SAMA EMERGENCY COURSE
Assad University hospital
Satarday , February 26, 2012
Alexander Bogdanov- Blood Transfusion
Whole Blood
• 450 ml of donated blood+50 ml of anticoagulant
• Significant RBC, Plasma, Protein, platelets,
Leukocytes, and stable coagulation factors.
• Insignificant labile factors V, VIII,
• After 24 h platelets and leukocytes loose viability
• Indicated in trauma hypovolemic and actively
bleeding patient
• No other indications
Packed Red Blood Cells (PRBC)
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The most common type of transfusions
250-350 ml of Red blood cells
Indicated in chronic anemia
Indicated in active bleeding with and
without hypovolemia
• Not indicated in platelets or leukocytes
replacement
Washed RBC
• Washing RBC in saline
• Removing immunoglobline IgA
• Prevent Anaphylaxis and urticarial
reaction
Leukocytes-Reduced RBC
• Removing 99.9 % of leukocytes from
PRBC
• Special filters
• Indications:
• Prevent febrile non-hemolytic reaction
• Prevent alloimmunization
• Prevent post transfusion purpura
Irradiated RBC
• 2500 c Gray gamma irradiation
• Prevent post transfusion GVHD
• All immune suppressed individuals
should receive only irradiated blood
products
• FFP, and cryoprecipitate need no
irradiation
Random-Donor platelets
• 50-70 ml volume
• Indicated in bleeding patient with low platelets
• Indicated in non-bleeding patient with platelets
less than 10 000
• Indicated in bleeding patient with platelets
function abnormality
• Not indicated in none bleeding ITP patient
• Contraindicated in TTP, some DIC
HLA matched platelets
• Hemapheresis from HLA matched
individual donor
• Refractoriness to platelets transfusion
• HLA alloimmunization
• Fever, Sepsis
• DIC
• Hyperspleenisim
• Bleeding
• Indicated only in HLA alloimmunization
• Low platelets 1h and 24 h post RDP
transfusion indicates alloimmunization.
Granulocyte Concentrates
• Leukapheresis from single donor
• A unit contain 10x 10 granulocytes
• Should be infused immediately after
collection
• Indicated in septic neonates, granulocytes
dysfunction, profound neutropenia and sepsis
• Granulocyte concentrates transfusion has
conflicting trials results
Fresh Frozen Plasma FFP
• Separating and freezing plasma
within 6 h of phlebotomy
• 1ml FFP contain 1unit labile and
stable Coagulation factors
• Indicated in factors deficiency when
no single factor is available
• Indicated in liver dysfunction,
massive transfusion
Cryoprecipitate
• 5-20 ml
• 80U VIII, vWF,fibrinogen, some XIII,
fibronectin
• Indicated in fibrinogen replacement
• Not indicated in hemophilia A
• Not indicated in vW disease
TRANSFUSION
is BAD
• IMMUNE-MEDIATED REACTIONS
• Acute Hemolytic Transfusion Reactions
• Delayed Hemolytic and Serologic Transfusion
React
• Febrile Nonhemolytic Transfusion Reaction
• NONIMMUNOLOGIC REACTIONS
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Fluid Overload
Electrolyte Toxicity
Iron Overload
INFECTIOUS COMPLICATIONS
INFECTIOUS COMPLICATIONS
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Hepatitis, A, B, C, D, G ……….
HIV, HTLV-I, HTLV-II, ………
CMV
EBV
Malaria, Syphlis, Trypanosoma,
Toxolplasmosis, Bebesiosis, Brucelosis.
• Bacteria Gram +ve or Gram -ve
Acute Hemolytic Transfusion
Reactions
• ABO Incompatible Blood
• IgM, ANTI A, OR B Agglutinates
transfused RBC
• Fever, chills, chest arm and flank pain,
dyspnia, hemoglobinuria, oligouria,
shock, and DIC
• +ve coombs test, and hemolysis lab
• Treatment is suportive
Delayed Hemolytic and Serologic
Transfusion Reactions
• Primery or secondary immunization
against RBC alloantibodies
• Kell, Duffy, Kidd, RH system antigens
• Rapid fall in Hg after transfusion
• Most cases subclinical
• Occasional fever chills, nausea,
hemoglobinurea
Febrile Nonhemolytic
Transfusion Reaction
• Agglutinating, or cytotoxic antibodies against
antigen on transfused granulocyte
• Common in multitransfused patient
• Complement activation and cytokins release
• Chills, fever, rigor,
• Hemolytic transfusion reaction should be ruled
out
• Leukocytes reducing filters in future blood
products
Allergic Reactions
• Urticaria
• Anaphylactic reaction
• Alloimmunization
• To red cells antigens
– Delayed hemolytic transfusions reaction
• To platelets antigens
– Refractoriness
– Neonatal thrombocytopenia
– Post transfusion purpura P1-A
Graft-Versus-Host Disease
• Live T lymphocytes transfused to immune
suppressed patient
• Allo-lymphocytes with different HLA
recognize self HLA as foreign HLA
• Fever, elevated LFT’s, diarrhea, erythema
• Cytopenia,
• No available therapy
• Prevention by irradiation blood products
Post transfusion Purpura
• Very serious side effect of transfusion
• Most people are positive P1-A1 antigen
• Negative patient may develop antigen
destroy all platelets
• Develop in 5-10 days post transfusion
• Plasmapheresis
• Washed RBC for future transfusion
Transfusion-Related Acute
Lung Injury
• Potent leukoagglutinins
• Antibody-antigen leading to leak
syndrome in lung
• Respond quickly to supportive
treatment
Emergency Transfusion
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What products to use
From where are they to be obtained
To what degree are they to be tested
How will they be transported
How will they be stored
Triage is vital in mass casualty situations, ensuring
that scarce resources are used for those with the best
chance of recovery.
• Patients survive with low hemoglobin levels for
considerable periods,
• Speedy treatment of hypovolemia is imperative
Sudden increase the demand for blood
• May create a sudden massive influx of donors
• Restricts or eliminates the ability to collect, test,
processor distribute blood
• Restricts or prevent the use of the available
inventory of blood components (liquid and
frozen)
• Requires immediate replacement or re-supply of
blood from another region/country
Blood Volume Loss Of:
• 15 - 30 percent -- should be treated
with crystalloids or colloids, not
RBCs, in young, healthy patients;
• 30 - 40 percent -- requires rapid
volume replacement, and RBC
transfusion is probably necessary;
• >40 percent -- is life-threatening and
volume replacement, including RBC
transfusion, is required
Hemoglobin and Transfusion
• More than 10g/dL transfusion is rarely
indicated.
• Hemoglobin 6-10 g/dL indications for
transfusion should be based on the
patient’s risk of inadequate oxygenation
from ongoing bleeding and/or high-risk
factors.
• Hemoglobin < 6 g/dL transfusion is almost
always indicated.
Massive transfusion
• Transfusion more than50 %of a patient's blood
volume in 12 to 24 hours
• Hemostatic and metabolic complications
• Selection of the appropriate amounts and types
of blood components to be administered
• Volume status
• Tissue oxygenation
• Management of bleeding and coagulation
abnormalities
• Changes in ionized calcium, potassium, and
acid-base balance
ALTERNATIVES TO
TRANSFUSION
• Autologous blood transfusions
– Preoperative
– Intraoperative
– Postoperative blood salvage
• Usage of Growth factors
– Erythropoietin
– G-CSF, GM-CSF
– Erythropoietin, IL-11
• Blood substitutes
BLOOD GROUP ANTIGENS AND
ANTIBODIES
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The foundation of transfusion medicine
No mistake is excused
Compatibility test done on transfused RBC and recipient plasma
Compatibility test for RBC and whole blood
No compatibility test foe platelets, FFP , and cryoprecipitate
Compatibility test detects unexpected RBC alloantibodies
Cross match
BLOOD COMPONENTS
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Red blood cells
White blood cells
Platelets
Plasma
Different proteins, Coagulation
factors, Albumin
Case # 2
• 60 Y F while taking blood Unit
developed 39 fever and rigor
• Your next best step is
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Immediate discontinuation of transfusion
NSAID or Paracetamol,
Solo-cortef and Phenergan
Call your senior resident
Ignore fever
Further testing
Case # 3
• 16 Y O M with Bleeding ulcer, HG 4.5, BP80/60, HR
140/m. Bright red blood per NG tube. Hx of
multiple transfusions
• Blood group A +, all 10 U of PRBC were not
compatible
• You do what of the following
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Transfuse Non compatible blood
Cross match 10 more units
Call hematology
Wait until he cardiopulmonary arrest
Call surgery
Case # 4
• 20 Y M came to ER with severe hemolytic anemia
G6PD
• Hg 2 Gm, Decline any transfusion for religious
reason
• Your best management
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Oxygen
Fluid
Erythropoietin
Transfusion after general anesthesia
Call hematology
How many Unit to transfuse
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No magic number
Indication
Diagnosis
Medical plan
ABO ANTIGENS AND ANTIBODIES
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The major blood groups of this system are A, B, AB, and O
The genes determine the A and B found on chromosome 9p
RH SYSTEM
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Second most important blood group system
On chromosome 1
15 percent of people lack this antigen
Exposure of these Rh-ve people to Rh-ve cells, by either transfusion or
pregnancy, can result in the production of anti-D alloantibody.
OTHER BLOOD GROUP SYSTEMS AND
ALLOANTIBODIES
• Other ABO, D, antigen on RBC
• Kell, Duffy, Kidd blood group
• Not normally present unless
immunized by transfusion or
pregnancy
• Antibody screen
• Washing RBC and better selection
PRETRANSFUSION TESTING
• Hepatitis B, C, B core
• Antibodies for Human T lymphocyte
Virus I,II (HTLVI,II)
• HIV,I, II