Blood Component Therapy
Fundamentals in Acute Care
Minh-Ha Tran
Learning Objectives
• After participating in this activity, participants will be able to:
– Utilize newfound knowledge of transfusion risk to provide informed consent
for blood transfusion
– State evidence-based laboratory thresholds at which blood component
transfusion may be considered in otherwise stable patients
– Understand rationale behind proper labeling of specimens and of second
specimen rule
– Delineate between Type and Screen, Type and Hold, and Type and Crossmatch
– Recognize and manage:
• Febrile Non-Hemolytic and Allergic Transfusion Reactions
– Distinguish between:
• Transfusion Associated Circulatory Overload (TACO) and Transfusion Related Acute
Lung Injury (TRALI)
Frequency of Transfusion Reactions
Informed Consent
• Risks
– Infectious vs Noninfectious
• Infectious – quite rare
• Noninfectious – much more common than infectious
– Acute vs Delayed
• Acute
– Febrile, Allergic, Acute Hemolytic, Septic, Dyspnea
• Delayed
– Delayed Hemolytic or Delayed Serologic Transfusion
Reactions, HLA alloimmunization and platelet refractoriness,
Transfusional Siderosis
Informed Consent
• Use of Autologous Blood
– not an option for most patients with acute transfusion needs
• Preoperative Autologous Donation waning in popularity and use
– Incites preoperative anemia, increasing transfusion risk
– Adds patient inconvenience
– Creates dual inventory and risk for inadvertent cross-over
• Community donor generally regarded as safer than directed donor
– Indications for Directed Donor: rare red cell phenotype or need for antigen negative
maternal platelets in the setting of FNAIT
• Red Cell Alternatives
• EPO and IV Iron –
– Unlikely to raise hemoglobin rapidly (ie, over the few days during acute inpatient stay)
but reasonable if stable IDA
• Red Cell Substitutes –
– Not a readily available option, JAMA meta-analysis demonstrated higher risk for
MI/Death, requires eIND from FDA
• Plasma Alternatives
• Selected scenarios in which PCC may be reasonable
– Warfarin reversal in a volume sensitive individual
Otherwise Stable
Patients
• Anemia
– Physiologic Compensation
• Thrombocytopenia
– Non-bleeding, hem/onc
patients
– ITP with noncritical
bleeding
• Coagulopathy of Liver
Failure
– Benign Physical
Examination, lab stability
5
1
3
A Donor Undergoing Plateletpheresis
Platelet donors must pass all the
Same rigorous criteria as whole blood
donors. The donation interval for
platelets is no more than twice in a 7
day period and up to 24 times a year.
Each collection event takes up to 2.5
to 3 hours. 60% of our collections
result in 2 apheresis platelet units –
“doubles”.
The centrifuge pack freed from the
spool. On the left is the platelet
Concentrate which will be
resuspended in donor plasma to
yield a plateletpheresis product.
The resuspension process is
partially automated. The
instrument introduces donor
plasma into the collection chamber
and channels resuspended
platelets into the storage bag.
During this time, the operator can
mix the product, ensuring complete
resuspension.
6
2
4
A view of the platelet collection
chamber (on the left) and the
The operator readies the collection
separation chamber (on the right)
chamber for resuspension.
at the completion of the
plateletpheresis collection procedure.
The platelet product is divided
Between two gas-permeable storage
bags to ensure adequate gas
exchange and ‘rested’ for an hour
prior to transport over to the
Transfusion Services Laboratory
for Further processing.
Swirl
Thresholds
• Otherwise Stable Patients with:
– Anemia
• Assess duration of anemia and any clues provided by
history, physical, and indices
– Preceding volume challenges (hemodilution?),
– stark deviation in results (wrong blood in tube?),
– variation with HD cycles (hemodilution?),
• Most large studies are supporting threshold levels in
the 7 g/dL range in the absence of active myocardial
ischemia
• Two pilot RCTs of restrictive vs liberal thresholds acute
in myocardial ischemia had conflicting results
Medicine/Post-Operative
In ICU, CAD post Hip Frx, UGIB, Restrictive OK – may have benefits
Study
TRICC
Transfusion
Requirements
In
Critical
Care
FOCUS
Functional
Outcomes in
Cardiovascular
patients
Undergoing
Surgical hip
fracture repair
Acute
Upper GI
Bleed
Population
≥16 y/o (mean
57.5±18),
Euvolemic, ICU,
no active blood
loss, Hb <9
≥50 y/o (mean
81.6, 51-103)
wCAD/CAD RFs,
Post Hip Frx
Repair, Hb <10
>18 y/o, Non
Exsanguinating
UGIB, excluding
MI/PVD/
TIA/Stroke prev
90d
Primary
Outcome
Results
Restrictive
Liberal
Difference
(95% CI, p value)
30 day
mortality
N=418; 7-9
78 (18.7%)
N=420; 10-12
98 (23.3%)
4.7%
(95% CI -0.84 to 10.2), p=0.11
(Cardiac Events –
esp. pulmonary
edema and MI)
55 (13.2%)
88 (21.0%)
7.8%
(95% CI 2.7 to 12.9), p<0.01
Death or Inability to
Walk across room
without human
assistance at 60 day
follow up
N=1009; <8
347/1001
34.7%
N=1007; ≥ 10
351/998
35.2%
0.5%
(95% CI -3.7 to 4.7), p=0.9
No difference
All cause
mortality at 45
days
N=461; <7
Maintain 7-9
23/444 (5%)
N=460; <9
Maintain 9-11
41/445 (9%)
HR 0.55 (favoring restrictive)
(95% CI 0.33 to 0.92), p=0.02
(Cirrhosis A-B)
5/113 (4%)
13/109 (12%)
HR 0.30 (favoring restrictive)
(95% CI 0.11 to 0.85), p=0.02
Transfusion in Coronary Ischemia
Mixed Results – Use Judgement, Await Larger RCTs
Study
CRIT Study
Pilot RCT
Population
45 AMI
(excluding active
bleeding)
Age
Liberal:
76.4(13.5)
Restrictive: 70.3 (14.3)
110 NSTEMI/
STEMI/ACS/
Carson J, et al
Pilot RCT
stable angina  PCI;
Hb < 10g/dL
Excluded active
bleeding.
Age
Liberal:
67.3 (13.6)
Restrictive: 74.3 (11.1)
Primary
Outcome
Results
Restrictive
Liberal
Difference
(CI,p)
Composite: In-hospital
death, recurrent MI, or
new or worsening CHF
N=24; <24 (24-27%)
N=21; <30 (30-33)
3/24
13%
8/21
38%
New or worsening CHF
3/24
8/21
Younger
Older
N=54; <8
N=55; Maintain ≥10
Comp: 15.0%
Comp: 14/54
25.9%
Comp: 6/55
10.9%
(0.7 to 29.3) p=0.054
AgeAdj p=0.076
RR: 2.38 [0.99 to 5.73]
D30d: 7/54
13%
D30d: 1/55
1.8%
D30d: 11.1%
(1.5 to 20.8)
RR 7.13 [0.91 to 56.02]
Older
Younger
Composite:
death, MI,
unscheduled
revascularization
within 30d
Composite
P=0.046
CHF
P=0.03
p=0.032
Thresholds
• Otherwise Stable Patients with:
– Thrombocytopenia
• A 2012 Cochrane Review and 2 recent RCTs of
Prophylactic vs Therapeutic strategy
– Support continuation of prophylactic transfusions at ≤10
K/mcL
– Preprocedurally
• Most CVC, even tunneled catheters
– When performed by experienced operators using US guidance
» Low platelet counts and coagulation defects ok
• For surgery, consider a 40-50 K/mcL threshold
• Neurosurgery, consider 90-100 K/mcL threshold
Where do the 50 and 100 K/mcL thresholds come from?
• Gaydos, et al, NEJM 1962
Sum of days
for all
patients at
each level
3K-5K
<1K
92%
1K-3K
10K-20K
5K-10K
III: 0.8%
50K-100K III: 0.07%
20K-50K
III: 0.3%
>100K
Curve I: All hemorrhage
Curve II: Other than
skin/epistaxis
Curve III:Grossly
visible hemorrhage
Gross hematuria, melena, hematemesis
33%
8%
Thresholds
• Otherwise Stable Patients with:
– ESLD
• Especially if fresh stigmata of bleeding…
– assess for concomitant abnormalities (fibrinogen, uremia, etc)
• Preprocedural FFP transfusion is controversial
– Varies by institution: INR 1.7-2.0
• Platelet transfusion unlikely to result in major increment
– Splenic pooling, volume
– ‘Chasing’ a target preprocedural platelet count often futile
Proper Specimen Labeling
1)Pink or Purple Top + 2)Patient Label with Name and MR# + 3)Legible Last Name of Phlebotomist + 4)Date and Time of Draw
Properly
Labeled:
Proper
Specimen:
Patient Name
Patient MR #
Full Last Name of
Phlebotomist
Date and Time of
Draw
Plasma:
Proteins
Immunoglobulin
Clotting Factors
Soluble ABO
Substance
Lewis Substance
Bilirubin Pigments
Plasma Free
Hemoglobin
Lavender/Pink Top
Doe, John
1234567
987654321
01/01/60
Blankenship 10/12/11 08:56 AM
Example of Proper Labeling
Label
Label
Centrifuge
Pipette from
here for IAT and
Reverse Type
Red Blood
Cells:
Red Cell Antigens
May be bound in vivo
with Immunoglobulin
or Complement
Pipette from
here for DAT and
Forward Type
Second Specimen Rule
Prevents mistransfusion event leading to Acute Hemolytic Transfusion Reaction
• First-ever UCI Blood Bank Specimen
• Types as non-Group O
• Obtain and confirm ABO on second specimen
– Prior to transfusion of type-specific RBCs
• Please respect and heed blood bank’s request for
a second specimen
PreTransfusion Testing
• Type and Screen
• Type and Hold
• Type and Crossmatch
+
+
Plasma
Containing Antibodies
Red Blood Cells
Expressing Antigens
Anti-Human Globulin
Blood Bank Test
Serum/Plasma
Red Cells
AHG Phase
Forward Type
Anti-A1, Anti-B
Patient or Donor
Weak D Testing
Reverse Type
Patient or Donor
A1 and B RBCs
n/a
Antibody Screen
Patient or Donor
Panel Cells
PEG, LISS, Saline
Direct Antiglobulin Test
n/a
Patient or Donor
PEG, LISS, Saline
Crossmatch
Patient or Donor
Donor RBCs
IS vs AHG
Phenotype
Specific Anti-Sera
Patient or Donor
AHG
Elution
Eluate
Panel Cells
AHG
Adsorption
Patient
Auto vs Allo
AHG
Transfusion Reactions
• Febrile Nonhemolytic Transfusion Reaction
– Elevation in blood pressure 1C above 37
– Changes in BP, HR, RR occurring during or within 4
hours of a transfusion
– Negative (or unchanged) post-transfusion DAT, clerical
check ok
• Allergic Transfusion Reaction
–
–
–
–
Most limited to cutaneous manifestations
Pause, treat, resume
Exception might be systemic rash or severe allergic
Dose dependent, except for anaphylactic
Transfusion Reactions
• Transfusion Associated Circulatory Overload
– Risk Factors: Any organ failure state, pre-existing
cardiac disease, frail status
– Cardiogenic pulmonary edema
– Orders of magnitude more common than TRALI
– Response to diuretics/ultrafiltration
• Transfusion Associated Acute Lung Injury
– Noncardiogenic pulmonary edema
– Etiology is immunologic rather than volume related
Transfusion Reactions
• Acute Hemolytic
– DIC, flank pain, hemoglobinemia, hemoglobinuria,
sense of impending doom, fever, erythema tracking
proximally along infusing vein
– Post transfusion DAT positive, eluate most commonly
with anti-A or anti-B, less commonly a non-ABO
antibody (ie, Kidd)
• Delayed Hemolytic
– Decline in hemoglobin days after transfusion
– Fall by number grams/dL correlating with number of
antigen positive units
– May be primary or secondary
View the complete list at: http://www.choosingwisely.org/wp-content/uploads/2015/01/Choosing-Wisely-Recommendations.pdf
Responsible Laboratory Utilization