L-9 and 10 Transfusion I and II

Transfusion Objectives

• Describing the concept of the transfusion trigger helps analyze the risks and benefits in deciding whether to transfuse
• Listing the major blood components currently transfused and their major indications is important
• Creating and using a chart showing donor-recipient blood group compatibility is fundamental
• Stem cell transplantation's role in current and future hematological and organ system disease therapy is significant

Transfusion Trigger

• Transfusion trigger is the level of hemoglobin (Hb) which indicates RBC transfusion
• Transfusion target is the Hb level targeted after RBC transfusion
• Traditionally, a "10/30" rule was followed for RBC transfusion which is a Hb level of 10 g/dl or a hematocrit of 30% when recommended for surgical patients
• The decision to transfuse RBCs relies on laboratory values and the objective evaluation of the patient's clinical condition
• Compensating for blood loss depends on a patient's age, co-morbidities, illness severity, and hemorrhage rate/amount

Blood Loss

• Compensation for blood loss 0-15% is a blood loos volume of 500-1000ml, has no blood pressure change, and is characterized by palpitations, dizziness, and tachycardia
• Mild blood loss of 15-25% is a blood loss volume of 1000-1500ml, with a slight fall of 80-100 mmHg in blood pressure, and is characterized by symptoms of weakness, sweating and tachycardia
• Moderate blood loss of 25-35% is a blood loss volume of 1500-2000ml, with a marked fall of 70-80 mmHg in blood pressure, and is characterized by symptoms of restlessness, pallor, and oliguria (decreased urinary output)
• Severe blood loss of 35-45% is a blood loss volume of 2000-3000ml, profound blood pressure drop of 50-70 mmHg, and it is characterized by collapse, air hunger, and anuria (no urinary output)

Whole Blood

• Whole blood unit is 405 to 495 ml, and it is stored at 4°C
• Whole blood provides oxygen-carrying capacity and volume, but no functioning platelets or white cells
• Whole blood is indicated for acute hemorrhage with >25% blood loss, and it is the product of choice for providing oxygen-carrying capacity
• Whole blood is used to treat patients who need all the blood components, especially after trauma with >20% blood loss or surgery

Blood Component Production and Use

• Red blood cells are for trauma, surgery or severe anemia; stored for 42 days in the refrigerator or 10 years in the freezer
• Fresh frozen plasma treats coagulation factor deficiencies or shock from burn/bleeding plasma loss lasting 1 year in the freezer
• Platelet concentrate treats or prevents bleeding from low platelet levels and functional platelet problems, and is stored for 5 days at room temperature
• Cryoprecipitate is to treat fibrinogen deficiencies and has a storage length of 1 year

Rules for Infusion

• Rules for infusion are making sure to have Informed Concent, using the adequate Needle Size, setting a Rate of infusion, calculating Maximum infusion time, infusing useful Solutions and additives, using adequate Filtration, and adequate Documentation.

Autologous Red Blood Cells

• Autologous red blood cells are provided by a patient for their own use
• Autologous red blood cells follow the same indications as allogeneic blood, plus multiple allo-antibodies and rare types
• They are safer than allogeneic transfusions, but not 100% safe
• A possible complication is circulatory overload

Autologous Transfusions

• Pre-operative autologous donation is a type of autologous transfusion
• Intra-operative blood salvage involves drawing a patient's blood during surgery to return if needed
• Intra-operative hemodilution involves blood removal and fluid replacement to maintain blood volume which may lead to dilutional coagulopathy
• Post-operative blood salvage, or perioperative autologous transfusion (PAT), involves drawing or collecting a patient's blood and transfusing it back after surgery

Leukodepleted Blood Products

• Leukodepleted blood products are washed cells, frozen-deglycerolized cells, or filtered
• Leukodepleted blood products are for people that are likely to receive a massive transfusion, people in who platelet refractory would be problematic, people at risk of febrile reactions, and people at risk of severe CMV infection

Irradiated Blood Products

• Irradiated blood products help prevent "Graft vs. Host" Disease
• Irradiated blood products are for immuno-compromised hosts and first degree relatives
• Blood products to irradiate are whole blood, red cells, platelets, granulocytes and fresh plasma

Blood Transfusions

• Leukoreduced RBCs: HLA alloimmunization against class I antigens does not occur, and they do not transmit CMV; they are for chronically transfused patients, transplant recipients, febrile nonhemolytic reaction patients, and CMV negative patients
• Irradiated RBCs: eliminate immunologically competent lymphocytes, and prevent GVHD in patients with hereditary immune deficiency states
• Washed RBCs: considered when plasma proteins cause reactions like IgA deficiency or anaphylaxis

Leukoreduced/Irradiated Transfusion Indications

• Universal agreement
• T-cell defects (acquired/congenital)
• Hematopoietic stem-cell transplantation-HSCT (auto/allo, before/after)
• Intrauterine transfusions
• Premature infants <1200 g
• Hodgkin's lymphoma patients
• Transfusions from blood relatives
• HLA-matched products

Platelet Function

• Platelets must be adequate in number and function to participate optimally in homeostasis
• Functions of platelets in homeostasis are:
  • Maintenance of vascular integrity
  • Initial arrest of bleeding by platelet plug formation
  • Stabilization of hemostatic plug by contributing to fibrin formation

Platelet Concentrate

• Platelet Concentrate is 15 to approx. 50ml and contains platelets, RBC and WBC
• Platelet treatment is for thrombocytopenic bleeding, and the administration of 1 unit/kg can raise platelets 20,000–50,000 ml/mcl
• Platelets share same risks as RBC's
• A complication from pooled platelets can be alloimmunization, which can produce antibodies that quickly remove transfused platelets from circulation

Indications for Platelet Transfusions

• When Platelet count is below 5-10 x 10^9/L
• Because of their short half life, must be given 2 to 3 times/week in chronic conditions

Fresh Frozen Plasma

• A unit of fresh frozen plasma is 200-250 ml
• All coagulation factors are maintained
• Formulations are: FFP, donor retested plasma, and Plasma SD

Indications for use of Frozen Plasma

• Frozen Plasma contains Clotting Factors and is is use in patients with blood-clotting disorders
• No value as a volume expander

Cryoprecipitate and Desmopressin

• A typical bag of Cryoprecipitate contains 5 to 15 ml
• Cryoprecipitate provides Factor VIII, vWF, and Fibrinogen.
• Cryoprecipitate is an Rx for:
  • Hemophilia A
  • Von Willebrand's
  • HypofibrinogenemiaDysfibrinogenemia
• The other product is is DDAVP

Lyophilized Factor IX

• Is a Freeze Dried Factor II, VII, IX, and X
• Is now Recombinant Production for IX
• Now poses no Infection Risk

Plasma Derivatives

• Provide growth factors, cytokines, and chemokines targeting resident and immigrated cells belonging to the innate and adaptive immune system which are critical for pathogen clearance in early phase of wound repair
• Plasma Derivatives are factor VIII concentrate, factor IX concentrate, Anti-inhibitor Coagulation Complex (AICC), Albumin, Immune Globulins (including Rh Immune Globulin), Anti-Thrombin III Concentrate, and Alpha 1-Proteinase Inhibitor Concentrate.

Blood cross-matching

• A sample of patient's blood is taken to determine ABO and Rh status
• A Laboratory test to determine if patient is making antibodies to any red cell proteins is needed
• Donated red cell unit ABO and Rh status is determined along with antibody screening
• Blood is mixed with serum to test for any reaction, or "cross match"

Blood Types

• RBC antigens are called agglutinogens, and the called antigen A and B
• Agglutinogens are determined by carbohydrate moieties found on RBC surface
• Antibodies are called agglutinins and are found in plasma
• The agglutinins are Anti-A and anti-B
• ABO antibodies are naturally occurring from birth

ABO Blood Groups

• Type A: RBCs carry agglutinogen A
• Type B: RBCs carry agglutinogen B
• Type O: RBCs carry no A nor B agglutinogens
• Type AB: RBCs carry both A and B agglutinogens
• Blood type is determined by agglutinogens

Blood Type B

• RBCs carry type B agglutinogens
• Plasma contain agglutinin against A agglutinogens

Blood Type O

• RBCs carry neither type A nor type B agglutinogens
• Plasma contains agglutinin against both A and B agglutinogens
• A person with blood type O can only accept type O blood transfusion

Blood Type AB

• Type AB blood has Agglutinogen A and B
• Type AB blood has neither Agglutinin A nor B

Summary of ABO Blood Groups

• Blood Type Agglutinogen and Agglutinin is summarized:
  • A: A and B
  • B: B and A
  • O: none and A and B
  • AB: A and B and none

Summary: ABO for the non-Blood Banker

• A summary of the May Receive versus May Give Blood to is listed:
  • Group A/A Antigen/Anti B/ Group A & O/ Group A & AB
  • Group B/B Antigen/Anti A/ Group B & O/ Group B & AB
  • Group AB/ Both Antigen A and B/Neither Anti A nor Anti B/Group A, B, AB & O/ Group AB Only
  • Group O/ Neither Antigen A nor B/ Both Anti A and Anti B/ Group O Only/ Group A B, AB or O

Rh Blood Groups

• classify blood groups based on Rh agglutinogens other than A/B agglutinogens which can be positive or negative
• Rh positive have RBCs that contain Rh agglutinogens
• Most human beings are Rh positive

Rh Blood Groups: Rh negative

• The RBCs contain no Rh agglutinogens, and agglutinins against Rh-positive RBCs are produced after Rh-negative blood sees Rh-positive RBCs
• In the case of a transfusion, a Rh-negative patient can receive moderate amounts of blood except that with the Rh antigen

Universal Donors Vs Universal Acceptors

• Universal donors: can donate their blood to anyone, and have O negative blood group
• Universal acceptors: can accept blood from anyone, and have AB positive blood group

Blood Type Statistics

• The frequency of blood types are:
  • O+=38%
  • A+=34%
  • B+=9%
  • O-=7%
  • A-=6%
  • AB+=3%
  • B-=2%
  • AB-=1%

Rh hemolytic disease develops

• Erythroblastosis fetalis of hemolytic disease of the newborn is likely to occur in the following circumstances:
  • If the fetus is Rh+
  • If the father is Rh+
  • If this is the mother's second pregnancy

First Pregnancy Complications

• Less likely to cause hemolytic disease of the newborn because of protection by the placenta-blood barrier
• The mother is not exposed to Rh agglutinogens until the time of childbirth due to placental tearing

Treatment During Second Pregnancy

• Born with severe anemia Erythroblastosis Fetalis
• Prophylaxis: use anti-Rh y globulin (Rh IgM) to mask Rh agglutinogens

How To Read Your Results

• You can determine your blood type by observing how the blood sample interacts with various indicator treatments such as anti-A, anti-B and anti-D treatments.

Future of Blood Transfusions

• The future of blood transfusions lies in
  • Artificial Blood Substitutes
  • Pathogen Reduction Technologies
  • In Vitro Expansion of Cellular Blood Elements
  • Gene Therapy

Stem Cells

• Stem cells are found in bone marrow, peripheral blood, and cord blood

Stem Cells:

• Hematopoietic stem cell transplantation (HSCT) is a standard of care for hematologic malignancies such as multiple myeloma, multiple sclerosis, Non-Hodgkin lymphoma, Hodgkin lymphoma, and Chronic Myeloid leukemia CML
• HSCT is also standard of care for congenital or acquired disorders of the hematopoietic system like Thalassemia Also applied as a therapeutic option in some of the solid tumors

Informed Transfusion Consent

• Communicate: Describe/dicuss why a patient might need a transfusion
• Objections: Give information on risk, benefits and alternatives to transfusion
• Notify: All relevant staff
• Safety: -Inform patient -No donation after transfusion -Donor screening -Risk associated with transfusion

Gaining an Informed Transfusion Consent

• Explain : Transfusion information and provide information i.e., leaflets, Give the patient the opportunity to ask questions (with the right to refuse)
• Notes: Document in patient notes, list the reason for the transfusion, and date/time/signature of clinician and witness before transfusion commences
• Transfuse: Only when the above steps have been performed and blood has been checked and rechecked and then checked again
• consent can only be taken by a physician

Blood Transfusions Complications -

• Types Of Blood Transfusion Reactions are: -Acute hemolytic transfusion reaction -Delayed hemolytic transfusion reaction -Pyrogenic reaction -Allergic reaction -Anaphylactic reaction -Transmission of infectious disease

Decision to Transfuse

• In all cases transfusion must be a balance of the risk versus the benefits
• Transfusion is never completely risk free
• Consideration is the of Transfusion Triggers, not just the lab values

Indications for Blood Transfusion

• Sympatomatic blood transfusion are for the following symptoms:
  • Tachycardia >100 bpm
  • Mental Status Changes
  • ECG signs of cardiac ischemia
  • Angina(not chest pain)
  • SOB, light headedness, or dizziness and mild distension
• The never be based on lab values alone

Clinical indications (adult) for Blood Transfusion are:

-Hgb <8 in an asymptomatic patient patient
-Hg<11 in a symptomatic patient
-Chronic transfusion regimen (i.e. sickle cell anemia)

Transfusion Trigger

• Transfusion is initiated on the following indicators.
  • patient's age
  • co-morbidities
  • severity of illness
  • the rate and amount of hemorrhage are taken into account before transfusion.

Summary: Informed consent for Transfusion

• Consent for Transfusion Required as standard of care -Must contain all required elements - Expected benefits - Possible risks - Alternative therapy - Understandable language - Chance to ask questions Patient should never be forced/pressured into having a transfusion

The follow rules should be taken during the procedure

• Make sure the correct blood is given to the right patient.
• The most critical period of the transfusion is the initial period.
• Stop the transfusion and keep the IV open when the reaction is suspected.
• Follow the following protocols
  • What solutions or medications can you safely mix with Blood? - Not all medications can be transfused with the blood. - What size needle must you use? -How long should it take to infuse one unit of blood? -Large gaged MUST -you use a blood filter? Restoration of perfusion is more important than the restoration of Oxygen carrying capacity.

Rules of Transfusion

• S/S of Transfusion Reactions may vary.
• Reactions can occur with any blood product, and can occur with "compatible" blood products. Complications of Blood Transfusions

Complications of Blood Transfusions

• Complications of Blood Transfusions consist of:
  • Hemolysis Immediate IgM-mediated lysis of RBC. Delayed hemolysis due to generation of an IgG antibody response -Infection Viral, e.g., HIV, Hep C Bacterial. -And infectious agents. -Hemochromatosis or Iron overload

Transfusion Reactions:

InCorrect blood/component transfused the most common cause leading to a complication from a blood transfusion is due to. Any unfavorable incident occurring in a recipient during or after a transfusion is considered a transufion reaction.

Types of Transfusion Reactions

• Acute (Minutes to Hours) -Immunologic -Non-Immunologic
• Delayed (Days to Weeks) -Immunologic -Non-Immunologic

Acute Transfusion reactions types

are:

• Immunologic; Dermal (Hives); Febrile Non-Hemolytic (FNHTR); Anaphylactic; Pulmonary (TRALI); Hemolytic
• Non-Immunologic ; Non-Immune Hemolysis; Metabolic, Emboli; Volume Overload; Infectious (Bacterial sepsis) TRALI = Transfusion-related acute lung injury FNHTR = Febrile non-hemolytic transfusion reaction

Diseases Transmitted Through Blood Transfusions

• Hepatitis (*A,*B,*C,D,E, F,G,H *most common in US)
• HIV/AIDS (Type 1, 2, O).
• HTLV (Type 1, 2).
• CYTOMEGLAOVIRUS (CMV).
• Bacteria.
• Lues (A SERIOUS INFECTIOUS DISEASE PARTICULLARYL SYPHYLLIS).
• Malaria According to the CDC Hepatitis C is the most common chronic bloodborne infection in the US ; Injection drug use is now the most common risk factor for Hepatitis C in the US MUST BE SCREENED FOR BEFORE A TRANSFUSION The follow diseases also may be transmitted: Babesiosis, WNV, Lyme’s Disease, Severe Acute Respiratory Syndrome -Coronavirus; EBV Epstein-Barr virus Parvovirus B19; HH8 HUMAN HERPES VIRUS 8, Chagas, Leishmaniasis, NEW VARIANT FIRM CREUTZFELDT-JACOB DISEASE; ZIKA VIRUS; Chikungunya, DENGUE MUST BE SCREENED FOR BEFORE A TRANSFUSION Yet to be discovered viral illnesses

Transfusion-related acute lung injury(TRALI)

• Transfusion-related acute lung injury Diagnosis show; Hypoxic respiratory distress; Pulmonary crackles may be present without signs of congestive heart failure or volume overload.
• Evaluate the follow for TRALI Patients present with the rapid onset of dyspnea and tachypnea, and there may be associated fever, cyanosis and hypotension; Treatment: , associated with a high morbidity and the majority of patients require ventilatory support.

Distinguish TRALI from TACO (TACO transfusion associated circulatory overload)

• TRALI Fever
• Hypotension
• Acute dyspnoea
• JVP unchanged
• Auscultation- rales
• X-Ray- diffuse b/l infiltrates
• EF- normal
• Pulmonary edema fluid-exudate
• Response to diuretic- minimal
• TACO NO fever
• Hypertension
• Acute dyspnoea
• Can be changed
• Rales + S3
• Diffuse b/l infiltrates
• Decreased
• Transduate
• Significant improvement

Distinguish Dermal Reactions & Treatment

• Signs include HivesPruritis , Erythema andNo other S/S;
• Treatment included that's a Sensitization to foreign Immuno-globulins that are treated be Slow transfusion (No need to stop),
• Notify MD, May give Antihistamines & monitor Pt.

Febrile Non-Hemolytic & Treatment

Signs ChillsMyalgiaHeadacheTachypnea from Anti-WBC or Anti-Platelet antibodies in sensitized patient, Treatment should Stop transfusion, Notify MD & BB, Must R/O Hemolysis, May restart TX if W/U is NEGATIVE Antipyretics, Luekodeopletion. Myalgia =muscle aches and pain Tachypnea = rapid breathing

How to resolve Transfusion Related Hemolytic Symptoms

Sign Back or chest painFever, Shock, Dark Urine Renal FailureBleeding (DIC) Cardiac arrest, And should get Treatment with AntiRBC antibodies with complement fixation and RBC destruction to stop Transfusion, Notify MD & BB. Hydration, Supportive RX. DIC = disseminated intervascular coagulation

Alternatives to Blood Transfusions:

• Medications -Blood substitutes EXOSOME capital Cell salvage. Acupuncture. -Oxygen therapy. Other alternatives include:
  • Albumin, Recombinant Human Erythropoietin, Recombinant Human Active Factor VIla, , Acute Normovolemic Hemodilution, and Hypotensive Anesthesia Surgical is by with of Tourniquets; Minimally techniques ; Meticulous hemostasis Meticulous hemostasis, Fibrin sealants & Medications
• Other products include:Oxygen Therapy, Iron replacement, Erythropoetin & Desmopressin (DDVAP) Preoperative Autologous Donations & Artificial Blood: (Human /Bovine Hemoglobin Solutions, and Fluosol.
• Goal of Transfusion Alternatives are:Same as Transfusion Medicine,Consider the whole patient not just the lab values And Achieve the best outcome for the patient at the lowest risk.