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 Most common Mostly from platelets units Gram positive cocci Rarely from RBCs units Yersinia entercocokitica Symptoms: High fever/rigor Abdominal cramping nausea & vomitting Shock Treatment: stop transfusion Culture patient and product bag IV antibiotics Presssor support Prevention: Proper phlebotomy techniques at dination (proper sterilization) Careful donor history pH testing and/or culture of platelets units

1.1.4. HTLV 1/2 Human T lymphocyte Virus

1.1.5. Malaria

1.2. non-infectious

1.2.1. Hemolytic reaction Incompatible RBCs: Due to ABO incompatiblity (IgM) Due to alloimmunizarion from prior transfusion and/or pregnancy (IgG) Most common cause Clerical error (Human error) Treatment: IV fluid for hypotension Diuretic - maintain urine output at 30 - 100 ml/h low dose of dopamine (severe cases) Heparin Prevention: Blood type & antibody screen every 3 days

1.2.2. Transfusion Related Acure Lung Injury (TRALI): Pathophysiology Anti-HLA donor plasma activates PMNs in pulmonary capillaries of recipient => capillary leakage Anti-HLA antibodies form after prior transfusion or pregnancy Symptoms Sudden hypoxemia (O2 saturation < 90%) or increase FiO2 requirment. CXR with bilateral infiltration (like ARDS) Absent of sings of circulatory overload No pre-existing lung injury or ARDS Onset within 6 hours of transfusion Treatment Supportive measures Prevention Use of male plasma Defer implicated donor All blood components implicated Fresh-frozen plasma (FFP) most commonly Incidence 1 in 1000 transfusions

1.2.3. Transfusion Associated Circulatory Overload (TACO): most common 1 in 100 transfusions Pathophysiolgy High volume or rate of transfusion exceeds ability of patient's cardiovascular system to handle addtional workload Symptoms Dyspnea, Orthopnea Hypoxemia Pulmonary edema Hypertension (>50 mmHg increase in systolic BP) increase central venous pressure increase Brain Natriuretic peptide (BNP) Treatment Stop or slow rate of infusion Diuretic oxygen Supportive care Prevention Vigilant assessment of pt's ins/outs Slow rate of infusion/aliquote Diuretics

1.2.4. RBCs autoantibody: antibody react with all RBCs, including the patient own causes: Autoimmune disease medication idopathic

1.2.5. Febrile Non-hemolytic transfusion reaction: Majority of transfusion reactions increase in tempreture with no other cause of feverj Pathophusiology: Pyrogenic cytokines in cellukar units. Treatment: Anti-pyretics 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 -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 prevention: Leuko-reduced unit Acetaminophen premedication

1.2.6. Allergic Transfusion Reaction 45% of all transfusion reactions More common with FFP Symptoms: Puritus Urticaria Pathophysiology recipient IgE react with donot plasma proteins Donor plasma IgE react with recioient plasma protein Treatment Benadryl Corticosteroids The only reaction in which the transfusion can be resumed Prevention: Benadryl premedication Washed RBCs/Platelets Washed RBCs/Platelets

1.2.7. Anaphylactic Transfusion Reactions More severe allergic reaction Pathophysiology IgA deficent patient with anti-IgA Almost immediate reaction Clinical symptoms range from urticaria to shock & cardiac arrest. Treatment Epinephrine Corticosteroids Prevention Washed products IgA deficent products

1.2.8. Other complications of Transfusion Allo-immunization In Sickle cell patient In thalassemia patient Iron overload Metabolic abnormalities Hypocalcemia Hyperkalemia coaguloPathy Hypothermia GVHD Graft-Versus-Host-Disease

2. Time Required for units

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


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 Whole blood plasma 200 - 250 ml collected by apheresis jumbo FFP All coagulation factors and other proteins expect 20-30% increase in all factor levels indications CoaguloPathy due to multiple factor deficiencies: Whole blood plasma 200 - 250 ml collected by apheresis jumbo FFP All coagulation factors and other proteins expect 20-30% increase in all factor levels indications CoaguloPathy due to multiple factor deficiencies:

4.1.2. Cryoprecipitate Made from 1 unit partiallyn thawed FFP 15 ml composition: Fibrinogen factor VIII Von Willebrand Factor (VWF) Factor XIII Dose: 1 unit/10 Kg 10-20 unit in average adult indications Fibrinogen deficiency von Willebrand's disease Topical fibrin glue 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 Prepared from whole blood or apheresis 250-300 ml RBCs Stored from 21 to 42 days depends on the anti-coagulants 1-6 C, increase the temp. could destroy the RBCs Indiccation for RBCs units: Symptomatic anemia: Cardiac or pulmonary diseases 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 Transfusion Requirments in Critial care (TRICC): Restrictive treansfusion: Liberal transfusion: All outcomes evaluated favored restrictive transfusion group. Contraindications for RBCs units: acute blood loss < 20-30% blood volume Nutritional anemia Hb > or = 10 gm/dL Expected Results of RBC transfusion: with one RBC unit for average adult RBCs transfusion suppress recipient RBC production!! Modified RBC units Leckucyte-reduced RBCs Washed RBCs Irradiated RBCs CMV negative RBCs Frozen RBCs

4.2.2. Platelets Whole blood derived platelets taking blood units (usually from multiple donations) then put it into centrifuge to extract the platelts. Single-donor platelets (Apheresis platelets) 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!) advantage: ABO & Rh antigens in platelets? Platelets express ABO antigens Platelets DO NOT express Rh antigens Indication of platelets: Thrombocytopenia ThrombocytoPathy Modified Platelets unit: Washed platelets Lecukocyto-reduced platelets Irradiated Failure of expected platelets increment slide 36 Consumption (after 24 hours) Anti-HLA or platelet-antigen antibodies (after 10-69 minutes) Contraindications for platelets: TTP/HUS Heparin-induced thrombocytopenia ITP (relative contraindication) Uremia-related platelets dysfunction important notes about platelets: 1 unit/10 kg of body weight increases Plt count by 50,000 Platelet: For surgery, platelet count must be more >50,000 (in some cases more than 100,000) Last year exam Q: For a 70 kg patient, 1 unit of platelets transfusion increases platelets counts by Approximately.

4.2.3. Granulocytes Collected via apheresis 250- 300 ml should be given once daily for at least 5 days indications Persistent fever ot infection not responding to anti-microbial therapy. Severe neutropenia (< 500/uL) Reversible bone marrow hypoplasia Must have CMV-negative donor to prevent CMV transmission. 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,