surgery slide 6 _ blood transfusions

7/28/2019 surgery slide 6 _ blood Transfusions

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Blood Transfusion

Types, Indications andComplications

Vascular / Endovascular Surgery


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History of Transfusions

Blood transfused in humans since mid-

1600s

1828First successful transfusion

1900Landsteiner described ABO groups

1916First use of blood storage

1939Levine described the Rh factor


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Transfusion Overview

Integral part of medical and surgical treatment

Most often used in Hematology/Oncology, and

other specialties as well (surgery, ICU, etc) Objectives

Blood components

Indications for transfusion

Safe delivery

Complications


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Blood Components

Prepared from Whole blood collection or apheresis

Whole blood is separated by differential centrifugation

Red Blood Cells (RBCs)

Platelets

Plasma

Cryoprecipitate

Others

Others include Plasma proteinsIVIg, CoagulationFactors, albumin, Anti-D, Growth Factors, Colloid volumeexpanders

Apheresis may also used to collect blood components


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Differential Centrifugation

First Centrifugation

Whole Blood

Main Bag

Satellite Bag

1

Satellite Bag

2

RBCs Platelet-richPlasma

First

Closed System


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Differential Centrifugation

Second Centrifugation

Platelet-rich

Plasma

RBCs PlateletConcentrate

RBCs

Plasma

Second


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Whole Blood

Storage

4 for up to 35 days

Indications Massive Blood Loss/Trauma/Major Operations.

Considerations

Use filter as platelets and coagulation factors will not

be active after 3-5 days

Donor and recipient must be ABO identical


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RBC Concentrate

Storage

4 for up to 42 days, can be frozen

Indications Many indicationsie anemia, hypoxia, etc.

Considerations

Recipient must not have antibodies to donor RBCs

(note: patients can develop antibodies over time) Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)

Usually transfuse over 2-4 hours (slower for chronicanemia


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Platelets

Storage Up to 5 days at 20-24

Indications Thrombocytopenia, Plt


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Plasma and FFP

ContentsCoagulation Factors (1 unit/ml)

Storage

FFP--12 months at18 degrees or colder

Indications Coagulation Factor deficiency, fibrinogen replacement, DIC, liver

disease, exchange transfusion, massive transfusion

Considerations

Plasma should be recipient RBC ABO compatible Account for time of heating.

Usual dose is 20 cc/kg to raise coagulation factors approx 20%


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Cryoprecipitate

Description Precipitate formed/collected when FFP is heated at 4

Storage

After collection, refrozen and stored up to 1 year at -18

Indication Fibrinogen deficiency or dysfibrinogenemia

vonWillebrands Disease

Factor VIII or XIII deficiency

DIC (not used alone)

Considerations

ABO compatible preferred (but not limiting)

Usual dose is 1 unit/5-10 kg of recipient body weight


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Granulocyte Transfusions

Prepared at the time for immediate transfusion (nostorage available)

Indicationssevere neutropenia assoc withinfection that has failed antibiotic therapy, andrecovery of BM is expected

Donor is given G-CSF ( Colony Stimulating

Factor ) Complications

Severe allergic reactions


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Leukocyte Reduction Filters

Used for prevention of transfusion reactions

Filter used with RBCs, Platelets, FFP,

Cryoprecipitate Other plasma proteins (albumin, colloid

expanders, factors, etc.) do not need filters

May reduce RBCs by 5-10%

Does not prevent Graft Verses Host Disease(GVHD)


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RBC Transfusions

Preparations Type

Typing of RBCs for ABO and Rh are determined for

both donor and recipient Screen

Screen RBCs for atypical antibodies

Approx 1-2% of patients have antibodies

Crossmatch

Donor cells and recipient serum are mixed and

evaluated for agglutination


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Compatibility

PatientBlood Gp

Compatible with Approx% in UK

O O 47

A A and O 42

B B and O 8

AB AB, A, B and O 3


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RBC Transfusions

Administration Dose

Usual dose of 10 cc/kg infused over 2-4 hours

Maximum dose 15-20 cc/kg can be given to hemodynamically

stable patient Procedure

May need Premedication .

Filter useroutinely leukodepleted

MonitoringVS q 15 minutes, clinical status

Do NOT mix with medications

Complications

Rapid infusion may result in Pulmonary edema

Transfusion Reaction


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Platelet Transfusions

Preparations ABO antigens are present on platelets

ABO compatible platelets are ideal

This is not limiting if Platelets indicated and typespecific not available

Rh antigens are not present on platelets

Note: a few RBCs in Platelet unit may sensitize the

Rh- patient


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Platelet Transfusions

Administration Dose

May be given as single units .

Usual dose is approx 4 units/m2

Procedure

Should be administered over 20-40 minutes

Filter use

Premedicate if hx of Transfusion Reaction ComplicationsTransfusion Reaction


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Transfusion Complications

Acute Transfusion Reactions (ATRs)

Chronic Transfusion Reactions

Transfusion related infections


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Acute Transfusion Reactions

Hemolytic Reactions (AHTR)

Febrile Reactions (FNHTR)

Allergic Reactions

TRALI ( Acute Lung Injury )

Coagulopathy with Massive transfusions

Bacteremia


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Frequency of Transfusion Reactions

Adverse Effect Frequency Comments

Acute Hemolytic Rxn 1 in 25,000 Red cells only

Anaphylactic hypotensive 1 in 150,000 Including IgA

Febrile Nonhemolytic 1 in 200 Common

Allergic 1 in 1,000 Common

Delayed Hemolytic 1 in 2,500 Red cells only

RBC alloimmunization 1 in 100 Red cells only

WBC/Plt

alloimmunization

1 in 10 WBC and Plt only


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Acute Hemolytic Transfusion

Reactions (AHTR) Occurs when incompatible RBCs are transfused into a

recipient who has pre-formed antibodies (usually ABO or

Rh)

Antibodies activate the complement system, causing

intravascular hemolysis

Symptoms occur within minutes of starting the transfusion

This hemolytic reaction can occur with as little as 1-2 cc of

RBCs

Labeling error is most common problem

Can be fatal


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Symptoms of AHTR

High fever/chills

Hypotension

Back/abdominal pain

Oliguria

Dyspnea

Dark urine

Pallor


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What to do?

If an AHTR occurs STOP TRANSFUSION

ABCs

Maintain IV access and run IVF (NS or LR)

Monitor and maintain BP/pulse

Give diuretic

Obtain blood and urine for transfusion reactionworkup

Send remaining blood back to Blood Bank


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Blood Bank Work-up of AHTR

Check paperwork to assure no errors

Check plasma for hemoglobin

Repeat crossmatch

Repeat Blood group typing

Blood culture


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Labs found with AHTR

Hemoglobinemia

Hemoglobinuria

Hyperbilirubinemia

Abnormal DIC panel


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Monitoring in AHTR

Monitor patient clinical status and vitalsigns

Monitor renal status (BUN, creatinine) Monitor coagulation status (DIC panel

PT/PTT, fibrinogen, D-dimer/FDP, Plt,Antithrombin-III)

Monitor for signs of hemolysis (LDH, bili,haptoglobin)


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Febrile Nonhemolytic Transfusion

Reactions (FNHTR) Definition--Rise in patient temperature >1C

(associated with transfusion without other fever

precipitating factors) Occurs with approx 1% of PRBC transfusions and

approx 20% of Plt transfusions

FNHTR caused by alloantibodies directed against

HLA antigens

Need to evaluate for AHTR and infection


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What to do?

If an FNHTR occurs STOP TRANSFUSION

Use of Antipyretics

Use of Corticosteroids for severe reactions Use of Narcotics for shaking chills

Future considerations

May prevent reaction with leukocyte filter

Use single donor platelets Use fresh platelets

Washed RBCs or platelets


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Washed Blood Products

PRBCs or platelets washed with saline

Removes all but traces of plasma (>98%)

Indicated to prevent recurrent or severe reactions Washed RBCs must be used within 24 hours

Does not prevent GVHD


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Allergic Nonhemolytic Transfusion

Reactions Etiology

May be due to plasma proteins or bloodpreservative/anticoagulant

Best characterized with IgA given to an IgA deficientpatients with anti-IgA antibodies

Presents with urticaria and wheezing

Treatment

Mild reactionsCan be continued after antihistamine

Severe reactionsMust STOP transfusion and mayrequire steroids or epinephrine

PreventionPremedication (Antihistamines)


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TRALI

Transfusion Related Acute Lung Injury Clinical syndrome similar to ARDS

Occurs 1-6 hours after receiving plasma-

containing blood products Caused by WBC antibodies present in

donor blood that result in pulmonaryleukostasis

Treatment is supportive

High mortality


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Massive Transfusions

Coagulopathy may occur after transfusionof massive amounts of blood

(trauma/surgery) Coagulopathy is caused by failure to replace

plasma

See electrolyte abnormalities

Due to citrate binding of Calcium

Also due to breakdown of stored RBCs


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Bacterial Contamination

More common and more severe withplatelet transfusion (platelets are stored at

room temperature) Organisms

PlateletsGram (+) organisms, ie Staph/Strep

RBCsYersinia, enterobacter

Risk increases as blood products age (usefresh products for immunocompromised)


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Chronic Transfusion Reactions

Alloimmunization

Transfusion Associated Graft Verses Host

Disease (GVHD)

Iron Overload

Transfusion Transmitted Infection


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Alloimmunization

Can occur with erythrocytes or platelets

Erythrocytes

Antigen disparity of minor antigens (Kell, Duffy, Kidd) Minor antigens D, K, E seen in Sickle patients

Platelets

Usually due to HLA antigens

May reduce alloimmunization by leukoreduction (since

WBCs present the HLA antigens)


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Transfusion Associated GVHD

Mainly seen in infants, BMT patients

EtiologyResults from engraftment of

donor lymphocytes of an immunocompetentdonor into an immunocompromised host

SymptomsDiarrhea, skin rash,pancytopenia

Usually fatalno treatment

PreventionIrradiation of donor cells


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Transfusion Associated

Infections Hepatitis C

Hepatitis B

HIV

CMV

CMV can be diminished by leukoreduction,

which is indicated for immunocompromised

patients


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Prevention

Leukocyte

Depletion

Filter

Gamma

Irradiation

CMV

Negative

Single Donor

Platelets

(Apheresis)

Febrile Transfusion

Reactions X1

XAlloimmunization X X

CMV ?2 X

Transfusion Related

GVHDX

1 In PRBC transfusion

2 Leukocyte Reduction by filtration may be an alternative to CMV-negative blood


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Summary

Blood Components

Indications

Considerations

Preparation and Administration of blood

products

Acute and chronic transfusion reactions


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Transfusion Reaction Summary

AHTR can be fatal

Stop the Transfusion

Monitor for symptoms and complete evaluation FNHTR is a diagnosis of exclusion

TRALI (ARDS-like reaction)

Chronic Transfusion reactions Prevention methodsusing filters, irradiation and

premedication


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Q1- With regard to hemolytic transfusion reactions , Which of the

following is true ?

A. They generally caused by ABO incompatibility .

B. Urticaria and pruritus are the commonest symptoms .

C. Acidification of urine prevents precipitation of hemoglobin

D. Intra venous diphenylhydramine shoud be given immediately.


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Q1- With regard to hemolytic transfusion reactions , Which of the

following is true ?

A. They generally caused by ABO incompatibility .

B. Urticaria and pruritus are the commonest symptoms .

C. Acidification of urine prevents precipitation of hemoglobin

D. Intra venous diphenylhydramine shoud be given immediately.


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Q2- The most common cause of transfusion reaction is :

A. Air embolism.

B. Contaminated blood.

C. Human Error.

D. Unusual circulating anti-bodies.


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Q2- The most common cause of transfusion reaction is :

A. Air embolism.

B. Contaminated blood.

C. Human Error.

D. Unusual circulating anti-bodies.


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Q3- The most common clinical manifestation of a hemolytic

transfusion is :

A. Flank pain.

B. Jaundice.

C. Oliguria.

D. A shaking chills.


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Q3- The most common clinical manifestation of a hemolytic

transfusion is :

A. Flank pain.

B. Jaundice.

C. Oliguria.

D. A shaking chills.


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Q4- The most common fatal infectious complication of a blood

transfusion is :

A. AIDS.

B. CMV.

C. Malaria.D. Viral Hepatitis.


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Q4- The most common fatal infectious complication of a blood

transfusion is :

A. AIDS.

B. CMV.

C. Malaria.D. Viral Hepatitis.


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Q5- One unit of Fresh blood arises the Hb% concentration by :

A. 0.1 gm%

B. 1 gm%

C. 2 gm%

D. 2.2 gm%


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Q5- One unit of Fresh blood arises the Hb% concentration by :

A. 0.1 gm%

B. 1 gm%

C. 2 gm%

D. 2.2 gm%


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Thank you all

surgery slide 6 _ blood transfusions

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