basics of transfusion therapy
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Basics of
TransfusionTherapy
Resident EducationLecture Series
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Hemoglobin Level and Symptoms
HGB (GM%) SM!T"MS
#$ M&'&ML
*+ ,-,.T&"'L /S!',
0*1 2,3',SS
4*1 /S!', T .,ST
5$5*+ H,.T 6&L7.,
LINMAN
NEJM 279:812, 1968
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.B8 Transfusion9 &ndications
cute Blood Loss
Symptomatic nemia Suboptimal "5 8apacity
,:change (SS; 8o)
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RBC Transfusion: The Bathtu !rin"i#$e
Kidney
Kidney
Kidney
1%%
&%
%
1%%
'%
%
B$oo( )o$u*e B$oo( )o$u*eB$oo( )o$u*e
1%%
&%
%
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!re$Transfusion Testing
BL""/ T!&'G9 B"; / ntigens only
("ther antigens are <ea= immunogens) 'T&B"/ S8.,,'9
!atient serum vs* cell panel
8."SSMT8HMa>or9 !atient Serum vs* /onor 8ells
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.B8 !roducts PRBC MOST TRANSFUSIONS
2H"L, BL""/ 87T, BL,,/&'G,-8H'G,!LSM ',,/,/
2SH,/ .,M"?, !LSM
6."@,' .., .B8 !H,'"T!,
&../&T,/ &MM7'"/,6&8&,'T 8M? ',GT&?, &MM7'"/,6&8&,'T
S,."',GT&?,; ',"'T,
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.B8 Transfusion ?olume
7sual9 7p to +ccA3g in 4$ hours
7nusual9 cute Hemorrhage9replace ongoing losses
8hronic nemia; Heart 6ailure; CB!
5ccA3gAGm HGB/iuretic
,:change
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Transfusion ?olume
1ccA3g !.B8 5* GM% in HGB
1ccA=g D - ccA=g 5* GM% /esired HGB rise
!.B8 cc D Blood ?olume : (HGB6$ HGB&)
HGBT
B?D1ccA3G; E1$#1ccA3G ne<born
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Hemolytic Transfusion .eactions
cute HT. A5+;1116atal cute HT. $A;111;111
/elayed HT. A+$1;111
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Symptoms and Signs of cute
Hemolytic .eactions Severe Bac= !ain Substernal Tightness; /yspnea
Hypotension A 8irculatory collapse ?omiting; diarrhea &cterus Hemoglobinuria
.enal shutdo<n /iffuse "oFing from <oundsApunctures
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.esponse to Suspected Hemolytic
.eaction Stop Transfusion Hydrate
Specimens to Blood Ban=7nitABagSerum
.ed cells7rine
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cute Hemolysis9 /iagnosis
/o a direct antiglobulin test on post$transfusion sample
"btain post$transfusion blood and urine andinspect visually Recheck paperwork .echec= B" type of unit and pre$and post$
transfusion specimens .un urinalysis $ to chec= for hemoglobinuria
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8ause of cute HT. B" incompatibility9source of error1% at phlebotomyAlabeling54% in Transfusion Lab0% transfusion administration (at the
bedside)
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'onhemolytic Transfusion .eactions
Leu=ocyte ssociated 6'HT. Transfusion G?H/
'eonatal 'eutropenia &mmunoglobulin ssociated 7rticariaA6ever &g , T.L&
!latelet ssociated !ost transfusion !urpura 'eonatal Thrombocytopenia
MetabolicA !hysical 8itrate To:icity Hypothermia
8irculatory "verload Massive Transfusions Haemostatic bnormalities Metabolic complications Hgb$"5 8urve Shift
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TRAN+-+I.N/RELATE0 INECTI.N
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.is= of Transfusion$
Transmitted &nfectionH&? in 5;111;111Hepatitis 8 in 5;111;111
Hepatitis B in +;111Hepatitis .areHTL? &A&& in 4;111;111
Bacteria A4;111 (for platelets)Malaria; T 8ruFi; Babesia; ersinia;
Syphilis; Lyme; 8/; 2est 'ile ?irusII
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!ost Transfusion H8?
!ercent 'umber
&ncidence +$1 +1$411;1118hronic +1 +$+1;111
8irrhosis 51 +$41;111
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'eonatal !ost Transfusion 8M?
&ncidence9 5+% of seronegative infants
receiving J+1ml 8M?
seropositive blood
Severity +1% severe or lethal manifestations
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'eonatal Transfusion 8M?
!revention by 6iltering BloodSeroconvertATotal
6iltered !.B89 1A41
7nfiltered !.B89 #A5
Gilbert; L9#E955E; #E#
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!revention of !ost Transfusion
&nfection /onKt Transfuse MinimiFe Transfusion
Limited /onors (dedicated units) utologous Transfusions ,rythropoetin /onor Screening9 H&? b; H&? 'T; H8? b;
H8? 'T; HB? g; b; HBc b; ?/.L; 2est'ile 'T; HTL?&A&& b; 8M? b; Bacterial8ulture (!latelets)
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Strategies to /ecrease "perative .B8
TransfusionHemostasis
Hemodilution
8ell salvage
//?!
utologous Transfusion,rythropoetin
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'eutropenia9 infection ris=
0
10
20
30
40
50
60
0 1 2 3 4 5
!MNs *i"roL3
4 #
a t i e n t ( a 5 s 6 i t h
i n f e " t i o n
100 100-500 500-1000 1000
Relapse
Remission
Bodey. Ann Int Med 64:328, 1966.
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2B8 &ndications 511
!M'9 'e<born Sepsis
8ongenitalAcuired 'eutropenia
!M' /ysfunction.efractory Gram 'egative Sepsis
Ly9 /isseminated ?aricella$@oster
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2B8 transfusion9
Logistics /onors .eceive G$8S6 A$ /ecadron 5$4 Hour 8ytapheresis 11 8ells by Standards /onors pretested for &/ mar=ers 8ells decay rapidly9 limited value at> hour! po!t"collectio#
Nuantitative impact limited
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6resh 6roFen !lasma
511$5+1 ml of plasma containing allclotting factors; T &&&; !rotein 8 O S*
8ompatibility &mportant 8an Give9 plasma to or " patient
B plasma to B or " patient
" plasma to " patientB plasma to anyone
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&ndications9 66!
.eplacement of 8oagulation 6actors bnormal Bleeding <ith coagulopathy
Multiple factor deficiency9 Liver disease /&8 .eversal of 2arfarin /ilutional
&solated factor deficiency$no concentrate 6actor -&; -&&&
.eplacement of regulatory proteins TT!; Hereditary angioedema 'ot indicated for9 volume e:pansion; reversal of
Heparin; correction of &'. P %*+
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Guidelines9 66! 7se
7sual dosing9 dult 1mlA3g
!eds 1$+mlA3g
+$51% rise in factor levels 7sually does not correct laboratory
coagulation status to QnormalR
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8ryoprecipitate
1$+ ml per unit (bag) 6ibrinogen 5+1 mg
6actor ?&&& E1$51 units ?on 2illebrand 6actor 1$1% of 66! 6actor -&&& 51$41% of 66!
6ibronectin 51$1 mg
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8ryoprecipitate9 /osing
$5 7nits A 1 3g
,:pect 01$11 mgAdl rise in fibrinogen Goal9 6ibrinogen 1$11 mgAdl
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!latelets9 .is= of Spontaneous
Hemorrhage
8ount Site
J 1;111 Minimal
51$1;111 G& Mucosa
+$51 S=in; Mucus Membranes
P + 8'S; Lung
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0
10
20
30
40
0 50 100 150 200 250 300
!$ate$ets *i"roL3
B $ e e ( i n 7 t i * e 1 * i n 3
&T!
2S
S
7
remia
v2/
Harker. NEJM 287:155, 1972.
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!rophylactic !latelet T- Guidelines
!latelet 8ountAl .ecommendation
1$+;111 l<ays
+$1;111 &f 6ebrile of Minor Bleeding $51;111 &f coagulopathy or minor
procedure
J51;111 &f Ma>or Bleed or invasive
procedure
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Transfused !lateletsASurvival
0 units D single donor unit (S/!)available as U; V and full S/! /ose9 child unitA+$0 =g
adult unitAE$1 =g Lifespan9 $1 /ays 'ative
5$4 /ays Transfused 6actors shortening Lifespan9
6ever; Sepsis HL; !latelet Specific bs /&8 !roduct geI
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T.! Trial
,ffect of Leu=odepletion on lloimmuniFation'o .:
pooled
6ilter
!ooled
7?$B
!ooled
6ilter
S/!
'umber 4 4 41 45
L8T-$B +% E% 5% %
L8T-$B
refractory
4% 4% +% %
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2hen in /oubt9 8all the TransfusionServiceW
500$5#
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From ABPCertifyin E!am Content "ut#ine
2 Transfusion an( "o$$e"tion of $oo(
$nderstand t%e ris& of transmittin infectious
diseases durin '#ood transfusion(s) Reconi*e t%at eryt%rocyte transfusions may 'e
associated +it% %emo#ytic, fe'ri#e, and urticaria#reactions
$nderstand t%e ro#e of eryt%rocyte transfusionsin t%e manaement of anemia
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Credits
Bruce Camitta -.
- / Lan&ie+ic* -.