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BLOOD TRANSFUSION Dr. Nischal Shrestha Intern College of Medical Sciences Teaching Hospital Bharatpur-10, Chitwan Nepal

BLOOD TRANSFUSION

BLOOD TRANSFUSION Dr. Nischal Shrestha Intern College of Medical Sciences Teaching Hospital Bharatpur-10, Chitwan Nepal

Dr. Nischal Shrestha

Intern

College of Medical Sciences Teaching Hospital Bharatpur-10, Chitwan Nepal

DEFINITIONS

Blood product

Any therapeutic substance prepared from human blood

Whole blood

Unseparated blood collected into an approved container containing an anticoagulant-preservative solution

Blood component

A constituent of blood, separated from whole blood, such as:

Red cell concentrate Plasma Platelet concentrates Cryoprecipitate

WHOLE BLOOD (CPD-

Adenine-1)

Description 350 ml donor blood 49 ml anticoagulant-preservative solution

Hemoglobin approximately 12 g/ml Hematocrit 35%45%

No functional platelets

No labile coagulation factors (V and VIII)

Unit of issue 1 donation, also referred to as a ‘unit’ or ‘pack’

Infection risk Not sterilized

Capable of transmitting any agent present in cells or plasma which has not been detected by routine screening for transfusion-transmissible infections

Storage Between +2°C and +6°C

Transfusion should be started within 30 minutes of removal from refrigerator

Indications Acute blood loss with hypovolemia

Exchange transfusion

Patients needing red cell transfusions where red cell concentrates or suspensions are not available

Contraindications Risk of volume overload in patients with:

Chronic anemia Incipient cardiac failure

Administration Must be ABO and RhD compatible with the recipient

Never add medication

Complete

transfusion

commencement

within

4

hours

of

RED CELL CONCENTRATE

(‘Packed red cells’, ‘plasma-reduced blood’)

Description 150200 ml

red cells

from

which

plasma has been removed

most

of

the

Hemoglobin approximately 20 g/100 ml (not less than 45 g per unit)

Hematocrit 55%75%

Unit of issue 1 donation

Infection risk: Same as whole blood

Storage: Same as whole blood

Indications Replacement of red cells in anemic patients

Use with crystalloid replacement fluids or colloid solution in acute blood loss

Administration Same as whole blood

To improve transfusion flow, normal saline (50100 ml)may be added using a Y-pattern infusion set

PLATELET CONCENTRATES

Description

Single donor unit 5060 ml of plasma should contain:

At least 55 x 10 9 platelets

<1.2 x 10 9 red cells

<0.12 x 10 9 leucocytes

Unit of issue

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 10 9 platelets

Infection risk Same as whole blood

Normal adult dose involves between 4 and 6 donor exposures

Bacterial contamination: 1% of pooled units

Storage Up to 72 hours at 20°C to 24°C

Indications

Treatment of bleeding due to:

Thrombocytopenia

Platelet function defects

Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure

Contraindications

Not generally indicated for prophylaxis of bleeding

in

surgical

patients, unless known to have

significant pre-operative platelet deficiency

Not indicated in:

ITP TTP Untreated DIC Thrombocytopenia

associated

with

septicemia, until

treatment

commenced or in cases of

has

hypersplenism

Dosage 1 unit of platelet concentrate/10 kg body weight

Increment will be less if there is:

Splenomegaly Disseminated intravascular coagulation Septicemia

Administration

After pooling, platelet concentrates should be infused as

soon as possible within 4 hours, because of bacterial proliferation

the

risk of

Must not be refrigerated before infusion as this reduces platelet function

Infused through a fresh standard blood administration set 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

Give

platelet

concentrates

whenever possible

that

are

ABO

compatible,

Complications

Febrile

non-hemolytic

and

allergic

urticarial

reactions are common, especially in patients receiving multiple transfusions

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

Factor VIII plasma level

level at least 70% of

normal fresh

Unit of issue Usual volume of pack is 200300 ml

Smaller volume packs may be available for children

Infection risk If untreated, same as whole blood

Very

low

risk

if

treated

with

methylene

blue/ultraviolet light inactivation

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

Indications

Replacement of multiple coagulation factor deficiencies:

Liver disease Warfarin overdose

Depletion of coagulation factors in patients receiving large volume transfusions

DIC

TTP

Precautions

Acute allergic reactions are not uncommon, especially with rapid infusions

Severe life-threatening anaphylactic reactions occasionally occur

Hypovolemia alone is not an indication for use

Dosage Initial dose of 15 ml/kg

Administration

Must normally be ABO compatible to avoid risk of hemolysis in recipient

No compatibility testing required

Infusion using a standard blood administration set as soon as possible after thawing

Labile coagulation factors rapidly degrade, should be used within 6 hours of thawing

CRYOPRECIPITATE

Description

Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C and re-suspending it in 1020 ml plasma

Contains

about

half

of

the

Factor

VIII

and

fibrinogen in the donated whole blood

Unit of issue

Usually supplied as a single donor pack or a pack

of

6

or more

pooled

single donor units that have been

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

Indications

As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of:

von

Willebrand

Factor (von Willebrand’s

disease) Factor VIII (hemophilia A) Factor XIII

As

a

source

of

fibrinogen

coagulopathies: e.g. DIC

in

acquired

Administration If possible, use ABO-compatible product

No compatibility testing required

After

thawing,

should

be

infused

as

soon as

possible through a standard blood administration

set

Must be infused within 6 hours of thawing

ACUTE

TRANSFUSION

REACTIONS

Acute intravascular hemolysis

Antibodies in the patient’s plasma hemolyse the incompatible transfused red cells.

The most common cause is an ABO incompatible transfusion.

Even blood

a small volume (1050 ml) of incompatible

can

cause

a

severe

reaction

and

larger

volumes increase the risk.

In the conscious patient, signs and symptoms usually appear within minutes of commencing the

transfusion, sometimes when less than 10 ml have

been given.

In

an

unconscious

or anaesthetized patient,

hypotension and uncontrollable bleeding due to

disseminated intravascular coagulation (DIC) may be the only signs of an incompatible transfusion.

This almost always arises from:

Errors in the blood request form

Taking blood from the wrong patient into a pre- labelled sample tube

Incorrect labelling of the blood sample tube sent to the blood bank

Inadequate

checks

of

the

blood

against

the

identity

of

the

patient

before

starting

a

transfusion.

Prevention Correctly label blood samples and request forms.

Place the patient’s blood sample in the correct sample tube.

Always check the blood against the identity of the patient at the bedside before transfusion

Bacterial contamination

and

septic shock

Blood may become contaminated by:

Donor’s skin during blood collection (usually skin staphylococci)

Bacteremia present in the blood of donor at the time the blood is collected (e.g. Yersinia)

Improper handling in blood processing

Defects or damage to the plastic blood pack

Thawing fresh frozen plasma or cryoprecipitate in a water-bath (often contaminated).

Some

contaminants,

particularly

Pseudomonas

species, grow at 2°C to 6°C and so can survive or multiply in refrigerated red cell units.

Staphylococci grow in warmer conditions and proliferate in platelet concentrates at 20°C to 24°C, limiting their storage life.

Affects up to 0.4% of red cells and 12% of platelet concentrates.

Signs usually appear rapidly after starting infusion, but may be delayed for a few hours.

A severe reaction may be characterized by sudden onset of high fever, rigors and hypotension.

Urgent supportive care and high-dose intravenous antibiotics are required.

Fluid overload (Transfusion Associated Cardiovascular Overload [TACO] )

Fluid overload can result in heart failure and pulmonary edema (cardiogenic)

May occur when:

Too much fluid Too rapid Renal function is impaired

Fluid overload is particularly likely to happen in patients with:

Chronic severe anemia Underlying cardiovascular disease.

Anaphylactic reaction

A rare complication.

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

bronchoconstriction

and

occasional recipients.

may be

one

cause of

vasoconstriction

in

Occurs within minutes of starting the transfusion and is characterized by:

Cardiovascular collapse Respiratory distress No fever

Anaphylaxis is likely to be fatal if it is not managed rapidly and aggressively.

Transfusion-

associated acute lung injury (TRALI)

Caused by donor plasma that contains antibodies against the patient’s leucocytes

Rapid

failure

of

pulmonary function usually

presents within 1 to 2 hours of starting transfusion

(always before 6 hours), with diffuse opacity on the

chest X-ray.

There is no specific therapy.

Intensive respiratory and general support in an intensive care unit is required.

Risk factors

Donor factors Increased risk: multiparous woman Decreased risk: male, nulliparous woman

Recipient factors

Increased risk: smoking, chronic alcohol use, shock, liver surgery (transplantation),

mechanical

ventilation

>30cm

h20

pressure

support and positive fluid balance

Guidelines for the recognition

and management of

acute transfusion reactions

Delayed hemolytic transfusion reactions

Signs and symptoms

Signs appear 510 days after transfusion:

Fever Anemia Jaundice Occasionally hemoglobinuria

Severe life-threatening are rare.

Management No treatment is normally required

Treat

as

for

acute

intravascular

hemolysis

if

hypotension and renal failure occur

Investigations:

Recheck the patient’s blood group

Direct antiglobulin test is usually positive

Raised unconjugated bilirubin

Prevention

Careful laboratory screening for red cell antibodies in the patient’s plasma and the selection of red cells compatible with these antibodies.

Some reactions are due to rare antigens (i.e. anti- Jka blood group antibodies that are difficult to

detect pre-transfusion)

Post-transfusion purpura

A

rare

but

potentially

fatal

complication

of

transfusion of red cells or platelet concentrates

Caused by antibodies directed against platelet- specific antigens in the recipient.

Most commonly seen in female patients.

Signs and symptoms Signs of bleeding

Acute, severe thrombocytopenia 510 days after transfusion, defined as a platelet count of less than 1,00,000 cells/mm 3 .

Management High dose corticosteroids.

High dose IV immunoglobulin, 2 g/kg or 0.4 g/kg for 5 days

Plasma exchange

Monitor the patient’s platelet count

Recovery of platelet count after 24 weeks is usual

Prevention Expert

advice

is

essential and only platelet

concentrates that are compatible with the patient’s antibodies should be used.

Graft-versus-host disease

A

rare

and

transfusion.

potentially

fatal

complication

of

Occurs in such patients as:

Immunodeficient transplants

recipients

of

bone marrow

Immunocompetent patients transfused with blood from individuals with whom they have a compatible tissue type (HLA: human leucocyte

antigen), usually blood relatives.

Signs and symptoms Typically occurs 1012 days after transfusion.

Characterized by:

Fever Skin rash and desquamation Diarrhea Hepatitis Pancytopenia.

Management

Usually fatal. Treatment is supportive; there is no specific therapy.

Prevention

Gamma irradiation of cellular blood components to stop the proliferation of transfused lymphocytes

Iron overload

There

are

no

physiological

eliminate excess iron

mechanisms

to

Transfusion-dependent patients can, over a long period of time, accumulate iron in the body

resulting in hemosiderosis.

Signs and symptoms

Organ failure, particularly of the heart and liver in transfusion-dependent patients.

Management and prevention

Iron-binding agents, such as desferrioxamine, are widely used to minimize the accumulation of iron in transfusion-dependent patients

Aim to keep serum ferritin levels at <2000 mg/L

Transfusion-transmitted infections

The following infections may be transmitted by transfusion:

HIV-1 and HIV-2 HTLV-I and HTLV-II Hepatitis B and C Malaria

Syphilis (Treponema pallidum) Chagas disease (Trypanosoma cruzi) Cytomegalovirus (CMV)

Other rare transfusion-transmissible infections, including human parvovirus B19, brucellosis, Epstein-Barr virus, toxoplasmosis, infectious mononucleosis and Lymesdisease.

CONCLUSION

Used

correctly,

transfusion

can

be

life-saving.

Inappropriate use can endanger life.

Transfusion should be prescribed only when the

benefits to the patient are likely to outweigh the

risks.

A trained person should monitor the transfused patient and respond immediately if any adverse

effects occur.

Blood donated by family/replacement donors carries a higher risk of transfusion-transmissible infections than blood donated by voluntary non-

remunerated donors.

Paid

blood

incidence

donors

generally

and

prevalence

have

of

transmissible infections.

the

highest

transfusion-