Blood Products

ABO

What is the MOST important blood group and mismatches are associated with acute hemolytic transfusion reactions?

Rh type (D antigen)

What is the 2nd most important blood group and is SUPER immunogenic?

autologous

What type of blood donation reduces the risk of transfusion-transmitted diseases and sensitization to donor’s blood group, but requires different donation criteria?

Volunteer

What type of blood donation requires donors to meet specific criteria, is NOT paid, and involved whole blood made into components?

Commercial (plasma)

What type of blood donation is a PAID position and used to manufacture specific products?

ABO, Rh, antibodies, infectious disease (HIV, HCV, west nile, syphilis, etc)

What is Donor blood tested for?

Antibody screen and panel

What type of blood bank test detects and identifies atypical antibodies using a panel for identification if positive?

Direct antigobulin test (DAT)

What type of blood bank test detects immune coating of RBCs and is used in transfusion rxn work ups, autoimmune hemolytic anemia workups, HDFN evals?

Type and Screen

What type of blood bank test includes a ABO, Rh, and antibody screen and is usually done before surgery to assure blood is available OR in pregnant women to assess risk of HDFN?

Type and cross

What type of blood bank test includes type and screen, AND units crossed and held for a specific patient, typically for surgery?

overall clinical condition (hypoxic, anemia), HGB level and rate of decline, alternative therapies, patient preference

Considerations before transfusing blood

HGB 7 gm/dl (adult), 8 gm/dl (pre-sugery, pre-existing cardiac issues)

Transfusion guidelines - DO NOT apply to severely thrombocytopenic, acute coronary syndrome, chronically transfusion dependent

Standard unit is 450 ml of RBCs (200-250) and plasma - rare usage

Tell me about whole blood

Made by removing most of the plasma from whole blood, 220-250 ml, NO clotting factors, stored 1-6 degrees Celcius

Tell me about packaged RBCs (PRBCs)

Maximize O2 delivery w/o increasing volume (acute blood loss), intrauterine/exchange transfusion, symptomatic anemia, ECMO

Indications for PRBCs

NORMAL SALINE (get another large bore IV)

PRBCs can only be given with

ABO, Rh

PRBCs matching rules

HCT by 3%, HGB by 1 gm/dl

1 unit of PRBCs should increase

leukoreduced, washed, frozen, irradiated, pediatric

Types of PRBCS

Leukoreduced (take out the WBCs)

What type of PRBCs decreases the risk of HLA sensitization, febrile non-hemolytic transfusion reactions, CMV transmission?

Washed PRBCs

What type of PRBCs removes most of the remaining plasma and is outdate in 24 hours?

Non ABO identical transfusions (neonate exchange transfusion, intrauterine transfusion), IgA deficient individuals with anti IgA, repeated allergic reactions

Indications for washed PRBCs

Frozen RBCs

What type of PRBCs is used for the storage of rare blood types/military stockpiles and requires special preparation and thawing procedures BUT can be store for up to 10 years

Irradiated PRBCs

What type of PRBCs decreases the risk of transfusion associated GVHD

immunocompromised peeps - in utero transfusions, neonatal exchange, stem cell transplant patients, ECMO, chemo, radiation

Indications for irradiated PRBCs

Pediatric aliquots

What type of PRBCs is when a single unit is aliquoted into small volumes to limit sensitization to 1 donor

exchange transfusion, severe HDFN

Indications for pediatric aliquots

Usually 200-250, ABO identical, ALL labile and stable coag factors, last 24 hours - 5 days after being thawed

Tell me about Fresh frozen plasma (FFP)

DIC, massive transfusion (prevents dilution of clotting factors), plasma exchange in therapeutic apheresis, coag factor deficiencies (liver, genetic), single coag factor deficiency, reduce warfarin

Indications for FFP

Made from FFP (30-50 ml), self life of 4 hours, contains fibrinogen, factor VII, vWBF, Factor XIIII, NO ABO rh match

Tell me about CRYO (cryoprecipitated anti-hemophilic factor)

hypofibrinogenemia (primary), DIC, vonWillebrand’s disease, Factor XIII deficiency, trauma

Indications for CRYO

Most from single donors via apheresis, MUST be ABO and Rh matched, 5 day shelf life, stored at room temperature, tested for bacterial contamination

Tell me about platelets

3 X 10^11 platelets (increases count by 30,000-50,000)

Standard dose of a bag of platelets

functionally abnormal platelet, thrombocytopenia (active bleeding, decreased production, increased consumption)

Indications for platelets

underlying idiopathic/immune destruction

Who are we NOT giving platelets too?

fever, sepsis, DIC, active bleeding

If a platelet doesn’t respond as expected to a platelet transfusion what do we need to rule out before jumping to refractory thrombocytopenia

Antibody mediated destruction of platelets

Refractory thrombocytopenia is caused by

HLA matched platelets

Refractory thrombocytopenia can be avoided with

Apheresis

What removes specific components and returns the remainder to the the donor and usually takes 1 ½ - 3 hours

patients become refractory to random platelets, multiple previous platelet transfusions, provide HLA platelets

Plateletpheresis must be used when

500,000+ WBCs, septic and unresponsive to antimicrobials, good chance of recovery

Which is leukapheresis indicated?

Peripheral blood stem cells

What is used in place of manual bone marrow transplant collections to obtain cells for transplant - can be allogeneic or autologous?

leukemia, lymphoma, genetic immune deficiencies (multiple myeloma)

Indications for Peripheral blood stem cells

NO ABO or Rh match, colloid volume expander, increases osmotic pressure

Tell me about serum albumin

shock, burns, early in massive transfusions, replacement fluid in therapeutic plasma exchanges

indications for serum albumin

Congenital immunodeficiency, Immune cytopenia, post-transplant, GVHD, MS, myasthenia gravis, guillain-barre

When is IVIG (intravenous immunoglobin) indicated

DIC

Who is NEVER getting IVIG

Rh Immune globulin (RhIg, Rhogam)

What can be given to Rh negative women pregnant with Rh positive babies to prevent sensitization and HDFN or Rh negative children receiving Rh positive blood?

prenatal at 28 weeks, postnatal w/in 72 hours

When during pregnancy is RhIg given

O neg uncrossedmatched, ABO/Rh identical uncrossedmatched, ABO/Rh identical immediate spin crossedmatched

ER blood orders draft picks

Maximum surgical blood order

What is a hospital policy - that for each type of surgery maximum units that can be ordered for crossmatch are defined (prevents waste)

informed consent

Before we transfuse, what is step 1?

Patient ID

What is a critical step in specimen collection and administration of blood products

children, women of childbearing age

Who should we prioritize Rh neg blood for

prior, 15 min, 30 min, hourly after

When administering blood when do we need to monitor and record vitals?

Transfusion reaction

Adverse effect related to transfusion that can be mild to severe, immediate or delayed, immunologic or non-immunologic, and may or may not result in hemolysis?

acute hemolytic, delayed hemolytic, febrile non hemolytic, allergic, anaphylactic, TRALI

Types of immunologic transfusion reactions

TACO, septic shock, transfusion-transmitted disease, transfusion-transmitted disease, GVHD

Types of non-immunologic transfusion reactions

clerical error (patient ID at sample collection)

#1 cause of acute hemolytic transfusion reaction

Stop the transfusion, AHTR

So, ER-PA-C you decide to transfuse Jimmy bob for his hemoglobin of 5.5. You start the transfusion and 10 min later Jimmy starts to report symptoms of pain at his IV site and back, dyspnea, and feeling of dread. Vitals show a fever, hypotension, and tachycardia. What do you need to do and what is this?

shock, renal failure, DIC, death

Complications of AHTR

Delayed hemolytic transfusion reaction

What is characterized by production of antibodies 2-14 days after a transfusion and the expected increase in HGB does not occur, patients may be asymptomatic, febrile, or have elevated bilirubin

Febrile non-hemolytic transfusion reaction (FNHTR)

What is characterized by a reaction of recipient antibodies to donor HLA antigens and is pretty uncommon due to leukoreduced units, patients report fever, chills, HA, flushing, muscle/chest pain?

premedicate wit anti-pyretics

Ways to prevent FNHTR

O2/ventilatory support; diuretics, corticosteroids

So, ER-PA-C you decide to transfuse Jimmy bob for his hemoglobin of 5.5. You start the transfusion and 5 hours later Jimmy starts to report symptoms of dyspnea and feeling feverish. On a physical you note cyanosis, hypotension, and hypoxemia. Treatment plan and what are you NOT going to give this patient?

Transfusion associated circulatory overload (TACO)

What type of transfusion reaction is characterized by volume overload with pulmonary edema where patient report symptoms of hypertension, tachycardia, and respiratory distress?

diuretics, O2

Treatment plan for TACO

bacterial endotoxins in blood products (usually platelets)

Septic shock can be caused by

Stop the transfusion, clerical check, call the lab and send a sample, document!

Gameplan if you think we have a transfusion reaction on our hands

Direct antibody test, inspection of plasma for hemolysis, clerical check

What is the laboratory workup for suspected transfusion reaction

replacement of body blood volume within 24 hrs, use of 20 PRBCs in 24 hours, 50%+ replacement with/in 3 hours, >150ml/min blood loss

How is a massive transfusion defined?

fluids (crystalloids, colloids)

If we have a decreased volume

FFP

If we have dilutional coagulopathy

platelets

If we have dilutional thrombocytopenia

PRBCs

If we need oxygen delivery