Transfusion Medicine

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Transfusion Medicine by Mind Map: Transfusion Medicine

1. Transfusion risk

1.1. infectious

1.1.1. Viral Hepatitis B & C

1.1.2. HIV

1.1.3. Bacterial contamination/sepsis

1.1.3.1. Most common

1.1.3.2. Mostly from platelets units

1.1.3.2.1. Gram positive cocci

1.1.3.3. Rarely from RBCs units

1.1.3.3.1. Yersinia entercocokitica

1.1.3.4. Symptoms:

1.1.3.4.1. High fever/rigor

1.1.3.4.2. Abdominal cramping

1.1.3.4.3. nausea & vomitting

1.1.3.4.4. Shock

1.1.3.5. Treatment:

1.1.3.5.1. stop transfusion

1.1.3.5.2. Culture patient and product bag

1.1.3.5.3. IV antibiotics

1.1.3.5.4. Presssor support

1.1.3.6. Prevention:

1.1.3.6.1. Proper phlebotomy techniques at dination (proper sterilization)

1.1.3.6.2. Careful donor history

1.1.3.6.3. pH testing and/or culture of platelets units

1.1.4. HTLV 1/2

1.1.4.1. Human T lymphocyte Virus

1.1.5. Malaria

1.2. non-infectious

1.2.1. Hemolytic reaction

1.2.1.1. Incompatible RBCs:

1.2.1.1.1. Due to ABO incompatiblity (IgM)

1.2.1.1.2. Due to alloimmunizarion from prior transfusion and/or pregnancy (IgG)

1.2.1.2. Most common cause

1.2.1.2.1. Clerical error (Human error)

1.2.1.3. Treatment:

1.2.1.3.1. IV fluid for hypotension

1.2.1.3.2. Diuretic - maintain urine output at 30 - 100 ml/h

1.2.1.3.3. low dose of dopamine (severe cases)

1.2.1.3.4. Heparin

1.2.1.4. Prevention:

1.2.1.4.1. Blood type & antibody screen every 3 days

1.2.2. Transfusion Related Acure Lung Injury (TRALI):

1.2.2.1. Pathophysiology

1.2.2.1.1. Anti-HLA donor plasma activates PMNs in pulmonary capillaries of recipient => capillary leakage

1.2.2.1.2. Anti-HLA antibodies form after prior transfusion or pregnancy

1.2.2.2. Symptoms

1.2.2.2.1. Sudden hypoxemia (O2 saturation < 90%) or increase FiO2 requirment.

1.2.2.2.2. CXR with bilateral infiltration (like ARDS)

1.2.2.2.3. Absent of sings of circulatory overload

1.2.2.2.4. No pre-existing lung injury or ARDS

1.2.2.2.5. Onset within 6 hours of transfusion

1.2.2.3. Treatment

1.2.2.3.1. Supportive measures

1.2.2.4. Prevention

1.2.2.4.1. Use of male plasma

1.2.2.4.2. Defer implicated donor

1.2.2.5. All blood components implicated

1.2.2.5.1. Fresh-frozen plasma (FFP) most commonly

1.2.2.6. Incidence

1.2.2.6.1. 1 in 1000 transfusions

1.2.3. Transfusion Associated Circulatory Overload (TACO):

1.2.3.1. most common

1.2.3.1.1. 1 in 100 transfusions

1.2.3.2. Pathophysiolgy

1.2.3.2.1. High volume or rate of transfusion exceeds ability of patient's cardiovascular system to handle addtional workload

1.2.3.3. Symptoms

1.2.3.3.1. Dyspnea, Orthopnea

1.2.3.3.2. Hypoxemia

1.2.3.3.3. Pulmonary edema

1.2.3.3.4. Hypertension (>50 mmHg increase in systolic BP)

1.2.3.3.5. increase central venous pressure

1.2.3.3.6. increase Brain Natriuretic peptide (BNP)

1.2.3.4. Treatment

1.2.3.4.1. Stop or slow rate of infusion

1.2.3.4.2. Diuretic

1.2.3.4.3. oxygen

1.2.3.4.4. Supportive care

1.2.3.5. Prevention

1.2.3.5.1. Vigilant assessment of pt's ins/outs

1.2.3.5.2. Slow rate of infusion/aliquote

1.2.3.5.3. Diuretics

1.2.4. RBCs autoantibody:

1.2.4.1. antibody react with all RBCs, including the patient own

1.2.4.2. causes:

1.2.4.2.1. Autoimmune disease

1.2.4.2.2. medication

1.2.4.2.3. idopathic

1.2.5. Febrile Non-hemolytic transfusion reaction:

1.2.5.1. Majority of transfusion reactions

1.2.5.2. increase in tempreture with no other cause of feverj

1.2.5.3. Pathophusiology:

1.2.5.3.1. Pyrogenic cytokines in cellukar units.

1.2.5.4. Treatment:

1.2.5.4.1. Anti-pyretics

1.2.5.4.2. 1- STOP TRANSFUSION 2- ABC’s 3- Maintain IV access and run IVF (NS or LR) 4- Monitor and maintain BP/pulse 5- Give diuretic 6- Obtain blood and urine for transfusion reaction workup 7- Send remaining blood back to Blood Bank

1.2.5.4.3. -BLOOD bank: 1- Check paperwork to assure no errors 2- Check plasma for hemoglobin 3- Repeat crossmatch 4- Repeat Blood group typing 5- Blood culture

1.2.5.5. prevention:

1.2.5.5.1. Leuko-reduced unit

1.2.5.5.2. Acetaminophen premedication

1.2.6. Allergic Transfusion Reaction

1.2.6.1. 45% of all transfusion reactions

1.2.6.2. More common with FFP

1.2.6.3. Symptoms:

1.2.6.3.1. Puritus

1.2.6.3.2. Urticaria

1.2.6.4. Pathophysiology

1.2.6.4.1. recipient IgE react with donot plasma proteins

1.2.6.4.2. Donor plasma IgE react with recioient plasma protein

1.2.6.5. Treatment

1.2.6.5.1. Benadryl

1.2.6.5.2. Corticosteroids

1.2.6.5.3. The only reaction in which the transfusion can be resumed

1.2.6.6. Prevention:

1.2.6.6.1. Benadryl premedication

1.2.6.6.2. Washed RBCs/Platelets

1.2.6.6.3. Washed RBCs/Platelets

1.2.7. Anaphylactic Transfusion Reactions

1.2.7.1. More severe allergic reaction

1.2.7.2. Pathophysiology

1.2.7.2.1. IgA deficent patient with anti-IgA

1.2.7.3. Almost immediate reaction

1.2.7.3.1. Clinical symptoms range from urticaria to shock & cardiac arrest.

1.2.7.4. Treatment

1.2.7.4.1. Epinephrine

1.2.7.4.2. Corticosteroids

1.2.7.5. Prevention

1.2.7.5.1. Washed products

1.2.7.5.2. IgA deficent products

1.2.8. Other complications of Transfusion

1.2.8.1. Allo-immunization

1.2.8.1.1. In Sickle cell patient

1.2.8.1.2. In thalassemia patient

1.2.8.2. Iron overload

1.2.8.3. Metabolic abnormalities

1.2.8.3.1. Hypocalcemia

1.2.8.3.2. Hyperkalemia

1.2.8.4. coaguloPathy

1.2.8.5. Hypothermia

1.2.8.6. GVHD

1.2.8.6.1. Graft-Versus-Host-Disease

2. Time Required for units

2.1. Uncrossmatch Group O-negative = less than 5 min

2.1.1. BEST CHOICE IN EMERGENCY!!

2.2. Uncrossmatched type specefic RBCs = 15 min

2.3. Crossmatched RBCs = 30-45 min

2.4. Full ABO type,Screen & crossmatch = 1 hour

2.5. Fresh-frozen plasma (FFP) = 30 - 40 min

2.6. Cryoprecipitate = 15 min for thawing

2.7. When to order RBC units

2.7.1. When you are ready to transfure!

2.7.2. After unit are out of refrigeration they must be transfured within 4 hours

2.7.3. To be returned to stock unit must be out of regrigeration less than 30 min !

2.7.4. Temperature must not be more than 10' C

3. Type, Screen & Cross

3.1. Type: Blood gruop (ABO)/Rh

3.1.1. Takes 5 min

3.2. Screening: for antibodies

3.2.1. antibody screen = 25 min

3.2.2. antibody identification = 1 hour or more

3.3. Crossmatch: mix donor and recipient blood to see if there's reaction or not

3.4. - Cross match order when you need to transfuse

3.5. - Type and screen order when a surgery with less tendency of bleeding and you need blood to be available (e.g. hysterectomy

3.6. O are universal donors for RBC, AB are universal donors for Plasma

3.7. - Basic screening test after six-unit transfusion ( VERY IMPORTANT ) 1- Hemoglobin and platelets count 2- Coagulation profile ( Pt prothrompine time , activated partial thromboplastine time (APTT), INR) 3- Plasma fibrinogen concentration 4- Fibrin degradation products 5- PH from arterial blood gas analysis 6- Electrolyte

4. Blood prodcts:

4.1. Acellular components:

4.1.1. Fresh-frozen plasma (FFP), Thawed plasma

4.1.1.1. Whole blood plasma

4.1.1.1.1. 200 - 250 ml

4.1.1.2. collected by apheresis

4.1.1.2.1. jumbo FFP

4.1.1.3. All coagulation factors and other proteins

4.1.1.4. expect 20-30% increase in all factor levels

4.1.1.5. indications

4.1.1.5.1. CoaguloPathy due to multiple factor deficiencies:

4.1.1.6. Whole blood plasma

4.1.1.6.1. 200 - 250 ml

4.1.1.7. collected by apheresis

4.1.1.7.1. jumbo FFP

4.1.1.8. All coagulation factors and other proteins

4.1.1.9. expect 20-30% increase in all factor levels

4.1.1.10. indications

4.1.1.10.1. CoaguloPathy due to multiple factor deficiencies:

4.1.2. Cryoprecipitate

4.1.2.1. Made from 1 unit partiallyn thawed FFP

4.1.2.2. 15 ml

4.1.2.3. composition:

4.1.2.3.1. Fibrinogen

4.1.2.3.2. factor VIII

4.1.2.3.3. Von Willebrand Factor (VWF)

4.1.2.3.4. Factor XIII

4.1.2.4. Dose:

4.1.2.4.1. 1 unit/10 Kg

4.1.2.4.2. 10-20 unit in average adult

4.1.2.5. indications

4.1.2.5.1. Fibrinogen deficiency

4.1.2.5.2. von Willebrand's disease

4.1.2.5.3. Topical fibrin glue

4.1.2.5.4. NOT FOR replacment formfactor VIII

4.1.3. Factor concentrate (VIII, IX)

4.1.4. Albumin

4.1.5. Intravenous immunoglobulin

4.2. Cellular components:

4.2.1. RBCs

4.2.1.1. Prepared from whole blood or apheresis

4.2.1.2. 250-300 ml RBCs

4.2.1.3. Stored from 21 to 42 days depends on the anti-coagulants

4.2.1.4. 1-6 C, increase the temp. could destroy the RBCs

4.2.1.5. Indiccation for RBCs units:

4.2.1.5.1. Symptomatic anemia:

4.2.1.5.2. Cardiac or pulmonary diseases

4.2.1.6. RBC: 1 unit of pRBC will increase Hgb 1 gm. Each 500 ml of blood loss = 1 gm drop in Hgb (compensate with one unit) … Last year exam Q: RBC stored in tempreture of : 4C

4.2.1.7. Transfusion Requirments in Critial care (TRICC):

4.2.1.7.1. Restrictive treansfusion:

4.2.1.7.2. Liberal transfusion:

4.2.1.7.3. All outcomes evaluated favored restrictive transfusion group.

4.2.1.8. Contraindications for RBCs units:

4.2.1.8.1. acute blood loss < 20-30% blood volume

4.2.1.8.2. Nutritional anemia

4.2.1.8.3. Hb > or = 10 gm/dL

4.2.1.9. Expected Results of RBC transfusion:

4.2.1.9.1. with one RBC unit for average adult

4.2.1.9.2. RBCs transfusion suppress recipient RBC production!!

4.2.1.10. Modified RBC units

4.2.1.10.1. Leckucyte-reduced RBCs

4.2.1.10.2. Washed RBCs

4.2.1.10.3. Irradiated RBCs

4.2.1.10.4. CMV negative RBCs

4.2.1.10.5. Frozen RBCs

4.2.2. Platelets

4.2.2.1. Whole blood derived platelets

4.2.2.1.1. taking blood units (usually from multiple donations) then put it into centrifuge to extract the platelts.

4.2.2.2. Single-donor platelets (Apheresis platelets)

4.2.2.2.1. using device which draw the blood from the donor and centrifuge it to separate the platelets out, the remaing blood is returned back to the donor. (that's why called single donor platelets!)

4.2.2.2.2. advantage:

4.2.2.3. ABO & Rh antigens in platelets?

4.2.2.3.1. Platelets express ABO antigens

4.2.2.3.2. Platelets DO NOT express Rh antigens

4.2.2.4. Indication of platelets:

4.2.2.4.1. Thrombocytopenia

4.2.2.4.2. ThrombocytoPathy

4.2.2.5. Modified Platelets unit:

4.2.2.5.1. Washed platelets

4.2.2.5.2. Lecukocyto-reduced platelets

4.2.2.5.3. Irradiated

4.2.2.6. Failure of expected platelets increment slide 36

4.2.2.6.1. Consumption (after 24 hours)

4.2.2.6.2. Anti-HLA or platelet-antigen antibodies (after 10-69 minutes)

4.2.2.7. Contraindications for platelets:

4.2.2.7.1. TTP/HUS

4.2.2.7.2. Heparin-induced thrombocytopenia

4.2.2.7.3. ITP (relative contraindication)

4.2.2.7.4. Uremia-related platelets dysfunction

4.2.2.8. important notes about platelets:

4.2.2.8.1. 1 unit/10 kg of body weight increases Plt count by 50,000

4.2.2.8.2. Platelet: For surgery, platelet count must be more >50,000 (in some cases more than 100,000)

4.2.2.8.3. Last year exam Q: For a 70 kg patient, 1 unit of platelets transfusion increases platelets counts by Approximately.

4.2.3. Granulocytes

4.2.3.1. Collected via apheresis

4.2.3.2. 250- 300 ml

4.2.3.3. should be given once daily for at least 5 days

4.2.3.4. indications

4.2.3.4.1. Persistent fever ot infection not responding to anti-microbial therapy.

4.2.3.4.2. Severe neutropenia (< 500/uL)

4.2.3.4.3. Reversible bone marrow hypoplasia

4.2.3.5. Must have CMV-negative donor to prevent CMV transmission.

4.2.3.6. MUST GIVEN WITHIN 24 hours of collection.

5. Apheresis?

5.1. is the process which separate blood components from each other.

5.2. Types:

5.2.1. Plateletpheresis

5.2.2. Leckapheresis

5.2.3. Erythrocytooheresis

5.2.4. Plasmapheresis

5.2.5. Stem cell collection

5.3. Why?

5.3.1. To give only the component which the patient need, some patient only need RBCs other only need platelets etc..

5.3.2. To washout all the immunoglobulins to avoid immunological reactions,