MLS 4130 - Transfusion Therapy and Special Considerations

Transfusion therapy is used primarily to treat two conditions. What are they?

Inadequate oxygen-carrying capacity because of anemia or blood loss

Insufficient coagulation proteins or platelets to prothrombin

The patient is brought in by EMS. They have a gun shot wound to the abdomen and is experiencing massive bleeding. Which product do you think would be most beneficial?

Whole blood is the best initial product for a patient with massive bleeding from trauma. If whole blood is unavailable, use a 1:1:1 ratio of RBCs:Plasma: Platelets to mimic whole blood.

Whole blood is used to replace what?

The loss of both RBC mass and plasma volume

What patients can revieve a whole blood?

Rapidly bleeding, although most commonly RBCs and plasma are used and are equally effective clinically

Contraindication to use of whole blood

Severe chronic anemia - reduced RBCs with compensated volume

For a 155 pound adult, how much does one unit of blood increase their Hgb and Hct?

Hgb - 1 g/dl

Hct - 3%

(Increase may not be apparent until 48-72 hours post transfusion)

A chemotherapy patient experiencinganemia of chronic disease is scheduled forinfusion therapy. Which product should beordered?

For a chemotherapy patient with anemia of chronic disease, order Packed RBCs to correct the anemia.

Who are packed RBCs for?

Patients who require increased oxygen-carrying capacity

Hgb of ____ or less if critical. Most physicians will not transfuse packed RBCs unless < ____ depending upon clinical picture.

6 g/dL

8 g/dL

Packed RBC contraincations

Patients with compensated anemia, nutritional deficiency anemia, enhancing well-being, promoting wound healing, preventing infection, expanding oxygen carrying capacity, and prevention of future anemia

What is the anticipated increase in Hgb and Hct per unit? What about for infants?

Hgb 1g/dL

Hct 3%

Infants - increase 2-3 g/dL per 10-15 mL of RBCs

What are leukocyte-reduced RBCs used for?

Reduce HLA alloimmunization, CMV transmission, FNHTR, TA-GvHD, and transfusion-related immune suppression

What must the leukocyte-recduced RBCs be reduced to?

<5.0 x 10^6 WBCs using leukocyte reduction filters

(Europe - 1x10^6)

Indications for use of leukocyte-reduced RBCs

Decrease febrile nonhemolytic transfusion reactions, decrease alloimmunization in WBC antigens, decrease transmission of CMV, delay in HLA antibodies

Leukocyte reduction filters are designed to remove how much of the WBCs from whole blood?

More than 99.9% of leukocytes from RBCs and PLT products

A patient has an IgA deficiency and anemia. The physician orders packed RBCs. Is this patient at increased risk for adverse reactions? What should be done to these units before transfusion?

Yes, the patient is at increased risk of an anaphylactic reaction because IgA-deficient patients can form anti-IgA antibodies that bind to donor plasma IgA.

Before transfusion, the packed RBC units should be washed to remove plasma proteins (including IgA).

What patients may use washed and frozen/deglycerolized RBCs?

Patients with severe anaphylactic transfusion reactions to ordinary units of RBCs

That washing process removes what?

Plasma proteins - the cause of most allergic reactions

How long until deglycerolized RBCs expire?

24 hours post-deglycerolization and washing

A patient is an allogenic bone marrow transplant recipient and is in need of blood units because of low Hgb/Hct levels. Is there anything that this patient is at risk for?

Yes. The patient is at risk for graft-versus-host disease (GVHD) from donor lymphocytes in the transfused blood.

To prevent this, all blood products should be irradiated before transfusion.

What are CMV-negative blood components?

Indicated for recipients who are CMV-negative and at risk for severe sequelae of CMV infections

Who are at risk of CMV?

CMV (-) pregnant women

Allogeneic CMV (-) bone marrow and hematopoietic progenitor cell transplant recipients

Premature infants weighing less than 1200g

A severely immunocompromised patient is in need of packed RBCs. Which product would need to be ordered?

Severely immunocompromised patients are at high risk for transfusion-associated graft-versus-host disease (TA-GVHD) caused by donor lymphocytes.

Irradiation inactivates donor lymphocytes, preventing this complication.

What are irradiated cellular blood components?

Gamma radiated blood components to prevent GvHD

Where can GvHD be seen?

Transfusion or transplantation of immunocompetent T lymphocytes

Histocompatibility differences between graft and recipient (major or minor HLA or other histocompatibility antigens)

Immunocompromised patients

Is irradiated blood used even if you are donoating to a family member?

Yes

When are GvHD most common?

Allogeneic bone marrow or hematopoietic progenitor cell transplantation

GvHD is a syndrome affecting mainly what?

Skin, liver, and GI tract

A patient is admitted with thrombocytopenia, with a platelet count of 50,000. If the physician wants their platelet count to increase to 100,000, how many: RDPs are needed? SDPs are needed?

Using RDPs: 50,000 ÷ 10,000 ≈ 5 RDPs

Using SDPs: 50,000 ÷ 50,000 ≈ 1 SDP

When would a patient need a platelet transfusion?

Thrombocytopenia or abnormally functioning platelets

How much platelets should be in one unit?

3x10^11 PLTs

Random donor platelet unit should increase the platlet count by how much?

5000-10000/μL per RDP

Single donor platelet unit should increase the platlet count by how much?

20000-60000/μL per SDP

If the 10 minute increment platelet count increase is less than 50% of that expected on two occasions, the patient is considered what?

Refractory - massive splenomegaly, high fever, sepsis, DIC, platelet or HLA antibodies

Positive platlet crossmatches and/or positive HLA antibody screen is considered evidence of what?

Alloimmunization

A patient suddenly becomes septic and is not responding to IV-vancomycin. What would you suggest using to help the patient?

In severe sepsis unresponsive to antibiotics—especially in neutropenic or immunocompromised patients—the body lacks enough white cells to fight infection.

Granulocyte transfusions provide functional neutrophils to help combat the infection until the patient's marrow recovers.

Granulocyte pheresis are for patients with what?

Documented infection for 24-48 hours and unresponsive to antibiotic/antifungal therapy

Fever, neutrophil counts less than 500/μL, septicemia, or bacterial infection unresponsive to antibiotics

Should granulocytre pheresis units be crossmatched?

Yes, due to significant RBCs left in the unit

A patient is admitted with an acute GI bleed.Aside from the obvious order of packedRBCs, what else should the physician beordering?

A GI bleed causes loss of not only red cells but also plasma volume and clotting factors, and sometimes platelets.

To restore hemostasis and volume:

Packed RBCs → replace oxygen-carrying capacity

FFP → replace clotting factors

Platelets → correct thrombocytopenia or platelet dysfunction

What does fresh frozen plasma contain? When does it expire?

All stable and labile coagulation factors

Expires 24 hours post thaw

What does plasma contain?

All coagfactors except labile factors V and VIII

When may a person need a plasma transfusion?

Liver disease or liver failure, DIC, Vit K deficiency, or Warfarin overdose, massive transfusion

Are congenital coagulation factor deficiencies treated with plasma?

Rarely, dose requirement for surgical produceures and serious bleeding can cause pulmonary edema as a result of volume overload

A patient is "going bad" in open-heart surgery, and their coagulation levels are dropping. Aside from RBCs, plasma, and platelets, what else can we give?

During open-heart surgery, if coagulation levels are falling despite giving RBCs, plasma, and platelets, the patient may be deficient in fibrinogen, Factor VIII, Factor XIII, or von Willebrand factor.

Cryoprecipitate is rich in these components, especially fibrinogen, and helps restore clot formation.

Cryoprecipiate is primarily used for what?

Fibrinogen replacement

AABB requirements for fibrinogen content is what?

150 mg fibrinogen and 80 units of factor VIII/unit

When would a patient need cryoprecipitate?

Liver failure, DIC, massive transfusion, surgery or trauma patients

What is mild or moderate factor VIII deficiency treated with?

Desmopressin acetate

How are patient's treated with von Willebrand's disorder?

Virus safe factor VIII with assayed amounts of factor VIII and vWF available to treat patients

Patients with hemaphilia A are treated with what?

Factor VIII is prepared from plasma obtained from paid donors or whole blood donors

Only factor VIII products labeled as containing what should be used for patients with von Willebrand's disorder

vWF

What is prepared from pooled plasma?

Factor IX complex (prothrombin complex)

What is factor IX recommended for?

IX-deficient patients (Hemophilia B), patients with factor VII or X deficiency (rare), and selected patients with factor VIII inhibitors, or for reversal of Warfarin overdose

Disadvantages of crossmatching for procedures with a low likelihood of requiring transfusion

An increasing number of cross-matches performed, an increasing number of units available for use by others, contribute to the aging of units

Advantages of a type and screen

If AS is negative - XM may be done utilizing IS

Positive effects on crossmatch to transfusion (CT) ratio of type and screen

Number of XM units should be no more than 2x number required for procedure

Autologous transfusions

Predeposit of blood by the patient

Intraoperative hemodilution

Salvage of shed blood during and after surgical procedures

What do autologous transfusions reduce?

Possibility of transfusion reaction or transmission of infectious disease

When are emergency transfusions done? What blood type is it usually?

Patients who are experiencing rapid or uncontrollable bleeding

(losing more than 20% of blood volume)

Type O negative

What is considered a massive transfusion?

About 10 units within 24 hours

Impact of patient's clinical status and lab results under a massive transfusion

PLTs are required if <50,000

Plasma is needed if the PT ratio or INR is >1.5

PTT is >60 seconds

Fibrinogen is <100 mg/dL

Protocol for massive transfusions

Type and XM testing two units of group O

Continuing 4-6 type specific or XM RBCs, 4 plasma, and 1 platelet pool

Monitor CBC, PLT count, PT/INR, PTT, and Fibrinogen

Why are neonatal transfusions important?

Premature infants frequently require transfusion of a small amount of RBCs to treat anemia or prematurity

How much does a neonatal transfusion increase Hgb?

10mL/kg increases Hgb 3g/dL

Five product specifics for neonatal transfusion

1. Blood must be fully tested, as done for adults

2. Blood units less than 7 days old are preferred to reduce the risk of hyperkalemia and to maximize the 2,3-diphosphoglycerate levels

3. CMV-seronegative or leukocyte-reduced is used to prevent CMV infection

4. Use of irradiated blood for intrauterine transfusions to prevent TA-GvHD

5. Infants who are hypoxic or acidotic should receive blood testing and be negative for Hgb S

Why would oncology patients need transfusions?

Bone marrow suppression due to chemotherapy, radiation, infiltration, and replacement of bone marrow with malignant cells

Risk of TA-GvHD

What are blood filters used for?

Gross clots and cellular debris

Rate of infusion

Slow for 10-15 minutes, rest of the unit within 4 hours of start time

Why is it important to keep the blood warm as it is transfused?

Cold blood can cause hypothermia, which may increase the risk of cardiac arrhythmia and hemorrhage