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BLOOD TRANSFUSSIONPEDIATRIC HEMATO-ONCOLOGY DIVISION MEDICAL FACULTY SUMATERA UTARA UNIVERSITY

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BLOOD: - THE BIGGEST ORGAN (GIGANTIC ORGAN) - BIOLOGICAL MULTIANTIGENIC MATERIAL - CIRCULATING IN CARDIOVASCULER SYSTEM - CONSISTS OF : 1. CORPUSCULAR COMPONENT : - RED BLOOD CELLS LIVING MATERIAL - WHITE BLOOD CELLS MULTI ANTIGENIC - PLATELETS 2. NON CORPUSCULAR COMPONENT: - PLASMA : FLUID, ELECTROLYTE, PROTEIN (ALBUMIN, TRANSFERIN, E1 - GLOBULIN, E2GLOBULIN, F- GLOBULIN, IMUNOGLOBULIN, CLOTTING FACTORS )2

BLOOD TRANSFUSSION: BLOOD TRANSFERING PROCESS FROM DONOR TO RECIPIENT } ORGAN TRANSPLANTATION CONSIDER OF: - BENEFIT AND RISK ASPECT - IMMUNOHEMATOLOGY OF TRANSFUSSION - INFORMED CONSENT OBTAINED TO EVERY NON EMERGENT TRANSFUSION GAVE BLOOD SAVE LIFE GLOBAL BLOOD SAFETY INITIATIVE WHO 1989: ANY TRANSFUSION WHICH IS NOT INDICATED IS CONTRAINDICATED

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PRINCIPLE EVERY BLOOD TRANSFUSSION CONSISTS OF MINIMAL ANTIGEN VARIATION AND OPTIMAL DOSES BLOOD COMPONENTS TRANSFUSSION MORE RATIONAL THAN WHOLE BLOOD THE GOAL OF TRANSFUSSION ACHIEVED IF : * GOOD MANUFACTURING PRACTICE: DONOR SELECTION, RECORDED, BLOOD SAMPLING, STORED, COMPONENT PROCESSING INCLUDE QUALITY CONTAINT * GOOD HOSPITAL PRACTICE: INDICATION , REQUESTED VOLUME, CARED, EVALUATE PATIENT BEFORE AND AFTER 4 TRANSFUSSION

PRETRANSFUSSION TESTS

BLOOD TUBE CLEAR LABELS

BLOOD GROUP

COOMBS TEST5

PROBLEMS BLOOD TRANSFUSSION: 1. INDICATIONS 2. CONTRAINDICATIONS 3. DOSES 4. BENEFIT 5. SIDE EFFECTS BLOOD COMPONENTS TRANSFUSSION : - FIRST IN 1960 - FROM WHOLE BLOOD SEPARATES: RED BLOOD CELLS, GRANULOCYTE, PLATELETS, FRESH FROZEN PLASMA, CRYOPRECIPITATE, ALBUMIN6

1. RED BLOOD CELL COMPONENTS - 640 Ag, CONSISTS OF 20 BLOOD GROUPS SYSTEM: ABO, CDE, MNS, P, LEWIS, KELL, DUFFY, LUTHERAN, KIDD, DIEGO. - BLOOD GROUP SYSTEM : * ABO: BY LANDSTEINER (1901) A,B,AB,O BASED ON SURFACE Ag OF ERYTROCYTE GROUP A B AB O GENOTYPE A/A or A/O B/B or B/O A/B O/O NATURAL Ab (SERUM) ANTI- B ANTI- A ANTI A & ANTI B7

* RHESUS : - LANDSTEINER & WIENER (1940) - BASED ON: Ag D ON ERITROCYTE SURFACE - INDONESIA : s100% Rh + - SERUM: NATURAL ANTIBODY (-) FROM BIRTH

RED BLOOD CELLS COMPONENTS1. A. FRESH WHOLE BLOOD - DOSE: 6 x BW (kg) x (Hb - USE 10% OF TOTAL BLOOD VOL, OR ONGOING LOSS AND Hb < 8 g/dl IN A CHILD UNABLE TO PRODUCE RED CELLS Hb < 7g/DL PRIOR TO GENERAL ANESTHESIA RECEIVING RADIATION THERAPY Hb > 10 g/dl14

5. 6.

2. PLATELETS TRANSFUSSIONINDICATIONS 1. PREMATURE OR SICK INFANTS - STABLE INFANT WITH PLATELET COUNT < 50x109 /L - DISTRESSED INFANT WITH PLATELET COUNT < 100x109 /L 2. CHILDREN - PLATELET COUNT < 10x109 /L , IF FEBRILE, INFECTED OR BLEEDING - PLATELET COUNT < 50x109 /L WITH ANTICIPATED INVASIVE PROCEDURE: - LUMBAR PUNCTURE - QUALITATIVE PLATELET DEFECT - SURGERY

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3. ONCOLOGY NON BLEEDING PATIENT WITH PLATELET COUNT < 10x109 /L INDUCTION CHEMOTHERAPY BRAIN TUMORS PLATELET COUNT MAINTAIN AT > 30x109 /L LUMBAR PUNCTURE WITH PLATELET COUNT < 3050x109 /L BLEEDING PATIENT WITH NORMAL COAGULATION STUDIES, PLATELET COUNT < 50x109 /L SURGICAL PROCEDURE WITH PLATELET COUNT < 100x109 /L INTRAMUSCULAR INJECTION , PLATELET COUNT < 20x109 /L16

DOSAGE 1 UNIT PLATELET /10kg INCREASED PLATELET 4050X109/L PHERESIS PLATELET HARVESTED FROM SINGLE DONOR , CONTAIN > 30x109/L PLATELET, EQUAL TO 6-8 UNITS OF RANDOM PLATELET THE VOLUME IS 250-300 ml

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3. GRANULOCYTE TRANSFUSSION- FROM LEUCOPHERESIS, FILTER NYLON - ABO / Rh COMPATIBLE, HLA MATCHED - GAVE AS SOON AS POSSIBLE BECAUSE CIRCULATING HALF LIFE IS 6-10 HOURS , SLOW INFUSSION IN 2-4 HOURS - 1 UNIT : 1,0x1010 CELLS, IN ADDITION TO OTHER LEUCOCYTES, PLATELETS, AND 20-50 ml RBC - RESUSPENDED IN APPROXIMATELY 200-300 ml OF ANTICOAGULATED PLASMA18

INDICATIONS 1. NEONATAL BACTERIAL SEPSIS 2. BACTERIAL OR FUNGAL SEPSIS, CULTURE POSITIVE, UNRESPONSIVE TO ANTIMICROBIAL THERAPY, ANC< 100/ L DOSAGE 1 UNIT GRANULOCYTE ADMINISTEREDAT 150 ml/m2/HOUR UNITS ARE GIVEN DAILY UNTIL ANC >100/ L AND THE INFECTION IS RESOLVING19

4. PLASMA AND PLASMA PRODUCTSWHOLE BLOOD FRESH PLASMA FRESH FROZEN PLASMA CRYOPRECIPITATE FVIII CONSENTRATE FIBRINOGEN VWF F XIII CRYOSUPERNATAN ALBUMIN PLASMAPHERESIS

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TYPE & INDICATION OF PLASMA PRODUCTS 1. FRESH FROZEN PLASMA - DOSES: 15-20 ml/kgBW FFP IN 1 HOUR - CONSISTS OF : - FACTORS II,V,VII,VIII,IX,X,XI - PROTEIN C, S AND ANTITHROMBIN III - ELECTROLYTES, ALBUMIN, IMMUNOGLOBULIN, PROTEIN COMPLEMENT - 1 BAG FFP : 200 UNITS F.VIII - SHOULD NOT BE USED IF COAGULOPATHY CAN BE CORRECTED WITH SPECIFIC TREATMENT : VIT K, CRYOPRECIPITATE, FACTOR CONCENTRATE21

2. CRYOPRECIPITATECONSISTS OF : FVIII, F.XIII, FIBRINOGEN, F.VON WILLEBRAND DOSAGE : 1 U/ 6 kg BW

3. ALBUMININDICATION HIPOPROTEINEMIA - EXCHANGE PLASMA PROTEIN FLAME BURN - EXCHANGE PLASMA VOLUME22

INDICATIONSFRESH FROZEN PLASMA 1. BLEEDING/INVASIVE PROCEDURE WITH CLOTTING FACTOR DEFICIENCY 2. TREATMENT OF ANTITHROMBIN III, PROTEIN C&S DEFICIENCY, OR F.XI DEFICIENCY (HEMOPHILIA C) 3. BLEEDING DURING MASSIVE TRANSFUSION CRYOPRECIPITATE 1. BLEEDING/INVASIVE PROCEDURE WITH F.VIII, F.XIII DEFICIENCY, VON WILLEBRAND DISEASE, HYPOFIBRINOGENEMIA 2. SUPPORTIVE TREATMENT OF DIC

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TRANSFUSSION REACTION 1. ALLERGIC REACTION URTICARIA, WHEEZING, ANGIOEDEMATOUS REACTIONS ANAPHYLACTOID REACTION : DYSPNEA, PULMONARY/LARYNGEAL EDEMA, BRONCHASPASM TRANSFUSION RELATED ACUTE LUNG INJURY TREATMENT : STOP TRANSFUSION, ANTIHISTAMINE, CORTICOSTEROID, EPINEPHRINE. FEVER, CHILLS DURING TRANSFUSION TREATMENT : STOP TRANSFUSION, EVALUATE VITAL SIGN AND BLOOD PRODUCT, TREATING THE SYMPTOMS.

2. FEBRILE NON HEMOLYTIC REACTIONS

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3. ACUTE HEMOLYTIC TRANSFUSION REACTION FEVER, CHILLS, URTICARIA, DYSPNEA, CHEST PAIN, ABDOMINAL OR LOWER BACK PAIN, TACHYCARDIA, SHOCK LAB: ANEMIA, DIC, HEMOGLOBINEMIA, HEMOGLOBINURIA, POSITIVE COOMBS` TEST TREATMENT : IMMEDIATE CESSATION OF TRANSFUSION, ADMINISTRATION OF FLUID, STEROID,MANITOL, AND MAINTAIN CARDIOVASCULAR STABILITY AND URINE OUTPUT

4. DELAYED TRANSFUSION REACTION SYMPTOMS OCCUR IN 2-14 DAYS AFTER TRANSFUSION UNEXPLAINED FEVER, POSITIVE DIRECT COOMBS`TEST AND ANEMIA25

5. ALLOIMMUNIZATION 6. GRAFT VERSUS HOST DISEASE 7. MICROBIAL CONTAMINATION 1. VIRUS: - HEPATITIS B,C,D,E AND A - HIV - EBV - HTLV I / II - HERPES VIRUS - CMV - PARVO VIRUS 2. BACTERIA : - T. PALLIDUM - M. LEPRAE - S. TYPHOSA - BRUCELLA ABORTUS - RICKETTSIA RICKETSII

3. PARACYTES - P.VIVAX, MALARIAE, FALCIPARUM,OVALE -TRYPANOSOMA CRUZI -MICROFILARIAE -AFRICAN TRYPANOSOMIASIS -T. GONDII -BABESIA MICROTI -L. DONOVANI26

DRUG USED IN TREATMENT OF NON HEMOLYTIC TRANSFUSION REACTION1 DIPHENHYDRAMI USE : TREATING PRURITUS AND RASH NE DOSE : 12.5-50 MG IV OVER 10-20 MIN (1 MG/KG/DOSE, MAX 50 MG) USE : SEVERE INFECTIONS: BRONCHOSPASM, 2 EPINEPHRINE HYPOTENSION, SHOCK (1:1000 AQUEOUS) DOSE : 0,01 ML/KG SQ (SINGLE DOSE MAX 1 MG). (1 MG/ML) REPEAT Q 15 MIN X 3-4 DOSES AS NEEDED 3 EPINEPHRINE USE : FOLLOWING STABILIZATION WITH (1:200 AQUEOUS) EPINEPHRINE (1,5 MG/0,3 ML) DOSE : 0,005 ML/KG SQ (MAX SINGLE DOSE 0,15 ML). REPEAT Q 8-12 H PRN27

FOR HYPOTENSIVE PATIENTS, A BOLUS 20 ML/KG OF NORMAL SALINE SHOULD BE ADMINISTERED SIMOULTANEOUSLY WITH EPINEPHRINE AND STEROIDS 5 NARCOTICS USE : SPECIFIC AND EFFECTIVE TREATMENT FOR RIGORS DOSE : 0,1 MG/KG MORPHINE IV (MAX DOSE 10 MG) 6 ACETAMINOPHEN USE : TO PREVENT OR REVERSE TEMPERATURE ELEVATIONS IN MILD TO MODERATE FEBRILE REACTIONS DOSE : 10-15 MG/KG PO (MAX DOSE 800 MG) 7 STEROIDS USE : IN MODERATE TO SEVERE REACTIONS : URTICARIA, FEVER, SHAKING, CHILLS, DIAPHORESIS, OR PALLOR DOSE : 1-2 MG/KG OF METHYLPREDNISOLONE (OR EQUIVALENT DOSE OF DEXAMETHASONE/ HYDROCORTISONE) 28 IV PUSH

4 FLUIDS

PREVENTION 1. BLOOD SCREENING: HBsAg ANTI HIV 1/2 SIFILIS ANTI HCV 2. BLOOD BAG IDENTITY A. RE-TEST ABO / Rh BLOOD GROUP B. LABEL ON BLOOD BAG AND EASY TO READ, CONSISTS OF : - NO. BLOOD BAG -BLOOD GROUP - BLOOD TYPE/ COMPONENT -SCREENING TEST - BLOOD VOL / COMPONENT - STORED TEMP. / EXPIRED DATE29