BT1 2023-2024 Blood Transfusion Lecture Notes PDF

“If You're a Blood Donor, You're a Hero to Someone, Somewhere, Who Received Your Gracious Gift Of Life.” THANK YOU FOR DONATION Transfusion Medicine ‫ادلكتـور هـــيمث أمحـــد الربيـــعي‬ Professor of Hematopatholo...

“If You're a Blood Donor, You're a Hero to Someone, Somewhere, Who Received Your Gracious Gift Of Life.” THANK YOU FOR DONATION Transfusion Medicine ‫ادلكتـور هـــيمث أمحـــد الربيـــعي‬ Professor of Hematopathology MBChB (1985) FIBMS - Hematopathology (1998) DEPARTMENT OF PATHOLOGY AND FORENSIC MEDICINE COLLEGE OF MEDICINE – UNIVERSITY OF BAGHDAD  Learning Objectives: At the end of this lecture, the student should be able to: Apply the principles of clinical transfusion practice. Appropriately select blood donors. Defer unfit blood donors. “Less blood, or what we call restrictive transfusion, did not harm patients. And Yet There was no evidence that using more blood or liberal transfusion improved outcomes.” “If you can’t show that more blood improves outcome” Then why would you use it?  Blood transfusion refers to the 'safe' transfer of blood or blood components from a donor to a recipient.  Prescribing blood: a checklist for clinicians Always ask yourself the following questions before prescribing blood or blood products for a patient: 1. What improvement in the patient’s clinical condition am I aiming to achieve? 2. Can I minimize blood loss to reduce this patient’s need for transfusion? 3. Are there any other treatments I should give before making the decision to transfuse, such as intravenous replacement fluids or oxygen? 4. What are the specific clinical or laboratory indications for transfusion for this patient? 5. What are the risks of transmitting HIV, hepatitis, syphilis or other infectious agents through the blood products that are available for this patient? 6. Do the benefits of transfusion outweigh the risks for this particular patient? 7. What other options are there if no blood is available in time? 8. Will a trained person monitor this patient and respond immediately if any acute transfusion reactions occur? 9. Have I recorded my decision and reasons for transfusion on the patient’s chart and the blood request form? Finally, if in doubt, ask yourself the following question. 10. If this blood was for myself or my child, would I accept the transfusion in these circumstances? PRINCIPLES OF CLINICAL TRANSFUSION PRACTICE: 1. Transfusion is only one part of the patient’s management. 2. Prescribing should be based on national guidelines on the clinical use of blood. 3. Taking individual patient needs into account: A. Blood loss should be minimized to reduce the patient’s need for transfusion. B. The patient with acute blood loss should receive effective resuscitation (intravenous replacement fluids, oxygen, etc.) while the need for transfusion is being assessed. 4. The patient’s Hb value, although important, should not be the sole deciding factor in starting transfusion. The decision of blood transfusion should be supported by: The need to relieve clinical signs and symptoms and Prevent significant morbidity or mortality. 5. The clinician should be aware of the risks of transfusion- transmissible infections in the blood products that are available for the individual patient. 6. Transfusion should be prescribed only when the benefits to the patient are likely to outweigh the risks. 7. The clinician should record the reason for transfusion clearly. 8. A trained person should monitor the transfused patient and respond immediately if any adverse effects occur.  PRINCIPLES Blood donation should always be voluntary. Never give transfusion unnecessarily. Blood transfusion should follow components policy. https://www.youtube.com/watch?v=tCJBdWOA3Ok Blood Component Production ✓ Donor must be fit & healthy. ✓ It should not harm the donor. ✓ It should not transmit any disease to the recipient. Before blood donation; the donor should be subjected to: 1. Detailed medical history (Questionnaire form). 2. Limited physical examination.  Questionnaire form Registration: 1. Name of the donor. 2. Date and time of last donation: not < 12 weeks 3. Address 4. Gender 5. Age 6. Weight 7. Donor consent: written consent.  Measures used for donor selection and deferment Donor selection: Age 18–70 years (maximum 65 at first donation) Weight > 50 kg * Hb >13 g/dL for men, >12 g/dL for women Minimum donation interval of 12 weeks (16 weeks advised) and three donations per year maximum Apheresis for platelets or plasma up to 24 times in 12 months Pregnant and lactating women excluded because of high iron requirements; donation deferred for 6 months post pregnancy *Vasovagal reactions become more common in those who weigh < 50 kg, as the standard donation represents a greater proportion of their total blood volume. A set of eight pedipacks split from a single unit of red cells. The most common hazard of blood donation is Fainting, reported in 2 – 5% of all donors, but being especially common in young people and in those donating for the first time, particularly if they are nervous or apprehensive. A sympathetic approach by blood collection staff, provision of a drink prior to donation, enforcement of an adequate rest period, and constant vigilance to detect warning signs of an impending vasovagal attack can help avert this problem. Once a faint occurs, the standard treatment of rest in an horizontal position and elevation of the legs is usually sufficient.  Donor deferment Measures used to protect the donor Exclusion of any donor returning to occupations such as driving bus, plane or train, heavy machine or crane operator, mining, scaffolding, etc. because delayed faints occurring after a donor has left the clinic are potentially hazardous and is a contraindication to further donation. For this reason, such donors should not return to work on the day of donation. Defer for 12 months after body piercing or tattoo, paid sex, or homosexual sex. Defer for 2 months after live vaccinations such as measles, mumps Defer if travel history suggests the risk of infection Exclusion of those with: Known cardiovascular disease (ischemia) Hypertension Defer permanently individuals with hypertensive heart or renal disease If recently started taking anti-hypertensive medication: defer for 28 days after the BP has been stabilized and controlled by medication. Significant respiratory disorders Exclusion of those with: Epilepsy and other CNS disorders Gastrointestinal disorders with impaired absorption Intravenous drug users Chronic renal disease (Stages 3-5) Cancer Ongoing medical investigation or clinical trials  Blood diseases such as leukemia, lymphoma, thalassemia major, sickle cell anemia, polycythemia, and abnormal bleeding tendency Drugs: certain drugs (potent teratogens, anticoagulants, and antiplatelet agents) are deferred History of blood transfusion: defer 6-12 months. Major surgery: defer 6-12 months. History of infectious diseases. 1. AIDS patients, AIDS contacts, homosexuals, drug abusers, those with multiple partners, and hemophiliacs receiving products of human origin, all should be indefinitely deferred. 2. Hepatitis: - Hepatitis A: defer 1 year after full recovery - Hepatitis B: defer if active infection (HBs Ag+ve) or a history of infection within the last 12 months. - Hepatitis C: defer permanently 3. Malaria: ▪ In endemic areas: defer individuals with a recent infection with malaria for 6 months after full recovery. ▪ In non-endemic areas: Persons who have traveled to an endemic area are deferred for 1 year, and those who have had malaria or who have immigrated from or lived in an endemic area are deferred for 3 years (after becoming asymptomatic). 4. Brucellosis: defer permanently 5. Herpes viruses: Herpes simplex type I and II, varicella-zoster, EBV, CMV: defer until 28 days after full recovery. Human herpes virus 8 (HHV-8): defer permanently. 6. Syphilis: defer permanently 7. Leishmaniasis: defer permanently 8. Gonorrhea: defer for 12 months following completion of treatment. 9. Tuberculosis (Mycobacterium tuberculosis): defer for 2 years following confirmation of cure. Polycythemia and therapeutic phlebotomy: Many subjects referred for are as healthy as volunteer donors (e.g. hereditary hemochromatosis), others are true patients who deserve close medical supervision. Blood collected from these procedures may be unsuitable for transfusion because of the patient/donor’s underlying medical condition or because the subject fails to qualify as a donor for other reasons. By tradition, therapeutic phlebotomy services have been located in an area separate from volunteer blood donation and have required a medical prescription from an attending physician. Some countries require that blood drawn from such donors be so labeled, and that the recipient be informed of the source of the transfusion. Polycythemia Vera Although red cells from PV patients survive normally, PV is a clonal, progressive, myeloproliferative neoplasm and patients are at increased risk for developing leukemia. As a rule, this blood is not used for transfusion, although the risk of acquiring a graft of malignant cells from the donor seems to be negligible, even in recipients whose immune mechanisms are suppressed by disease or drugs.  Physical Examination 1. General appearance (and skin lesions): if the donor looks ill, appears to be under the influence of drugs or alcohol, or is excessively nervous, it is best to defer the donation. 2. Temperature: must not exceed 37.5 °C (99.5 F). 3. Pulse: should exhibit no pathologic irregularity, and the frequency should be between 60 and 100 beats/ minute.  Physical Examination 4. Blood pressure: “within normal limits” arbitrary acceptable limits of systolic BP (100-140 mmHg) and diastolic BP (60-90 mmHg) are suggested. 5. Weight: at least 50 Kg. 6. Hb level: > 13 g/dL for males and Allogeneic > 12 g/dL for females 11 g/dL, (PCV = 33%) Autologous The donor should read and sign the following information: "I have read and understand the information provided to me regarding the spread of the AIDS virus (HIV) by blood and plasma. If I am potentially at risk for spreading the virus known to cause AIDS, I agree not to donate blood or plasma for transfusion to another person or for further manufacture. I understand that my blood will be tested for HIV and other disease markers. If this testing indicates that I should no longer donate blood or plasma because of the risk of transmitting the AIDS virus, my name will be entered on a list of permanently deferred donors. I understand that I will be notified of a positive laboratory test result(s). If, instead, the results of the testing are not clearly negative or positive, my blood will not be used and my name may be placed on a deferral list without my being informed until the results are further clarified." Under certain circumstances, it may be important to use blood or components from a “Specific donor” for a specific patient. Examples include: e.g., Wrb and Ena 1. Patients with an antibody to a high-incidence Ag. 2. A combination of antibodies that makes it difficult to find compatible blood (multi-transfused patient whose family members can provide components). 3. Infant with neonatal alloimmune thrombocytopenia whose mother can provide platelets. 4. Patients awaiting a kidney transplant from a living donor. Donor selection criteria for the plateletpheresis donor are: The same as for whole blood donation plus: Before each plateletpheresis procedure, a sample must be collected to determine the donor’s platelet count (must be at least 150,000/μL) to provide an adequate platelet collection and for the donor to safely undergo the collection procedure. If the platelet count is not immediately available, plateletpheresis can be done: Depend on the most recent platelet count for the donor for qualification. If it is the initial plateletpheresis collection for the donor. If 4 weeks have elapsed since the prior platelet donation. If platelet count was evaluated after the platelet collection. During a plateletpheresis procedure, the platelet count will be decreased by 30% to 60%. Plateletpheresis (single donors) may donate more often. The interval between donations is: At least 2-3 days, Not to exceed more than twice a week or Not to exceed more than 24 times a year.  Exceptions to any of these time periods can be made in unusual circumstances (HLA-matched platelets for a specific patient). The total volume of plasma collected during any one procedure cannot exceed 500 mL (or 600 mL if the donor weighs 79.4 kg or more) or the volume of plasma cleared by the FDA for the instrument. Apheresis platelets are leukocyte-reduced and contain < 5 ×106 WBCs per unit. Plateletpheresis collections should not be performed on potential donors taking medications that interfere with platelet function, as this would result in production of a suboptimal and therapeutically ineffective patient product.  Antiplatelet medications have differing deferral time periods: 48 hours for aspirin, aspirin-containing medications, and the anti-inflammatory drug Feldene, and 14 days for clopidogrel (Plavix), ticlopidine (Ticlid), ticagrelor (Brilinta), and prasugrel (Effient) Clopidogrel selectively inhibits the binding of adenosine diphosphate (ADP) to its platelet P2Y12 receptor and the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. The most common anticoagulant used for apheresis procedures is: a. Heparin. b. Sodium fluoride. c. Warfarin. d. Citrate (ACD). The most common anticoagulant used for apheresis procedures is: a. Heparin. b. Sodium fluoride. c. Warfarin. d. Citrate (ACD).  Random-donor platelets (collected from a single unit of blood) must contain at least 55 × 109 platelets. Single-donor platelets (plateletpheresis) must contain at least 300 × 109 platelets Each carries a shelf-life of 5 days.  One unit of random-donor platelets typically increases the platelet count in a 70-kg adult by 5,000 to 10,000/μL. One unit of apheresis platelets should increase the platelet count in a 70-kg adult by 30,000 to 60,000/μL Directed donors: (in USA) The public's AIDS-related concern about the safety of transfusion has generated demands from potential recipients to choose the donors to be used for their transfusions. In blood donation; state whether the following statements are true or false: a. Donor with history of hepatitis C is deferred permanently. b. Age of the donor should be between 18-70 years. c. Donor with well-controlled hypertension is not accepted for donation. d. A 30-year-old female with Hb level 13 g/dL, and her weight is 46 Kg is accepted for donation. e. Donors with brucellosis are deferred for 2 years from last febrile episode. In blood donation; state whether the following statements are true or false: a. Donor with history of hepatitis C is deferred permanently. b. Age of the donor should be between 18-70 years. c. Donor with well-controlled hypertension is not accepted for donation. d. A 30-year-old female with Hb level 13 g/dL, and her weight is 46 Kg is accepted for donation. e. Donors with brucellosis are deferred for 2 years from last febrile episode. Assessing the need for transfusion No set hemoglobin levels indicate a need for transfusion. The critical hemoglobin level is ≤ 6 g/dL. Consensus committees suggest trigger values of < 7 g/dL for most patients and ≤ 8 g/dL for certain patients with heart disease. Most patients can tolerate 7 g/dL, especially if on bedrest or at decreased levels of activity and given supplemental oxygen. In fact, healthy individuals can tolerate hemoglobin levels as low as 5 g/dL with minimal effects. Red Blood Cells: The human body compensates for anemia by increasing: Plasma volume, Heart rate, Respiratory rate, and Oxygen extraction from the RBCs: Normally, only about 25% of the oxygen is extracted, but with increased demand at the organ and tissue level, up to 50% of the oxygen can be extracted. When the demand exceeds 50% of the oxygen content, the compensatory mechanisms fail, and the patient requires transfusion. Transfusion therapy is used primarily to treat 2 conditions: 1. Inadequate oxygen-carrying capacity because of anemia or blood loss and 2. Insufficient coagulation proteins or platelets to provide adequate hemostasis. Some patients do not require transfusion, even in anemia or thrombocytopenia, because their clinical conditions are stable and they have little or no risk of adverse outcomes. Thank you Any questions?