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Transfusion Medicine:

Types, Indications and


Complications
Dr Putra Hendra SpPD
Uniba
Definisi
Blood transfusion is generally the process of
receiving blood products into one's circulation
intravenously.
Transfusions are used for various medical
conditions to replace lost components of the
blood.
Early transfusions used whole blood, but
modern medical practice commonly uses only
components of the blood, such as red blood
cells, white blood cells, plasma, clotting
factors, and platelets.
History of Transfusions
 Blood transfused in humans since mid-
1600’s
 1828 – First successful transfusion
 1900 – Landsteiner described ABO groups
 1916 – First use of blood storage
 1939 – Levine described the Rh factor
Golongan darah
 Penggolongan Darah Menurut Landsteiner

1. Penggolongan Darah ABO

2. Penggolongan Darah Rhesus


Aglutinogen dan Aglutinin adalah kandungan
protein didalam darah
Aglutinogen : protein berupa antigen.
Terdapat pada eritrosit

Aglutinin : protein berupa antibodi.


Terhadap pada plasma darah
Sistem Penggolongan Darah ABO
Berdasarkan komposisi aglutinogen dan
aglutininnya golongan darah manusia
dibedakan menjadi 4:

Golongan Golongan Golongan Golongan


Darah A Darah B Darah AB Darah O
2. Golongan Darah Sistem MN
 Tahun 1927 K.Landsteiner dan P Levine menemukan
antigen baru lagi disebut antigen M dan Antigen N.
 Reaksi dari sel – sel darah merah denagn antiserum
pada golongan darah tipe MN

Jika eritrosit Reaksi Denga Anti serum Golongan


mengandung Anti M n Anti N Darah
Hanya M + - M
Hanya N - + N
Hanya M & N + + MN
Cross matching
(Reaksi silang)
- Reaksi silang perlu dilakukan

sebelum melakukan transfusi


darah untuk melihat apakah
darah penderita sesuai dengan
darah donor.
Crossmatch

No agglutination ~
compatible

Agglutination ~
incompatible

Donor Patient serum


RBCs
(washed)
 Mayor crossmatch adalah serum penerima dicampur
dengan sel donor

 Minor Crossmatch adalah serum donor dicampur


dengan sel penerima.

 Jika golongan darah ABO penerima dan donor sama,


baik mayor maupun minor test tidak bereaksi.

 Jika berlainan umpamanya donor golongan darah O


dan penerima golongan darah A maka pada test
minor akan terjadi aglutinasi.
(A) The ABO blood
types. Schematic
representation of
antigens on the
RBCs and
antibodies in the
plasma.
(B) Typing and
cross-matching.
indikasi
Indications for transfusion of blood or its
components
 Whole blood: Acute massive bleeding
1 unit increases Hb: 1g/dl, Hct: 3%

 Fresh whole blood:


 Massively bleeding patient/shock
 Exchange transfusion, open heart surg, severe renal or hepatic
failure,

 Red blood cells:


 (To increase the oxygen carrying capacity in case of symptomatic
anemia not treatable by other means or due to urgency of
symptoms)
 Symptomatic anemia (May be due to different causes), post-
bleeding hypovolemia
This is not a guide to be used in
every patient

 Hemoglobin >10 g/dL : Tx rarely needed


 Hemoglobin < 6-7 g/dL: Tx mostly
necessary
 Hemoglobin : 6-10 g/dL: Dependable
Komponen darah
Apheresis:
Platelets
Plasma
White cells (or
subsets)
Red cells

The procedure
can be done for
treatment or
transfusion
purposes.
Istilah
 Autologous
 derived from organisms of the self; same
individual; "autologous blood donation"

 Heterologous
 derived from organisms of a different but related
species; "a heterologous blood donation”
 Apheresis
 Greek work meaning “take out”
 The process of removal of whole blood from a donor or
patient, separating out specific portions, and returning
the other portions to the donor/patient
 Can be done for
 Harvesting specific components for transfusion (plasma, platelet,
red cells)
 Removal of specific pathologic substances

 Cytapheresis
 Toharvest specific cellular components such as
platelets, granulocytes or red cells.
 Plasmapheresis
 Toharvest plasma only and return back the cellular
components to the donor/patient
Blood Components
 Prepared from Whole blood collection or apheresis
 Whole blood is separated by differential centrifugation
 Red Blood Cells (RBC’s)
 Platelets
 Plasma
 Cryoprecipitate
 Others

 Others include Plasma proteins—IVIg, Coagulation


Factors, albumin, Anti-D, Growth Factors, Colloid volume
expanders
 Apheresis may also used to collect blood components
Differential Centrifugation
First Centrifugation

Closed System

Whole Blood Satellite Bag Satellite Bag


Main Bag 1 2
First

Platelet-rich
RBC’s Plasma
Differential Centrifugation
Second Centrifugation

RBC’s Platelet-rich
Plasma
Second

Platelet Plasma
RBC’s Concentrate
Whole Blood
 Storage
 4° for up to 35 days
 Indications
 Massive Blood Loss/Trauma/Exchange Transfusion
 Considerations
 Use filter as platelets and coagulation factors will not
be active after 3-5 days
 Donor and recipient must be ABO identical
RBC Concentrate (Packed red
cell/pRC)
 Storage
 4° for up to 42 days, can be frozen
 Indications
 Many indications—ie anemia, hypoxia, etc.
 Considerations
 Recipient must not have antibodies to donor RBC’s
(note: patients can develop antibodies over time)
 Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)
 Usually transfuse over 2-4 hours (slower for chronic
anemia
Platelets
 Storage
 Up to 5 days at 20-24°
 Indications
 Thrombocytopenia, Plt <15,000
 Bleeding and Plt <50,000
 Invasive procedure and Plt <50,000
 Considerations
 Contain Leukocytes and cytokines
 1 unit/10 kg of body weight increases Plt count by 50,000
 Donor and Recipient must be ABO identical
Plasma and FFP
 Contents—Coagulation Factors (1 unit/ml)
 Storage
 FFP--12 months at –18 degrees or colder
 Indications
 Coagulation Factor deficiency, fibrinogen replacement, DIC, liver
disease, exchange transfusion, massive transfusion
 Considerations
 Plasma should be recipient RBC ABO compatible
 In children, should also be Rh compatible
 Account for time to thaw
 Usual dose is 20 cc/kg to raise coagulation factors approx 20%
Cryoprecipitate
 Description
 Precipitate formed/collected when FFP is thawed at 4°
 Storage
 After collection, refrozen and stored up to 1 year at -18°
 Indication
 Fibrinogen deficiency or dysfibrinogenemia
 vonWillebrands Disease
 Factor VIII or XIII deficiency
 DIC (not used alone)
 Considerations
 ABO compatible preferred (but not limiting)
 Usual dose is 1 unit/5-10 kg of recipient body weight
Granulocyte Transfusions
 Prepared at the time for immediate transfusion
(no storage available)
 Indications – severe neutropenia assoc with
infection that has failed antibiotic therapy, and
recovery of BM is expected
 Donor is given G-CSF and steroids or Hetastarch
 Complications
 Severe allergic reactions
 Can irradiate granulocytes for GVHD prevention
Leukocyte Reduction Filters
 Used for prevention of transfusion reactions
 Filter used with RBC’s, Platelets, FFP,
Cryoprecipitate
 Other plasma proteins (albumin, colloid
expanders, factors, etc.) do not need filters—
NEVER use filters with stem cell/bone marrow
infusions
 May reduce RBC’s by 5-10%
 Does not prevent Graft Verses Host Disease
(GVHD)
RBC Transfusions
Preparations
 Type
 Typing of RBC’s for ABO and Rh are determined for
both donor and recipient
 Screen
 Screen RBC’s for atypical antibodies
 Approx 1-2% of patients have antibodies
 Crossmatch
 Donor cells and recipient serum are mixed and
evaluated for agglutination
WHOLE BLOOD ABO AND
RH COMPATIBILITY
DONOR
RECIPIENT A B O AB Rh Rh
Positive Negative
A 
B 
O 
AB 
Rh Positive  
Rh Negative 
RBC Transfusions
Administration
 Dose
 Usual dose of 10 cc/kg infused over 2-4 hours
 Maximum dose 15-20 cc/kg can be given to hemodynamically
stable patient
 Procedure
 May need Premedication (Tylenol and/or Benadryl)
 Filter use—routinely leukodepleted
 Monitoring—VS q 15 minutes, clinical status
 Do NOT mix with medications
 Complications
 Rapid infusion may result in Pulmonary edema
 Transfusion Reaction
PACKED RBC ABO AND RH
COMPATIBILITY
DONOR
RECIPIENT A B O AB Rh Rh
Positive Negative
A  
B  
O 
AB    
Rh Positive  
Rh Negative 
Platelet Transfusions
Preparations
 ABO antigens are present on platelets
 ABO compatible platelets are ideal
 This is not limiting if Platelets indicated and type
specific not available
 Rh antigens are not present on platelets
 Note: a few RBC’s in Platelet unit may sensitize the
Rh- patient
Platelet Transfusions
Administration
 Dose
 May be given as single units or as apheresis units
 1 apheresis unit contains 6-8 Plt units (packs) from a
single donor
 Procedure
 Should be administered over 20-40 minutes
 Filter use
 Premedicate if hx of Transfusion Reaction
 Complications—Transfusion Reaction
Transfusion Complications
 Acute Transfusion Reactions (ATR’s)
 Chronic Transfusion Reactions
 Transfusion related infections
Acute Transfusion Reactions
 Hemolytic Reactions (AHTR)
 Febrile Reactions (FNHTR)
 Allergic Reactions
 Over load
 TRALI
 Coagulopathy with Massive transfusions
 Bacteremia
Febrile Nonhemolytic
Transfusion Reactions (FNHTR)
 Definition--Rise in patient temperature
>1°C (associated with transfusion without
other fever precipitating factors)
 Occurs with approx 1% of PRBC
transfusions and approx 20% of Plt
transfusions
 FNHTR caused by alloantibodies directed
against HLA antigens
 Need to evaluate for AHTR and infection
What to do?
If an FNHTR occurs
 STOP TRANSFUSION
 Use of Antipyretics—responds to Tylenol
 Use of Corticosteroids for severe reactions
 Use of Narcotics for shaking chills
 Future considerations
 May prevent reaction with leukocyte filter
 Use single donor platelets
 Use fresh platelets
 Washed RBC’s or platelets
Allergic Nonhemolytic Transfusion
Reactions
 Etiology
 May be due to plasma proteins or blood
preservative/anticoagulant
 Best characterized with IgA given to an IgA deficient
patients with anti-IgA antibodies
 Presentswith urticaria and wheezing
 Treatment
 Mild reactions—Can be continued after Benadryl
 Severe reactions—Must STOP transfusion and may
require steroids or epinephrine
 Prevention—Premedication (Antihistamines)
Massive Transfusions
 Coagulopathy may occur after transfusion
of massive amounts of blood
(trauma/surgery)
 Coagulopathy is caused by failure to
replace plasma
 See electrolyte abnormalities
 Due to citrate binding of Calcium
 Also due to breakdown of stored RBC’s
Acute Hemolytic Transfusion Reactions
(AHTR)
 Occurs when incompatible RBC’s are transfused into a
recipient who has pre-formed antibodies (usually ABO or
Rh)
 Antibodies activate the complement system, causing
intravascular hemolysis
 Symptoms occur within minutes of starting the
transfusion
 This hemolytic reaction can occur with as little as 1-2 cc
of RBC’s
 Labeling error is most common problem
 Can be fatal
Symptoms of AHTR
 High fever/chills
 Hypotension
 Back/abdominal pain
 Oliguria
 Dyspnea
 Dark urine
 Pallor
What to do?
If an AHTR occurs
 STOP TRANSFUSION
 ABC’s
 Maintain IV access and run IVF (NS or LR)
 Monitor and maintain BP/pulse
 Give diuretic
 Obtain blood and urine for transfusion reaction
workup
 Send remaining blood back to Blood Bank
Blood Bank Work-up of AHTR
 Check paperwork to assure no errors
 Check plasma for hemoglobin
 DAT
 Repeat crossmatch
 Repeat Blood group typing
 Blood culture
Labs found with AHTR
 Hemoglobinemia
 Hemoglobinuria
 PositiveDAT
 Hyperbilirubinemia
 Abnormal DIC panel
Monitoring in AHTR
 Monitor patient clinical status and vital
signs
 Monitor renal status (BUN, creatinine)
 Monitor coagulation status (DIC panel–
PT/PTT, fibrinogen, D-dimer/FDP, Plt,
Antithrombin-III)
 Monitor for signs of hemolysis (LDH, bili,
haptoglobin)
Bacterial Contamination
 More common and more severe with
platelet transfusion (platelets are stored
at room temperature)
 Organisms
 Platelets—Gram (+) organisms, ie
Staph/Strep
 RBC’s—Yersinia, enterobacter
 Risk increases as blood products age (use
fresh products for immunocompromised)
Transfusion Associated Infections
 Hepatitis C
 Hepatitis B
 HIV
 CMV
 CMV can be diminished by leukoreduction,
which is indicated for immunocompromised
patients
Chronic Transfusion Reactions
 Alloimmunization
 Transfusion Associated Graft Verses Host
Disease (GVHD)
 Iron Overload
 Transfusion Transmitted Infection
Alloimmunization
 Can occur with erythrocytes or platelets
 Erythrocytes
 Antigen disparity of minor antigens (Kell, Duffy, Kidd)
 Minor antigens D, K, E seen in Sickle patients
 Platelets
 Usually due to HLA antigens
 May reduce alloimmunization by leukoreduction (since
WBC’s present the HLA antigens)
Washed Blood Products
 PRBC’s or platelets washed with saline
 Removes all but traces of plasma (>98%)
 Indicated to prevent recurrent or severe
reactions
 Washed RBC’s must be used within 24 hours
 RBC dose may be decreased by 10-20% by
washing
 Does not prevent GVHD
TRALI
Transfusion Related Acute Lung Injury
 Clinical syndrome similar to ARDS
 Occurs 1-6 hours after receiving plasma-
containing blood products
 Caused by WBC antibodies present in
donor blood that result in pulmonary
leukostasis
 Treatment is supportive
 High mortality
Transfusion Associated GVHD
 Mainly seen in infants, BMT patients, SCID
 Etiology—Results from engraftment of
donor lymphocytes of an
immunocompetent donor into an
immunocompromised host
 Symptoms—Diarrhea, skin rash,
pancytopenia
 Usually fatal—no treatment
 Prevention—Irradiation of donor cells
Donor screening
2Donor Eligibility Criteria

Wt > 45 Kg
 Who can donate?

• Age: 18 - 60 years
• Weight : > 45 kgs
• Hemoglobin level: >12 gms/dl for men
and 12.5 gms/dl for women
• In good health
3. Deferral Criteria
Who CANNOT donate?
Life long 1 year 6 Months
х Abnormal bleeding o Surgery o Tattooing or
disorder body piercing
х Heart, Kidney, Liver o Typhoid
Disorder o Dental
х Thyroid disorder o Dog bite extraction

х Epilepsy, Mental
disorders o Unexplained o Root canal
weight loss treatment
х Tuberculosis, Leprosy,
х Asthma o Continuous o Malaria
х Cancer low grade
fever o Vaccination
3. Deferral Criteria…
(Donor Consent Form)

Postpone donation for 6 months if you have


risk factors for HIV/AIDS , such as..

 Having sex with more than one partner


without using condom
for vaginal, anal or oral sex
 Intravenous drug abuse
 Having sex with a person who could have
the above risk factors
3. Deferral Criteria…
(Donor Consent Form)
Female donors cannot donate
blood……
 During pregnancy
 After delivery for one year
 When lactating
 During menstrual period and for 7 days
therafter
Male donors cannot donate blood……
 If cosumed Alcohol in the previous 24
hours
5. Blood Donation Procedure
Remember!

The Donor Must ….

 have had good rest /


sleep

 have had light meal

 be mentally prepared
PHYSICAL EXAMINATION

 General appearance of donor


 Determination of hemoglobin
 Males Hb: >12.5 g/dl
 Females Hb: >12.0 g/dl
 Pulse
 50-100 beats/min
 Blood pressure
 Maximum 140/90 mm Hg
PHYSICAL EXAMINATION

 Temperature
 Maximum 37.5 0C
 Donor weight
 Minimum 45 Kgs
 Amount of blood to be drawn
 (Donor wt. in Kg÷50) X 450

 Venipuncture site
 Inspection for scar marks
TYPE OF BLOOD DONATION
 WHOLE BLOOD DONATION

 APHERESIS DONATION

 AUTOLOGOUS BLOOD DONATION


CRITERIA FOR APERESIS PLATELET
DONATION

 Preferably regular donor


 Weight
 >55 Kgs
 Good venous access
 Prior investigations required
 FBC
 VDRL
 HbsAg
 Anti HIV
 Anti HCV
Transfusion transmitted
pathogens
• Hepatitis ( C,B,A ,D etc ) • Malaria
• HIV • Lyme ? (not enough evidence)
• HTLV • Chagas
• CMV • Babesiosis
• E-Barr • Sy
• HHV • Toxoplasmosis
• Creutzfeldt-Jakob or • West Nil virus
• variant CJD (therotical)
• Parvovirus
HBV
 HBsAg become positive 50-60 days after
infection
 Preceded by a prolonged phase (up to 40
days) of low-level viraemia
 Long doubling time of 4 days
HBV
HCV
HIV
D. HIV
ADA beberapa RAPID TEST HIV (Food and Drug
Administration (FDA)
1. OraQuick Rapid HIV-1 / 2 Antibody Test
- spesimen
darah utuh
(whole blood),plasma, serum,
- hasil dalam 20 menit.
- larutan developer
- Posisi Tegak
5. Blood Donation Procedure
Volume of blood collection

Donor Blood Amount Used for


Weight collected
45 kgs - 350ml Single Whole Blood
55 kgs bag
> 55 kgs 450 ml Double / Blood
Triple Components
bag
Post Donation Advice
 Drink lots of fluids for next 24 hours
 Avoid smoking for one hour & alcohol till after
a meal
 Don’t use elevator to go up immediately after
donation as it will make blood rush to your feet
& make you dizzy!
 Avoid highly strenuous exercises & games
for a day
 If you feel dizzy, lie down & put your feet up.
You will be alright in 10-20 mins.
 Remove band-aid after 4 hours. If it bleeds,
apply pressure & reapply band-aid. If bruised and
painful, apply cold-pack 4 to 5 times for 5 mins
each. The bruise is due to blood seeping into the
surrounding tissue. It will take a few days to get
reabsorbed.
Benefits to Donor of blood donation

Health benefits:
Regular donation (2-3 times a year….)
 Lowers cholesterol
 Lowers lipid levels
 Decreases incidence of heart attacks,
strokes
What can YOU do?
 Make Blood Donation a HABIT
 Donate regularly – every 3 months
to commemorate special days like
birthdays, anniversaries ….
 Motivate others to donate
 Refer your friends and relatives