blood component therapy

major functions of plasma

Maintenance of blood volume

Suspend cellular elements: RBCs, WBCs, PLTs

Oxygen / carbon dioxide transport

Nutrient exchange

Hormone transport

Waste evacuation

Temperature regulation

RBC antigens

At least 80 different antigens on RBCs

1. ABO

2. Rh

ABO

A antigens, B antigens, or neither = O

A and B dominant over O, but codominant with each other

if Rh is present…

Rh +

if rh is not present…

Rh-

with Rh, which is dominant?

positive is dominant over negative

antibodies are in?

plasma

antigens are on?

the rbcs

blood types image

rh factor

all blood types can be Rh+ or Rh-

Only Rh+ are expressed, But Rh can be homozygous or heterozygous.

abo blood system chart

whats most common blood type in us

O+

whats least common blood type in US

AB-

transfusion

administration of whole blood or blood components directly into the bloodstream

Process is regulated by federal government

American Association of Blood Banks (AABB)

transfusion stringent requirements on:

collection, testing, storage, & distribution

transfusion options

1. homologous blood

2. autologous blood

3. designated (directed) blood

homologous blood

collected from random volunteer donors

autologous blood

collected from intended recipient prior to planned procedures

salvaged during surgery “cell saver”

eliminates risk of alloimmunization, immune-mediated transfusion reactions, & transmission of viral disease

designated (directed) blood

collected from donor designated by recipient

blood component types

Whole Blood

Red Blood Cells (Packed)

Modified Red Blood Cells

Leukocyte-poor (washed)

Irradiated

Platelets

Granulocytes

Fresh Frozen Plasma

Cryoprecipitate Antihemophilic Factor (AHF)

Coagulation Factor Concentrates

Albumin, Plasma Protein Fraction

Immune Serum Globulins

whole blood composition (400-500 mL/unit)

RBCs

plasma which contains plasma proteins (globulins, antibodies)

stable clotting factors

anticoagulant / preservative

who would get whole blood?

Symptomatic anemia & major volume deficit

Massive hemorrhaging with hypotension, tachycardia, SOB, pallor, low Hgb & Hct

Whole blood rarely required & often medically unnecessary

whole blood administration

ADMINISTRATION:

Must be ABO + Rh compatible

Rate of infusion

Initially: 1 mL/kg/hr (~70 cc/hr) for 15 min

Then: 125 cc/hr to infuse in 2-4 hours

as fast as tolerated in massive blood loss or shock

rate of infusion you usually always start?

slowlyyyyyy

equipment for whole blood transfusion

19 gauge needle or larger (needs to be big enough to fit RBCs through)

23 gauge for pediatric patients

standard straight or Y-type blood infusion set with 170-micron filter

0.9% normal saline

NEVER add medications or mix with other solutions

expected outcomes of whole blood

Resolution of symptoms of hypovolemic shock & anemia

1unit whole blood :

increase Hct by  ~3%

increase Hgb by 1 g/dL

complications of whole blood

Hemolytic reaction

Allergic Reaction

Hypothermia

Electrolyte disturbances

Citrate intoxication

Infectious diseases

packed red blood cells (250-350 mL/unit) composition

RBCs centrifuged from whole blood

80-90% of plasma removed

2 types of packed red blood cells

1. Citrate-phosphate-dextrose-adenine (CPDA)

   shelf life 35 days

   Hct 80%

2. Additive Solution (100mL) (AS-1, AS-3, or AS-5)

   higher shelf life (42 days)

   lower viscosity - Hct 55-60%

indications for packed red blood cells

Increase oxygen-carrying capacity in symptomatic anemia 

1. nutritional deficiencies

2. acute/chronic blood loss

without need for volume expansion

NOT for:

1. volume expansion

2. wound healing

3. general well-being

administration of RBCs

Must be ABO & Rh compatible

Rate of infusion

1. Initially: 1 mL/kg/hr (~70 cc/hr) for 15 min

2. Then: 125 cc/hr to infuse in 2-4 hours

May be subdivided into aliquots

Units without AS may be viscous & require dilution with NS (notttt likely)

aliquot

portion of

equipment for packed red blood cells

19 gauge needle or larger

23 gauge for pediatric patients

standard straight or Y-type blood infusion set with 170-micron filter

0.9% normal saline

NEVER add medications or mix with other solutions

RBC expected outcomes

Resolution of symptoms of anemia

1unit whole blood ®

increase Hct by  ~3%

increase Hgb by 1 g/dL

complications of RBCs

Infectious diseases

Hemolytic reaction

Allergic reaction

Hypothermia

Electrolyte disturbances

Citrate intoxication

Leukocyte-Poor Red Blood Cells composition

decrease number of WBCs (95% removed)

80% of RBCs remain

Accomplished by:

-centrifuged

-washed

-frozen deglycerolized

-microaggregate / leukocyte depletion filter

indications a person would need leukocyte poor red blood cells:

Prevent recurrence of febrile, non-hemolytic transfusion reactions

Washed or frozen deglycerolized:
lower incidence of urticarial or anaphylactic reactions

washing for Leukocyte-Poor Red Blood Cells

performed at time of collection

removes 80-95% of WBCs & virtually all plasma

lowers K level: You remove most of that plasma, and rinse off the extracellular K⁺ too

requires 1 hour for processing

must be transfused within 24 hours

freezing Leukocyte-Poor Red Blood Cells

performed within 6 days of collection

can be stored for 10 years

thawing & removal of cryoprotectant (glycerol) eliminates virtually all plasma & 99% WBCs

requires 90 min for processing

must be transfused within 24 hours

Leukocyte-Poor Red Blood Cells outcomes

Prevention of reaction caused by infusion of WBCs & foreign proteins

Removal of most (99.9%) of leukocytes may also lower risk of alloimmunization & transmission of CMV (cytomegalovirus is most often in WBCs)

Leukocyte-Poor Red Blood Cells complications

Hemolytic reaction

Hypothermia

Electrolyte disturbances

Citrate intoxication

Infectious diseases

irradiated RBCs composition

exposed to a measured amount of radiation

donor lymphocytes incapable of replication

performed prior to release

labeled “irradiated”

carries NO radiation risk to transfusionist or recipient

who would get irradiated RBCs

prevent post-transfusion graft-versus-host disease

Hodgkin’s or non-Hodgkin’s lymphoma

acute leukemia

congenital immunodeficiency disorders

low birth weight neonates

intrauterine transfusions

bone marrow transplants

expected otucomes of irradiated rbcs

prevention of GVHD

complications of irradiated RBCs

Hemolytic reaction

Hypothermia

Electrolyte disturbances

Citrate intoxication

Infectious diseases

composition platelets

Removed from 4-6 units whole blood

Contain some RBCs

Pooled: >5.5x1010 PLT in 50-70 mL plasma per unit

Apheresis: >30x1010 PLT in 200-400 mL plasma per unit

Types: random-donor, single-donor, HLA-matched

35-50 mL/unit

who needs platelets?

thrombocytopenia (chemotherapy)

Platelet dysfunction

PLT < 10-20,000 or active bleeding & PLT < 50,000

S/S: petechiae, gum bleeding, ecchymoses, hematuria, bloody stool

platelet therapy not for:

Immune thrombocytopenic purpura

Prophylaxis with massive blood loss or CABG

platelet administration

Do NOT refrigerate max storage 5 days

ABO testing not necessary but usu. done

Infusion rate (rapidly)

10 mL/min

infuse within 4 hours

equipment for platelet transfusion

Do NOT use RBC filter

Use component set with 170-micron filter obtained from blood bank

Leukocyte-poor filters also available

19 gauge or larger needle

0.9% (normal) saline

expected outcomes of platelet transfusion

Prevention or resolution of bleeding d/t thrombocytopenia or PLT dysfunction

1 unit platelets leads to higher PLT by  5,000/mL

PLT count within 1 hour of transfusion

complications of platelet transfusion

Infectious diseases

Allergic reactions

Febrile reactions

fresh frozen plasma composition

Plasma rich in clotting factors (V,VIII, IX) with platelets removed

91% water

7% protein (clotting factors, albumin, globulins, antibodies)

2% carbohydrates

Freezing within 6 hours preserves clotting factors

who needs FFP?

Demonstrated deficiency of clotting factors

DIC, liver disease, coagulopathies

Prior to invasive procedures

PT or PTT
> 1.5 x normal

what would you not use FFP for?

Volume expansion (use NS or albumin)

Nutritional Supplement

Prophylaxis with massive blood loss or CABG

administration of FFP

Contains no RBCs

Administer ABO & Rh compatible plasma

Transfuse w/in 24 hours of thawing

Infusion rate:

200 mL/hour

slower if risk of circulatory overload

equipment for FFP

Do NOT use RBC filter

Use component set with 170-micron filter obtained from blood bank

19 gauge or larger needle

0.9% (normal) saline

NEVER add medications or diluent

plasma compatability is…

opposite of RBCs

what is the universal donor for plasma?

ab

what is the universal donor for RBC?

O

Cryoprecipitate Antihemophilic Factor

Lyophilized concentrate containing Factor VIII

250 mg of fibrinogen

20-30% Factor XIII

from large pools of donor plasma

heat a/o solvent-detergent treatment  eliminates risk of viral transmission

who needs AHF?

Factor VIII [conc.]:

1. Factor VIII deficiency (Hemophilia A)

2, von Willebrand’s disease

3. Hypofibrinogenemia

4. Factor XIII deficiency

Factor IX [conc.]:

Factor IX deficiency (Hemophilia B)

AHF administration

Dose is calculated based on plasma volume

8-10 bags supply 2 g of fibrinogen (hemostatic dose)

Repeat doses may be necessary to attain satisfactory serum levels

Rate of infusion

~ 1-2 mL/min

usu. 4 units (60 mL) in 15 min

AHF equipment

Blood component administration set with 170-micron filter obtained from blood bank

19 gauge or larger needle

0.9% (normal) saline

NEVER add medications or diluent other than 0.9% normal saline

expected outcomes with AHF

Hemostasis d/t increased levels of deficient factor

Correction of factor and fibrinogen deficiencies

Cessation of bleeding

Lab values required to assess effectiveness of treatment

complications from AHF

Allergic reactions

Hepatitis

cyroprecipitate compatibility

same as plasma compatibility

Albumin & Plasma Protein Fraction composition

prepared from plasma

ALBUMIN:

96% albumin

4% globulin & other proteins

Available as:

5% iso-oncotic

25% solution

PLASMA PROTEIN:

83% albumin

17% globulins

Available as:

5% solution

who would need albumin and plasma proteins?

Volume expansion

plasma exchange

shock

massive hemorrhage

Acute liver failure

Burns

Hemolytic disease in the newborn

administration of albumin and plasma protein fraction

ALBUMIN:

5%: 1-10 mL/min faster in shock but assoc w/ hypotension

25%: 0.2-0.4 mL/min significant ­increase blood volume & ­ increase BP

PPF:

1-10 mL/min

ABO NOT a factor

equipment for albumin and plasma protein fraction

19 gauge or larger needle

standard IV infusion set

may require specific  filter

set & filter may be supplied with solution

expected outcome with albumin

Acquire & maintain adequate BP and volume support

albumin complications

Circulatory overload

Febrile reaction

Compatibility NOT a factor since there are no ABO blood group antibodies present

CANNOT transmit hepatitis or HIV infection since pasteurization process used to prepare products destroy viruses

immune serum globulins composition

Concentrated aqueous solution of gamma globulin containing a higher titer of antibodies

Nonspecific ISG:

Obtained from a large pool of random donors

Used to ­ increase gamma globulin levels & enhance immune response

specific ISG

Prepared from donors with high antibody titer to known antigens

Hepatitis B Immune Globulin (HBIG)

Rh (D) Immune Globulin (RhIG) aka RhoGAM

Varicella-Zoster Immune Globulin (VZIG)

who would need immune serum globulins?

Provide passive immune protection

HBIG – following exposure to HBV

RhIG – following exposure to Rh (D) antigens through transfusion or pregnancy to prevent antibody development

VZIG – immuno-compromised patients exposed to chicken pox

Treat hypogamma-globulinemia

special considerations with immune serum globulins

Patients with a history of severe allergic reaction to plasma should NOT receive ISG

Neither HIV nor Hepatitis B is transmitted by ISG, however some intravenous gamma globulin solutions have been reported to transmit Hepatitis C

administration of immune serum globulins

Most given IM but IV preparations also available

IM injections may be painful & result in local irritation – use warm compresses

NEVER give IM preparation IV d/t risk of anaphylaxis

READ package inserts carefully

Give ISG prior to, or as soon after, exposure as possible

RhIG & VZIG MUST be administered w/in 72 hrs of exposure to achieve optimal effect

wIntravenous ISG (IVIG)

Administer ONLY intravenously using a filter

DO NOT administer with other medications

Begin infusion w/in 2 hrs after reconstitution

expected outcome of immune serum globulins

Transient correction of gamma globulin deficiency or prevention of disease through the passive administration of antibody

granulocytes

WBCs that help us fight infection

granulocyte transfusion composition

1 unit contains:

minimum of 1.0x1010 granulocytes

Variable amounts of lymphocytes (usu. < 10%)

30-50 mL of RBCs

100-400 mL of plasma

6-10 units of platelets (optional)

granulocyte transfusion volume

With platelets: 200-400 mL

Without platelets: 100-200 mL

who would you give granulocytes to

Acquired neutropenia

Chemotherapy

Radiation

Congenital WBC dysfunction

Serious infection unresponsive to conventional antibiotics

Long-term therapeutic benefit still questionable

administration granulocyte transfusion

1 unit daily:
1.0x1010 granulocytes

Given slowly over 1 to 4 hours

Have short survival time

Infuse as soon as available (w/in < 24 hrs)

To prevent reactions, premedication with:

Antihistamine

Acetaminophen

Steroids

Meperidine

equipment for granulocyte transfusion

Use standard blood component set with 170-micron filter obtained from blood bank

19 gauge or larger needle

0.9% (normal) saline

NEVER add medications or diluent

Do NOT use depth-type microaggregate or leukocyte depletion filter that could trap WBCs during infusion

expected outcome for granulocyte transfusion

EXPECTED OUTCOME:

Improvement in or resolution of infection

No ­increase in peripheral WBC is seen in adults but may be seen in children

Improvement in clinical condition is only measurement of treatment effectiveness

complications for granulocyte transfusion

Rash

Febrile reaction*

Hepatitis

*  ­increase incidence of febrile, nonhemolytic reactions with transfusion of granulocytes
– infuse slowly &
– observe patient closely

DO NOT administer Amphotericin B w/in 4 hrs of granulocyte infusion d/t risk of pulmonary insufficiency

granulocyte compatibility is the same as…

RBC transfusion

acute transfusion reactions

Acute hemolytic

Febrile, non-hemolytic (most common)

Mild allergic

Anaphylactic

Circulatory overload

Sepsis

Transfusion-Related Acute Lung Injury (TRALI)

delayed transfusion reactions

Delayed hemolytic

Hepatitis B

Hepatitis C

HIV-1 (AIDS virus) infection

Iron overload

Graft-versus-host disease (GVHD)

Other:

CMV, HTLV-I, malaria

general manifestations of transfusion rxns

Fever (­ increase 1-2° C)

Chills

Muscle aches, pains

Back pain

Chest pain

Headache

Heat at site of infusion or along vein

nervous system manifestations of transfusion reaction

Apprehension

Sense of impending doom

Tingling, numbness

respiratory manifestations of transfusion reaction

Respiratory rate: Tachypnea or Apnea

Dyspnea

Cough

Wheezing

Rales

GI transfusion reaction manifestations

Nausea

Vomiting

Pain, abdominal cramping

Diarrhea (may be bloody)

renal transfusion reaction manifestations

Changes in urine volume

oliguria, / anuria

Renal failure

Changes in urine color

Dark, concentrated

Shades of red, brown, amber

May indicate the presence of RBCs or hemoglobin in urine

cardiovascular transfusion rxn manifestations

CARDIOVASCULAR:

Heart rate

Bradycardia

Tachycardia

Blood pressure

Hypotension, shock

Hypertension

Peripheral circulation

Cyanosis, facial flushing

Temperature:

Cool / clammy

Hot / flushed / dry

Edema

Bleeding

Generalized (DIC)

Oozing at surgical site

integumentary manifestations of transfusion rxns

Rashes / hives (urticaria) / swelling

Itching

Diaphoresis

NOTE:

Reactions from different causes can exhibit similar manifestations; therefore every symptom should be considered potentially serious and transfusion discontinued until the cause is determined

unconscious pt manifestations of transfusion rxn

Weak pulse

Fever

Hypotension

Visible hemoglobinuria

Increased operative bleeding (oozing at surgical site)

Vasomotor instability (tachycardia, bradycardia, or hypotension)

Oliguria / anuria

when a transfusion rxn occurs:

STOP the transfusion

Keep the IV open with 0.9% normal saline

Report the reaction to both the transfusion service and attending physician immediately

Do clerical check at bedside of identifying tags & numbers

Treat symptoms pre physician’s order and monitor vital signs

Send blood bag with attached administration set and labels to the transfusion service

Collect blood and urine samples and send to lab

Document thoroughly on transfusion reaction form and in patient chart

Acute Transfusion Reactions: Acute Hemolytic cause

Infusion of ABO-incompatible whole blood, RBCs, or components containing 10 mL or more RBCs

Antibodies in the recipient’s plasma attach to antigens on transfused RBCs causing RBC destruction