Blood Components And Hemotherapy PDF

BLOOD COMPONENTS AND HEMOTHERAPY L (7) Yasser Hassanein, D.H.Sc., M.Sc., MLS (ASCP)CM Hematology Consultant Overview • • • • • – – – Anticoagulants, preservatives, additives Storage – lesions, containers, equipment Tests required on units Label requirements Products Description Storage require...

BLOOD COMPONENTS AND HEMOTHERAPY L (7) Yasser Hassanein, D.H.Sc., M.Sc., MLS (ASCP)CM Hematology Consultant Overview • • • • • – – – Anticoagulants, preservatives, additives Storage – lesions, containers, equipment Tests required on units Label requirements Products Description Storage requirements Uses Anticoagulant/Preservative • • – 75% survival of RBCs in recipient blood 24 hrs. posttransfusion Amount must support whole blood volume: 14 mL anticoagulant/100 mL whole blood collected Anticoagulants currently available 1. 2. 3. ACD CPD CPDA-1 ACD • • • • Acid citrate dextrose Citrate: anticoagulant Dextrose: 2,3-DPG: 2,3-diphosphoglycerate, (enhancing the ability of RBCs to release oxygen near tissues that need it most) lost early in first week of storage Storage whole blood/RBC 21 days @ 1-6°C CPD • • • • • Citrate/phosphate/dextrose Citrate – anticoagulant Phosphate – ATP generation by glycolytic pathway Dextrose –maintains 2,3-DPG levels – CP2D has twice as much 21 days @ 1-6°C (Whole blood/RBCs) CPDA-1 • • Same as CPD – plus adenine-1 to provide a substrate from which RBCs can synthesize ATP during storage 35 days @ 1-6°C (Whole blood/RBCs) Action of ingredients of anticoagulant solution • • • • Glucose _ supports ATP generation by glycolytic pathways. Adenine _ synthesizes ATP, increases level of ATP, extends the shelf-life of red cells to 42 days. Citrate _ prevents coagulation by chelating calcium. Sodium di-phosphate prevents fall in pH, A fall in pH in the stored blood results in a decrease in red cell 2,3-DPG level, which results in increase in hemoglobin-oxygen affinity. Additive solutions 1. 2. 3. • Adsol Nutricel Optisol Major benefit of the additive system is increase in the level of ATP, and red cells viability is enhanced, extending the shelflife of the red cells to 42 days. Adsol • • • – – – – • AS-1 (Fenwal-Baxter) WB collected in CPD, centrifuged, remove plasma, add Adsol (100 or 110cc) Contains: Dextrose Adenine Mannitol Saline 42 days @ 1-6C (RBCs only) Nutricel • • – – – – – – – • • AS-3 (Cutter/Miles Laboratories) Same principle as Adsol but contains: Dextrose Adenine Monobasic sodium phosphate Saline Sodium citrate Citric acid NO mannitol Used for WB collected in CP2D (35 days) 42 days @ 1-6C (RBCs only) Optisol • • AS-5 (Terumo Medical) Contains: • • Used for WB collected in CPD (35 days) 42 days @ 1-6oC (RBCs only) – – – – Dextrose Adenine Mannitol Saline Storage Lesions • – – – – – – Biochemical changes Decrease in pH Decrease in glucose consumption Increase in lactic acid Decrease in ATP levels Increase in extracellular K+ Reversible loss of RBC function Monitor Component Storage • • • Temperature must be recorded every 4 hrs Continuous recording chart linked to internal thermometer Central alarm systems Audible Alarms • • • Component storage equipment must have audible alarms with 24 hr coverage Must be set to activate prior to temperature being out of range Alarm QC checks Allogeneic Blood – Testing Requirements • • • ABO, Rh (weak D) ABSC Syphilis Allogeneic Blood – Testing Requirements • HIV • HBV • HCV – – – – – – – Anti-HIV-1/2 (EIA) HIV-1 NAT (PCR/TMA) Anti-HBc (EIA/ChLIA) HBsAg (EIA/ChLIA) HBV NAT (PCR/TMA) – not yet used in US Anti-HCV (EIA/ChLIA) HCV NAT (PCR/TM) Label Requirements • • • • • • Component name Donor unit # ABORh Required storage temp Expiration date/time Amount of blood collected/amount of anticoagulant Label Requirements • • Name, address, and FDA license or registration number of collection facility Name address, and FDA license of all facilities performing any part of the component manufacturing Component administration • – – Aseptic technique Any component stored @ 1-6oC: if seal is broken, outdates in 24 hrs Any component stored @ RT: if seal is broken, outdates in 4 hrs (1) Whole Blood • • • • Whole blood 450 +/- 45 ml or 500 +/-50ml Expires 35 days @ 1-6oC Not generally available Splitting into components is a better use of a whole blood donation: RBCs, plasma, cryoprecipitate, platelets (2) Red Blood Cells • • • Expires up to 42 days @ 1-6°C 250-350 ml RBCs, little plasma 1 unit of RBCs increases HCT 3% or HGB 1g/dL Leukoreduced RBCs • • – – – – – Upon storage, leukocytes release “BRMs” (biologic response modifiers) BRMs: Include cytokines Interleukin-1 (IL-1) Interleukin-6 (IL-6) Tumor necrosis factor (TNF) Complement fragments, C5a and C3a Leukoreduced RBCs • • • Prepared by filtration process Must retain 85% of original RBCs after filtration Same storage 1-6oC • 2 methods of filtration : a)Pre- – storage leukoreduction Special filters remove 99.9% of leukocytes – b)Post-storage leukoreduction Removed in the blood bank or at bedside. Leukoreduced RBCs • • • • Prevent recurrent febrile nonhemolytic rxns Prevent HLA sensitizations with multiple transfusions Prevent infection with CMV, Epstein-Barr (fetus, transplants, immuno-suppressed) Prevent TRALI (3) Frozen RBCs • • Expires 10 years @ -65°C or colder (for units collected in CPDA-1) If Adsol is used, frozen unit is only good for 3 years; acceptable to freeze AS-1, AS-3 up to day 42 post-collection Frozen RBCs • • Cryoprotective agent must be used – prevents hemolysis during thawing Penetrating Method • Non-penetrating Method – – – – – – Penetrating agent – glycerol or DMSO Osmotically retains intracellular water Reduces ice damage to RBC membranes Used to freeze hematopoietic progenitor cells HES (hydroxyethyl starch) Larger molecule; forms shell that prevents intracellular dehydration Frozen RBCs • 1. 2. 3. Uses Autologous Rare cells (negative for high incidence antigens, or multiple antigen negative combinations) Military Frozen RBCs • 1. 2. 3. Limitations Patients with hereditary spherocytosis – can’t freeze blood – too fragile to survive the process Sickle cell units also suffer decreased survival; special process to thaw Fragile Deglycerolized RBCs • • • • Thaw in 30-37oC water bath Wash away glycerol with decreasing concentrations of saline: 12%, 1.6%, and 0.9% with 0.2% dextrose – prevents hemolysis Automated cell washer Expires 24 hours from thaw @ 16oC (4) Washed RBCs • • • 1. 2. 3. • Expires 24 hrs @ 1-6oC Wash with 0.9% (normal) saline (1 to 2 L) Indications IgA-deficient patients Patients with multiple progressive allergic reactions Patients with polyagglutiable cells Can also wash platelets (expire 4 hrs. at RT) (5) Irradiated RBCs • Expires 28 days @ 1-6oC from date of irradiation or original outdate, whichever comes first Indications: 1. 2. Prevents TA-GVHD (graft v host disease) Destroys replication power of T cells (6) Plasma • 1. 2. 3. 3 types of Plasma products Fresh Frozen Plasma (FFP) PF24 (plasma frozen with 24 hours of collection) Plasma cryoprecipitate-reduced FFP • • (1) Fresh Frozen Plasma – removed and frozen within 8 hrs of collection Expires 1 yr @ -18oC or colder FFP • – • – – • • Contains all plasma clotting factors 1 IU per ml To use FFP: Thaw it in a 30-37oC waterbath (wrapped to prevent contamination of ports) Once thawed: expires 24 hrs @ 1-6oC No crossmatch required ABO compatible/ Rh not required FFP • – – – – Indications Bleeding pt with multiple factor deficiencies Massively tx’d in short time DIC Coumadin overdose Liquid Plasma • • • • • – Separated anytime up to 5 days post expiration of the product Labeled “plasma” If frozen, 1 year @ <-18oC Expires 5 days @ 1-6oC Indications In conjunction with massive transfusion (7) Albumin (Human) • • Used in 2 concentrations: 5% (250 mL (25g), 500 mL (50g)) • 25% (50 mL (12.5g)) – – – – Volume replacement – equal volumes Maintain cardiac output, colloid oncotic pressure Volume replacement – about 3.5 times Correction of hypoproteinemia (8) Cryoprecipitate • • • • • Cold precipitated concentration of Factor VIII Thaw FFP at 1-6oC until slushy; separate liquid plasma from cryo slush with heavy spin Volume 10-15 ml Refreeze within 1 hr at <-18oC Expires 1 year @ <-18oC or colder Cryoprecipitate • • • • Contains FVIII (minimum 80 IU), fibrinogen (minimum 150 mg), von Willebrand’s factor, FXIII Expires 1 year frozen @ <-18oC Thaw 30-37oC water bath Expires 6 hrs thawed, 4 hrs pooled @ RT Cryoprecipitate • 1. 2. 3. 4. • • Indications Bleeding due to fibrinogen deficiency Factor XIII deficiency Second-line (not preferred) therapy for factor VIII deficiency and von Willebrand’s disease Improve PLT function in uremic patient No crossmatch required No ABO concerns unless newborn (9) Platelets • • • • PLTs must be ABO compatible (type specific is best) No crossmatch necessary Give Rh-neg to Rh-neg patients (or use RhIg) Volume reduce if necessary (to remove ABO incompatible plasma) Platelets • – Indications Thrombocytopenia • • Active platelet-related bleeding Prophylaxis (risk of bleeding) – Dysfunctional platelet disorders Platelets • • • Expires 5 days @ 20-24oC with constant agitation Associated with febrile reactions: can be leukoreduced since WBCs are present Fragile blood component – keep pH > 6.2; bag allows gas exchange RDP Random Donor Platelet • RDP QC – – – PLT CT in 75% of all tested must be >5.5x1010 Volume 50-70 ml pH >6.2 • 1 random PLT increases adult platelet count by 5,000-10,000 Pool (5-6 units) should increase by 20-60,000 – expire in 4 hours @ 20-24oC • SDP Single Donor Platelets • • • Single-donor platelets Apheresis product Apheresis donor must maintain PLT CT 150,000 as well as other allogeneic requirements SDP • • • • – – SDP QC: PLT CT 3.0 x 1011 in 75% of units tested LR requires <5 x 106 WBC/unit Used when patients become refractory to random donor platelets HLA matched or crossmatched platelets Irradiated (10)Granulocytes • • • • – – – Granulocytes Collect 1x1010 granulocytes Expires 24 hours @ 20-24oC – best used ASAP 3 requirements: WBC<500 documented bacterial infection antibiotics not working for 48 hrs Granulocytes • • • Irradiated (not leukoreduced!) Crossmatched since grossly bloody (ABO compatible) Recipient reactions – febrile, CMV (11)FVIII Concentrate • • – – • • Product of choice for Hemophilia A Human source Made from large volumes of pooled plasma Heat or chemically treated to destroy viruses Recombinant Porcine Factor VIII also available (12)NovoSeven • • • • • Recombinant FVIIa concentrate (rFVIIa) Hemophiliacs with FVIII, FIX inhibitors Congenital FVII deficiency Cardiac surgery, acquired coagulopathy (sometimes) Very expensive – cost is about $1/ug; 4.8mg vial = $5K; dose is 90ug/kg every 2-3 hrs (13)FIX Concentrate 3 types of Factor IX •Prothrombin complex FII, VII, IX, X •Monoclonal Factor IX •Recombinant Factor IX •Preferred treatment for Hemophilia B Factor Concentrates Calculation • Dose calculation: Patient plasma volume x desired increase in activity [Body mass x 70mL/kg x (1 – HCT)] x [goal – current activity] • • • • • Example: 70kg male HCT = 40% 1% FVIII activity (0.01 IU/mL) Goal = 100%(1 IU/mL) FVIII activity [70kg x 70mL/kg x (1 – 0.4)] x [0.99IU/mL] = 2910 IU Other products • – – Rh Immune Globulin (RhIg) RhoGam (intramuscular, for HDN) WinRho (intravenous, acute ITP)