulocytes: No significant damage unless
extremely high dose
Mature rbc: Extremely resistant; some K loss
Platelet functions: Impaired function only at
very high levels
145
Confirming Irradiation
Radio chromic film labels affixed to bags
prior to irradiation
When exposed to an adequate amount the
film portion darkens indicating adequate
irradiation
146
Expiration Date –
Irradiated Products
Red cell components – 28 days or original
expiration date of the unit whichever is
less
Platelets – minimal damage – expiration
does not change
147
Indications for
Irradiated Products
Patients at risk for TA-GVHD
Fetuses receiving intrauterine transfusions
Immunocompromised recipients
Recipients undergoing marrow or progenitor
cell transplantation
Recipients of HLA matched platelets
Recipients of Donor units from blood relatives
148
Cytotoxic Drug Treatment
Requirement for blood transfusion support
has increased dramatically with
The design of new cytotoxic drug treatment
protocols
More extensive use of these forms of
treatment for various malignant tumors
149
Cytotoxic Drug Treatment
Cytotoxic drugs
Act by either inhibiting cell division or by inhibiting
general cellular metabolism
Are used in various combinations to treat different
cancers
Malignancies
Characterized by a large number of cells that are
actively dividing or in active metabolic states
Other tissues in the body also consist of dividing and
metabolically active cells (bone marrow)
150
Roles in Blood Transfusion
Blood Bank Blood Administration
Identify patient and Prepare patient
sample Prepare site and
Perform all testing equipment
Store and handle Identify product
blood appropriately and patient
Release correct Administer product
product Assess for
Document reactions
Document
151
Immediately before initiating
transfusion:
Obtain vital signs
Temperature, pulse, respirations, blood pressure
Provide a baseline measurement against which any
changes during the transfusion can be compared
Should be recorded in the patient record
Fever:
May be cause for delaying transfusion
Could mask a symptom of an acute transfusion reaction
May compromise the efficacy of platelet transfusions
152
Premedication
May be required if patient has a history of adverse
reactions
Patient’s mediation regimen should be reviewed prior
to transfusion
Febrile reactions may be prevented by administering
acetaminophen
Antihistamines my be required for patients with a
history of allergic reactions
Meperidine hydrochloride may prevent or treat chills or
rigors accompanying granulocyte transfusions
153
Obtaining the Blood
Procedure will vary for institutions
Essential guidelines include:
Startof infusion within 30 minutes of the time
the component is released from the blood bank
Proper ID of the blood component and recipient
Careful handling while in transit
154
Identification
Accurate identification of the donor’s blood
and the intended recipient
Single most important step in ensuring a
safe transfusion
Identification when blood is issued
Identification when blood is administered
155
Administration of Blood
Final Inspection Before Issue:
Blood container have attached label or tag
indicating:
Intended recipients two independent identifiers
Donor unit number or pool number
156
Administration of Blood
At issue:
Verify:
Intended recipient’s two identifiers, ABO group and Rh
type
Donor unit number and donor ABO group and Rh type
(if required)
Interpretation of crossmatch if performed
Special transfusion requirements
Date and item of issue
157
Administration of Blood
Time Limits for Infusing Blood
Components
Within 4 hours
Concomitant Use of IV Solutions
Only Normal saline
Lactated Ringers – No
Drugs - No
158
Administration of Blood
Filters
Allblood components
must be administered
through a filter to remove
clots/debris
Standard blood filters
170 micron filter
Microaggregate filters
20 – 40 microns
pressure exerted
160
Administration of Blood
Blood Warming
Transfusions of cold blood at rates >100mL/minutes
associated with higher rate of cardiac arrest
(hypothermia)
Types
Coil of plastic tubing
Electrically heated plates
Clinical Situations for Possible Use
Neonatal exchange transfusion
Plasma exchange
Surgery
Trauma
Cold Agglutinin Disease
161
Return of Unused Blood
Refrigerated components may not be
returned to inventory if they have been
warmed to more than 10C
30 minute maximum allowable time out of
temperature monitored storage
162
Return of Unused Blood
Reissue of Blood and Components
Container closure has not been disturbed
Components maintained at correct temp
At least one sealed segment of the integral
donor tubing has remained attached
Records indicate that component has been
inspected and is acceptable for reissue
163
Costs- Blood collection center
perspective
Increased costs of producing a unit of blood
Recruitingdonors
Increased complexity and cost of testing
Competing with other industries to retain qualified
personnel
Increased regulatory requirements and voluntary industry
standards
Screening and testing for HIV, AIDs, Hepatitis
Safety measures, WBC reduction
164
Costs – Hospitals Perspective
Purchase of blood
Other significant
costs
Labor
Equipment and
supplies
Laboratory
Administration
Overhead
165
Reimbursement
“The financial risk to hospitals, as well as to hospital
departments, of potential underpayment for care
involving blood-related components and services
depends in part on the relative proportion of hospital
activity involving these components and services.
Hospitals that provide more blood-intensive care
relative to their total care will be at greater risk to
the extent that updates to the Medicare PPS fail to
account for cost increases in blood-related
components and services.” Transfusion –August 2003 Supplement
166
Blood Utilization Review
Joint Commission on the Accreditation of
Healthcare Organizations (1961)
American Association of Blood Banks
Part of quality plan
Code of Federal Regulations
Qualify for Medicare reimbursement
167
Blood Utilization Review
Blood usage audits/guideline development
Blood usage trends
Critical transfusion events
Transfusion reactions
Transfusion transmitted disease
surveillance
Blood administration practice
168
Blood Banking Case Study
Listed below is your current blood bank inventory at the Back of Bourke Hospital.
AS-1 RBCs
Number 10 15 5 4
RBC
Group A AB O
Number 15 4 10
FFP
For each of the following requests what would you issue
and crossmatch as required (assume each event independent) ?
1. Patient female 26 years, group AB NEG, 2 units of RBCs, 4 units of FFP
170
Question
Which one of the following units of RBCs is
acceptable to give to a Group B positive
recipient?
A. Group O positive
B. Group A positive
C. Group A negative
D. Group AB negative
171
Question
Which one of the following units of Whole
Blood is acceptable to give to a Group B
positive patient?
A. Group O positive
B. Group O negative
C. Group B positive
D. Group AB positive
172
Question
Which one of the following units of Whole
Blood is acceptable to give to a Group B
positive patient?
A. Group O positive
B. Group O negative
C. Group B positive
D. Group AB positive
173
Question
175