(وقل اعملوا فسيري الله عملكم ورسوله والمؤمنون) بسم الله الرحمن الرحيم (وقل اعملوا فسيري الله عملكم ورسوله والمؤمنون) صدق الله العظيم

BLOOD COMPONENT THERAPY Dr. Samy Marouf

BLOOD COMPONENT THERAPY It is the transfusion of specific blood components required by the patient. Principles Use blood products only when it is essential. Replace only the deficient component, if possible. Identify the cause and if possible, treat it. Use alternative , IV fluids

Blood components WB PLT PRBC FFP

Optimal additive solution Platelets rich plasma Platelets concentrate 2nd centrifugation Whole blood 1stcentrifugation FFP for clinical use Red Cell concentrate Fresh plasma FFP for fractionation Optimal additive solution Cryoprecipitate Red cells in OAS

Blood COMPONENTS AVAILABLE FROM THE BLOOD BANK Whole blood Packed RBCs Random donor Platelets Single donor platelets (Apheresis) Fresh Frozen Plasma (FFP) Cryoprecipitate 3

Whole Blood 450 ml of whole blood with 63 ml of anticoagulant need for oxygen carrying capacity and volume replacement no viable platelets or WBC decreased labile coagulation factors (Factor V and VIII) Not available since it is not efficient utilization of blood

Whole Blood Expected gain 1 gm /dl active bleeding >30% Neonatal exchange transfusion

Packed Red Blood Cells (PRBCs) 200-250 ml of RBCs and 50 ml of plasma Hematocrit 55-70% depending on anticoagulant shelf life 35 to 42 days depending on the anticoagulant treatment of symptomatic anemia where oxygen carrying capacity is needed

Packed Red Blood Cells (PRBCs) Indications : 1- Acute blood loss (100% blood volume = 5 Liters of blood) a – Amount of Loss: i - > 15% with severe cardiac or Respiratory disease. ii – 15 – 30% with preexisting Anemia , or continuous blood loss. iii- > 30% blood loss.

b- Hb: i- < 7 gm/ dl. ii - < 8 gm/dl in elderly with cardiovascular or Resp. disease. 3- Preoperative Transfusion : a- Treat cause of anemia. b- Avoid cause of bleeding . c- Follow Maximum Surgical blood usage list. 4- Chronic Anemia: b- Erythropoietion therapy.

d – sickle cell disease : i – if Hb < 7 gm/ dl. c – B- Thalassemia: Hb. Maintained > 9.5 gm/ dl. d – sickle cell disease : i – if Hb < 7 gm/ dl. ii – if Hb < 10 gm/ dl. In cases with: - Cerebro vascular accid. or at high risk. - Acute chest or abdominal syndrome. - pre operative for major surgery. - pregnancy . - priapism. Dose : 10 ml/kg

Indication for Platelet Transfusion Decrease platelet production (Bone marrow failure) Therapeutic:for patient who are bleeding associated with BMF caused by either disease, therapy or irradiation. Prophylactic: >10x 109/L to decrease morbidity in patients with thrombocytopenia due to B.M.F.

Indications for prophylactic Platelets transfusion major bleed, major surgery >100,000 minor bleed, minor procedure >50,000 prevent spontaneous bleed > 10,000

Pooled Platelets are prepared from the platelet portion of 6 whole blood units plus 300 ml of plasma (potential for 6 infectious disease exposures) expires after 5 days 6 X 5 X 10 E10 = 3.0 x 10 E 11 platelets 6 x 5000 rise /RD plt = 30,000 transfuse the patient with platelets from many donors to see which platelets will raise the platelet count

Plateletpheresis donated by a single donor 3.0 x 10 E11 platelets plus 300 ml of plasma, expires after 5 days raises the platelet count 30,000 used for all platelet transfusions until less than 10,000 platelet increase

Low Post-transfusion Increment to Platelets Definition : it is failure to obtain satisfactory response to platelet transfusion of unselected platelet components.

Low Post-transfusion Increment to Platelets 1 hour post (platelet recovery) poor platelet alloantibodies platelet autoantibodies hepatosplenomegaly 24 hour post (platelet survival) poor infection bleeding DIC fever

Administration of Platelet Concentrate: ABO compatible platelet are preferred but not necessary. Platelet concentrate should be transfused as soon as possible after reaching the ward with standard blood transfusion sets with 170 mm filters. The transfusion should normally be completed within 30 minutes. Observation during platelet transfusion should include pulse& temperature before& after transfusion.

Fresh Frozen Plasma (FFP) 200-250 ml of plasma frozen at -18C within 8 hours of collection no platelets are present contains all coagulation factors an unconcentrated source of fibrinogen use Cryo to correct a low fibrinogen level needs 20-30 min lead time to thaw prior to use

FFP Continued Definite indication: Replacement of single or multiple factor deficiencies Immediate reversal of warfarin effect Vitamin K deficiency Acute disseminated intravascular coagulation Thrombotic thrombocytopenic purpura not used if non bleeding or for volume replacement indicated when PT/PTT are >17/55 sec

Cryoprecipitate (Cryo) a white precipitate that forms when FFP at -18C is thawed to 4C volume is 10 to 15 ml adult dose is 10 to 20 pooled units 30 minutes is needed for thawing and pooling

Cryoprecipitate continued Cryoprecipitate can be used for the replacement of all of the following: vWF vWD Factor VIII Hemoplilia A Factor XIII Factor XIII def Fibrinogen dec. fibrinogen * head injury, massive bleed, trauma,

GRANULOCYTE CONCENTRATES Prepared by cytopheresis Donor prepared by administering cortisol (releases marginating pool) and hydroxyethyl starch (facilitates RBC/WBC separation) 1 X 1010 WBCs in 200 to 600 mL plasma Storage at RT for 24 hours ABO/Rh compatible; HLA compatible

Criteria for use < 500 WBC/mm3 -active infection (as evidenced by fever) not responding to antibiotics *myeloid hypoplasia with reasonable chance for survival *Limited usage; usually for neonates with sepsis (immature WBCs)

Leukocyte Reduced blood component

Leukocyte Reduced RBCs RBCs with 99.99% of WBCs removed by leukocyte reduction filter prevents repeated nonhemolytic febrile transfusion reactions reduces immunosuppression of recipient by donor WBC All cellular components are leukoreduced now

Leukocyte Reduced RBCs continued decreases post-operative surgical infections due to reduced immunosuppression prevents or delays HLA alloimmunization identical to CMV seronegative blood does not prevent graft versus host disease, only gamma irradiation prevents graft versus host disease

Indications for Leukocyte Reduced RBC continued after second nonhemolytic febrile transfusion reaction newly diagnosed leukemics long term multiple transfused patients sickle cell disease aplastic anemia thalassemia

Irradiated blood component

(Gamma) Irradiated RBCs RBCs and platelets are exposed to gamma irradiation at 2500 rads for 4.5 minutes this inactivates the T lymphocytes in the donor unit and prevents graft versus host disease in an immunocompromised recipient

Indications for Gamma Irradiated bone marrow transplant recipients congenital immunodeficiency syndromes intrauterine transfusions transfusions from all blood relatives Hodgkin’s disease WBC products (to neutropenic patient) (never Stem Cells)

Massive Transfusion

Massive Transfusion Definition : transfusion of a volume of blood equal to the patient total blood volume in less than 24 hours Problem of massive transfusion : thrombocytopenia , coagulation factor depletion , O2 affinity changes , hypocalecaemia , hyperkalemia , acid base disturbance , hypothermia Managemant: (saline, Ringer,albumin HES)

Massive Transfusion Give blood products as a ratio 1 dose : 1 dose : 1 dose : 1 dose 5 RBC : 2 FFP : 6 RD PLT : 10 Cryo ________________ (1 PPH) _________ Hgb(10gm) PT PTT(<1.5 N) Plt Ct (50000/ul)) Fib(>100mg%)

AUTOLOGOUS TRANSFUSION

AUTOLOGOUS TRANSFUSION Definition : It is the use of patient own blood. Autologous transfusion is alternative to allogenic transfusion in elective surgery (T& C) ,3 types (predeposite transfusion ,acute normovolaemic hemodilution , intraoperative blood salavage Advantages: no risk of viral infection ,all immunological reaction ,decrease post-operative infection ,tumor recurrence

AUTOLOGOUS TRANSFUSION Disadvantages: 50% discarded , not used for other patients , volume overload, bacterial contamination, clerical errors Exclusion criteria : unconfirmed date ,poor venous access, infection , anemia , hemodynaemic instability

AUTOLOGOUS TRANSFUSION Blood donation schedule: safety Donor and pre-transfusion test Storage

Blood warmers

Blood warmers Hypothermia is defined as the core body temperature below 35 C. Possible side effects of hypothermia are cardiac arrhythmia homeostasis abnormalities from impaired platelet function and slowed enzymatic reactions in the coagulation cascade vasoconstriction , dehydration , lack of oxygen to tissues increased red cell release of potassium and (with blood component transfusion) citrate toxicity. The metabolism of drugs is also impaired.

Advantages of blood warning devices: The primary advantage of using blood warming devices during massive transfusion is to prevent the complications caused by hypothermia thus improving survival rates and patient outcomes including decreased length of hospitalization. Hypothermia impairs immune function may promote surgical-wound infection and delay wound healing. Disadvantages and complication: 1-Risk of hemolysis. 2-Risk of sepsis. 3-Decreased infusion rate. 5-Expense.

Indication for use: • Massive transfusions (1 unit /10 minutes). • Trauma situations in which core-re-warming measures are indicated. • Administration rate >50 ml/minute for 30 minutes or more (adults). • Administration rate >15 ml/kg/hour (children). • Exchange transfusion of a newborn.

Warning: • • Do not warm blood components by placing on or near a radiator heater patient-warming blanket or in a conventional microwave oven or plasma thawer. • Do not allow the unit to sit at ambient room temperature for prolonged periods to warm up. • Do not place blood components under running hot tap water or in an unmonitored or improvised warm water bath. • Do not return blood components that have been warmed to inventory

Non infectious COMPLICATION OF BLOOD TRANSFUSION

Transfusion Reaction

Acute Hemolytic Transfusion Reaction a clerical error (wrong specimen, wrong patient) 1 in 6,000 to 25,000 transfusions back pain, chest pain, fever, red urine, oliguria, shock, DIC, death in 1 in 4 stop the transfusion

Administration Identity check

Work up of An AHTR start normal saline treat patient symptomatically send blood bag and tubing to culture send red top and purple top tubes urine specimen for hemoglobinuria DAT is positive

Non Hemolytic Febrile Transfusion Reaction NHFTR (1:100) Recipient has WBC antibodies to Donor WBCs contained within RBCs and Plateletpheresis products DAT is negative rise in temperature by 2F or 1C other causes for fever are eliminated blood that is hanging can be restarted ??

Allergic (Urticarial) Transfusion Reaction Recipient has antibodies to the Donor’s plasma proteins (1 in 1000) offending protein is not identified urticaria, itching, flushing, wheezing this is the only transfusion reaction where the blood that is hanging can be restarted after treatment with Benadryl if symptoms continue then STOP

Anaphlyactic Transfusion Reaction anaphylactic reaction (1 in 150,000) 1 in 700-900 people never made IgA occurs when exposed to normal blood products which contain IgA bronchospasm, vomiting and diarrhea and vascular collapse treat with Epinepherine, Solu-Medrol,

Circulatory Overload marginal cardiovascular status given blood components too rapidly develops acute shortness of breath, heart failure, edema (1: 10,000) systolic BP increases 50 mm infuse slowly, not to exceed 4 hours split the unit of RBC and give half

Transfusion Related Acute Leukocyte Lung Injury TRALI reaction (1:10,000) Donor plasma contains WBC antibodies that when transfused to the recipient cause agglutination of recipient’s WBC in the pulmonary capillary beds Chest X ray looks like ARDS Donor removed from donating blood

Blood Used on Emergency Basis

Blood Used on Emergency Basis for a patient that is bleeding out and the blood type is unknown group O, Rh negative, uncrossmatched recipient may have an unexpected antibody after 5 min use ABO and Rh type specific blood

Sepsis from Bacterial Comtamination Platelets: skin contaminants most common cause plateletpheresis 1 in 5000 pooled platelets 1 in 1000 RBC: Sepsis from RBC due to Yersinia, Enterics or Gram Positive 1 in 3,000,000

Knowing is not enough; we must apply. Willing is not enough; we must do."