1. Administration of Blood and Blood Component Dr.Azarm

2. Blood Products

3. روشهاي صحيح مصرف خون به منظور كاهش ترانسفوزيونهاي غير ضروري Dr.Azarm

4. چرا لازم است خون وفراوردههاي خوني صحيح و هدفمند مصرف شوند؟ ------------------------------------ 1-خون ساختني نيست بلكه بايد اهدا شود. 2-در همه جا خون فراوري نمي شود و در دسترس نمي باشد. 3-هميشه اهدا كننده اماده وجود ندارد. 4-عوارض انتقال خون هميشه بايد مد نظر باشد. Dr.Azarm

5. نكات مهم خون و فرآورده ‌ هاي خون بايد در اسرع وقت تزريق شود. چنانچه فرآورده ‌ اي براي 30 دقيقه يا بيشتر در دماي اتاق قرار گيرد نبايد تزريق شود. خون و فرآورده ‌ هاي خون نبايد در داخل يخچال اتاق پرستاري ذخيره شود مگر در مواقع خاص مانند اتاق عمل يا در اتاق recovery. چنانچه به هر علت واحد خون (RBC) باز نشود و در دماي مناسب قرار داشته باشد و در فاصله زماني كمتر از 30 دقيقه، به بانك خون برگردد مي ‌ توان از آن استفاده كرد.

6. نكات مهم خون نبايد در داخل ظرف حاوي آب داغ قرار گيرد زيرا اين عمل باعث هموليز گويچه ‌ هاي سرخ و آزاد شدن پتاسيم از گويچه ‌ هاي سرخ مي ‌ شود كه مي ‌ تواند براي زندگي بيمار مخاطره ‌ آميز باشد. فرآورده ‌ اي كه ذوب شده نبايد دوباره منجمد شود و بايد هرچه زودتر مصرف شود. در صورتي كه به هر دليل تاخيري در تزريق رخ دهد، بايد در دماي محيط نگهداري شده و در عرض 4 ساعت مصرف شود. توجه: مهم‌ترين مرحله نظارت، 15 دقيقه اول تزريق مي‌باشد.

7. Whole Blood Dr.Azarm

8. Whole Blood Description: Up to 510 ml total volume 450 ml donor blood 63 ml anticoagulant-preservative solution Haemoglobin approximately 12 g/ml Haematocrit 35%–45% No functional platelets No labile coagulation factors (V and VIII)

9. Infection risk Not sterilized, so capable of transmitting any agent present in cells or plasma which has not been detected by routine screening for transfusion-transmissible infections, including: HIV-1 and HIV-2, hepatitis B and C, other hepatitis viruses, syphilis, malaria and Chagas disease

10. Storage Between +2°C and +6°C in approved blood bank refrigerator, fitted with a temperature chart and alarm During storage at +2°C and +6°C, changes in composition occur resulting from red cell metabolism Transfusion should be started within 30 minutes of removal from refrigerator

11. Indications Red cell replacement in acute blood loss with hypovolaemia Exchange transfusion Patients needing red cell transfusions where red cell concentrates or suspensions are not available

12. Contraindications Risk of volume overload in patients with: Chronic anaemia Incipient cardiac failure

13. Administration Must be ABO and RhD compatible with the recipient Never add medication to a unit of blood Complete transfusion within 4 hours of commencement

15. RED CELL CONCENTRATE (‘Packed red cells’, ‘plasma-reduced blood’) Description 150–200 ml red cells from which most of the plasma has been removed Haemoglobin approximately 20 g/100 ml Haematocrit 55%–75%

16. Infection risk Same as whole blood

17. Storage Same as whole blood

18. Indications Replacement of red cells in anaemic patients Use with crystalloid replacement fluids or colloid solution in acute blood loss

19. مواردي كه نياز به تزريق وجود ندارد A: آنمي همراه با كمبود آهن B: آنمي پرنيسيوز C: كمبود تغذيه‌اي D: عدم جذب گوارشي E : ترميم زخم F: كمبود فولات و B12 G: آنمي همولتيك ارثي H: براي بهبود حال عمومي فقط هنگامي كه خونريزي فعال از دستگاه گوارش يا جاي ديگر بدن باشد نياز به تزريق داريم البته در چنين بيماراني هدف تصحيح هموگلوبين نيست بلكه هموگلوبين در حدي باشد كه بيمار علائم حياتي پايدار داشته باشد.

20. در بيماران با سن كمتر از 4 ماه هموگلوبين كمتر از 13 گرم در دسي‌ليتر همراه با بيماري‌هاي شديد و سيانوتيك قلب و ريه و يا نارسايي قلب هموگلوبين كمتر از 10گرم در دسي‌ليتر همراه با بيماري‌هاي ريوي متوسط از دست رفتن سريع و حاد بيش از 10% حجم خون هموگلوبين كمتر از 8 گرم در دسي ليتر همراه با آنمي علامت‌دار اين راهنماها يك پيشنهاد مي‌باشد و بايستي در مورد هر نوزاد به تنهايي تصميم ‌گيري كرد. * اين راهنماها يك پيشنهاد مي‌باشد و بايستي در مورد هر نوزاد به تنهايي تصميم ‌گيري كرد. در هموگلوبين كمتر از 10 گرم در دسي‌ليتر كه كانديد عمل جراحي بزرگ هستند. نوزادان و كودكان :

21. در كودكان با سن بيشتر از 4 ماه هموگلوبين قبل از عمل جراحي كمتر از 8 گرم در دسي‌ليتر و يا هماتوكريت زير 25% و يا هموگلوبين زير 8 گرم در دسي‌ليتر بعد از عمل كه همراه با علايم و نشانه‌هاي كم خوني باشد. كاهش و يا از دست رفتن سريع و حاد بيش از 15% حجم خون يا وجود علايم و نشانه‌هاي هيپوولمي كه به تزريق مايعات كريستالوئيد يا كلوئيدي پاسخ نداده باشد. هموگلوبين كمتر از 13گرم در دسي‌ليتر در بيماري شديد قلبي ريوي (سيانوز-دسترين تنفسي) هموگلوبين كمتر از 8 گرم در دسي‌ليتر در :

22. الف) بيماراني كه تحت شيمي‌درماني يا راديوتراپي هستند. (نارسايي مغز استخوان) ب ) بيماراني كه دچار كم‌خوني مزمن هستند كه به درمان طبي پاسخ نداده‌اند يا علايم و نشانه‌هاي كم خوني دارند. عوارض بيماري سيكل‌سل نظير حوادث عروقي مغزي، Acute chest syndrom و آمادگي براي عمل جراحي. در بيماران بتاتالاسمي هموزيگوت و يا هتروزيگوت كه بيشتر از ساير انواع تالاسمي دچار آنمي شديد مي‌شوند براي جلوگيري از عوارضي مانند رشد نابهنجار استخوان و بهبود در سرعت رشد و كاهش بار آهن بهتر است هموگلوبين در محدودة 10 گرم در دسي‌ليتر كنترل شود. البته قبل از تزريق نبايد هموگلوبين بيشتر از 5/9 گرم در دسي‌ليتر باشد تا از افزايش بار آهن جلوگيري شود.

23. Administration Same as whole blood To improve transfusion flow, normal saline (50–100 ml) may be added using a Y- pattern infusion set

24. RED CELL SUSPENSION Description 150–200 ml red cells with minimal residual plasma to which ±100 ml normal saline, adenine, glucose,mannitol solution (SAGM) or an equivalent red cell nutrient solution has been added Haemoglobin approximately 15 g/100 ml Haematocrit 50%–70%

25. Infection: risk Same as whole blood Storage: Same as whole blood Indications: Same as red cell concentrate Contraindications: Not advised for exchange transfusion of neonates. The additive solution may be replaced with plasma, 45% albumin or an isotonic crystalloid solution, such as normal saline

26. Administration : Same as whole blood Better flow rates are achieved than with red cell concentrate or whole blood

27. Frozen RBCs Add cryoprotectant glycerol to RBCs followed by appropriate freezing (-65°C or lower) allows storage of RBCs for 10 years. When Cells needed, unit thawed and washed with saline to remove glycerol. Washing “enters” storage bag-unit can be stored for only 24 hours at 1° to 6°C after thawing. Used primarily to maintain supplies of uncommon RBC phenotypes needed by patients with alloantibodies against frequently occurring RBC antigens Military uses to maintain emergent blood supplies.

28. Leukocyte Poor RBCs Leukocyte-Reduced Red Blood Cells Description A red cell suspension or concentrate containing <5 x 10 6 white cells per pack, prepared by filtration through a leucocyte-depleting filter Haemoglobin concentration and haematocrit depend on whether the product is whole blood, red cell concentrate or red cell suspension Leucocyte depletion significantly reduces the risk of transmission of cytomegalovirus (CMV)

29. Indications Minimizes white cell immunization in patients receiving repeated transfusions but, to achieve this, all blood components given to the patient must be leucocyte-depleted Reduces risk of CMV transmission in special situations Patients who have experienced two or more previous febrile reactions to red cell transfusion

30. Contraindications Will not prevent graft-vs-host disease: for this purpose, blood components should be irradiated where facilities are available (radiation dose: 25–30 Gy) Administration Same as whole blood A leucocyte filter may also be used at the time of transfusion if leucocyte-depleted red cells or whole blood are not available

31. Washed RBCs Washed RBCS are RBCs washed with saline to remove most of the plasma. Washed RBCs are not leukoreduced. Indications-patients who have had severe allergic reactions associated with transfusion or immunoglobulin A (IgA) deficiency. Washed RBCs must be given through a standard blood filter, can transmit hepatitis and other infectious diseases Because bag must be entered to introduce saline, washed RBCs must be given within 24 hrs of preparation.

32. Irradiated WB or RBCs Blood components exposed to standard dose of ionizing radiation to make viable lymphocytes unable to engraft (to reduce GvH) in premature newborns or highly immunocompromised patients (e.g., bone marrow or solid organ transplant). “Although no significant adverse red cell structural events have been noted, mild functional impairment manifested by significant leakage of potassium and accumulation of plasma hgb has been noted after gamma irradiation.” ASA Questions and Answers About Transfusion Practice- 2002

33. گرم كردن خون در مواردي كه يك حجم خون و يا بيشتر طي 24 ساعت جايگزين شود، تزريق خون را ماسيو مي‌نامند. يك حجم خون به ميزان ml/Kg 75 يا حدود ml 5000 تخمين زده مي‌شود. Exchange Transfusion نوزادان در صورتي كه بيمار داراي Ab‌هاي واكنش‌دهنده در دماي سرد(Cold Antibody) باشد. زماني كه بيمار آريتمي داشته باشد. براي زماني كه خون با سرعت 50 ml/minute براي 30 دقيقه يا بيشتر براي بزرگسالان و سرعت 15 ml/Kg/hour براي كودكان تنظيم شده باشد. براي بيماران در طول عمل جراحي Bypass در فاز re-warming پلاسمافرزيس درماني يا فرآيند Red cell exchange تزريق خون در نوزادان و كودكان سندرم رينود يا وازواكتيو ناشي از سرما

34. Use of RBCs in Massive Transfusion If 50-75% blood volume replaced by type 0 Blood (10 U RBCS in adult)- May need to continue with type 0 blood- “Otherwise, risk of major cross-match reaction increases. Patient may have received enough anti-A or anti-B antibodies to precipitate hemolysis if A,B, or AB units subsequently given” Smith, C.(2003)Current Practices in Fluid and Component Therapy ITACCS. Seminar-Massive Transfusion

36. FFP

37. Description Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin Factor VIII level at least 70% of normal fresh plasma level

38. FFP Collected by centrifugation of whole blood, or by apheresis as a single donor unit (taken for plasma, or as a by product of RBC or platelet apheresis) Must be frozen within 6 hours of collection,can be kept frozen for a year, takes 20-30 minutes to thaw, Before use, should be thawed in the blood bank in water which is between 30°C to 37°C. Higher temperatures will destroy clotting factors and proteins is then kept at 1-6° and transfused within 24 hours

39. FFP Need ABO Compatibility, but Rh Neg patients can receive Rh Pos FFP 4-5 Units of platelets, one unit WB all have same a similar quantity of coagulation factors as unit of FFP (except for labile factors lost to cold storage in WB)

40. Indications Replacement of multiple coagulation factor deficiencies: e.g. —Liver disease —Warfarin (anticoagulant) overdose —Depletion of coagulation factors in patients receiving large volume transfusions Disseminated intravascular coagulation (DIC) Thrombotic thrombocytopenic purpura (TTP)

41. Precautions Acute allergic reactions are not uncommon, especially with rapid infusions Severe life-threatening anaphylactic reactions occasionally occur Hypovolaemia alone is not an indication for use

42. FFP Goal- to raise level of clotting factor to 30% of normal Takes 10-15 cc/kg Rapid reversal of coumadin 5-8cc/kg FFP (Vitamin K would take 12-18 hours) Clin Anes Procedures-Mass Gen-2002

43. Cryoprecipitate

44. Description Prepared from fresh frozen plasma by collecting the precipitate formed during controlled thawing at +4°C and resuspending it in 10–20 ml plasma Contains about half of the Factor VIII and fibrinogen in the donated whole blood: e.g. Factor VIII: 80–100 iu/pack; fibrinogen: 150– 300 mg/pack; factor XIII: 40 to 60 U/pack

45. Cryoprecipitate Shelf life-Frozen: 1 yr (<–30°C) Thawed: Give within 6 hours Preferable to be ABO compatible (AABB) May have RBC fragments that can sensitize Rh-D neg patients

46. Indications As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of: — von Willebrand Factor (von Willebrand’s disease) — Factor VIII (haemophilia A) — Factor XIII As a source of fibrinogen in acquired coagulopathies: e.g. disseminated intravascular coagulation

47. Cryoprecipitate A dose of 1 unit (bag) of cryoprecipitate per 7- 10 kg body weight raises fibrinogen levels by at least 50 mg/dL. The half-life of fibrinogen is 3 to 5 days; additional doses given on the basis of lab test results.

48. Platelets

49. Description Single donor unit in a volume of 50–60 ml of plasma should contain: At least 55 x 10 9 platelets <1.2 x 10 9 red cells <0.12 x 10 9 leucocytes

50. Unit of issue May be supplied as either: Single donor unit: platelets prepared from one donation Pooled unit: platelets prepared from 4 to 6 donor units ‘pooled’ into one pack to contain an adult dose of at least 240 x 10 9 platelets

51. Infection risk Same as whole blood, but a normal adult dose involves between 4 and 6 donor exposures Bacterial contamination affects about 1% of pooled units Storage Up to 72 hours at 20°C to 24°C (with agitation) unless collected in specialized platelet packs validated for longer storage periods; do not store at 2°C to 6°C Longer storage increases the risk of bacterial proliferation and septicaemia in the recipient

52. Indications Treatment of bleeding due to: — Thrombocytopenia — Platelet function defects Prevention of bleeding due to thrombocytopenia, such as in bone marrow failure

53. در صورتي كه تعداد پلاكت‌هاي بيمار كمتر از 000/10 در ميكروليتر يا كمتر از 000/20 در ميكروليتر و همراه با تب باشد. مواردي كه توليد پلاكت در مغز استخوان كاهش يافته باشد و يا بين 000/20 - 000/10 در ميكروليتر باشد مانند بيماران داراي بدخيمي‌هاي خوني و يا بيماراني كه تحت كموتراپي بوده‌اند. شمارش پلاكت كمتر از 000/50 در ميكروليتر براي جراحي‌هاي كوچك. شمارش پلاكت كمتر از 000/80 در ميكروليتر براي جراحي‌هاي بزرگ. شمارش پلاكت كمتر از 000/50 در ميكروليتر در بيماراني كه خونريزي فعال دارند. شمارش پلاكت كمتر از 000/50 در ميكروليتر در بيماراني كه تحت ترانسفوزيون وسيع قرار داشته‌اند. شمارش پلاكت كمتر از 000/50 در ميكروليتر در بيماراني كه قرار است مورد اعمال تهاجمي قرار مي‌گيرند.

54. شمارش پلاكت كمتر از 000/100 در ميكروليتردر بيماران كه داراي يكي از خصوصيات زير: a: خونريزي رتين b: خونريزي مغز c: افراد تحت جراحي باي پاس(By-Pass) كه دچار خونريزي شده‌اند. با زمان سيلان بيش از 5/7 دقيقه با شمارش پلاكت طبيعي، خونريزي يا اعمال جراحي تهاجمي در بيماران دچار اختلال كيفي پلاكت در درمان لوكمي حاد براي جلوگيري از مرحله خونريزي وسيع (Episode Major Bleeding) به جز فاز انتهايي

55. Platelet Transfusion: Response evaluation to plt transfusion: Corrected Count Increment: ( CCI) CCI= Plt increment multiply BSA/ Number of plt transfused

56. Platelet Transfusion: Response Evaluation: CCI must be at least 7500 one hour and 4500,20 hours after transfusion. So if it doesn’t occur we can say that patient has platelet resistance.

57. Contraindications Not generally indicated for prophylaxis of bleeding in surgical patients, unless known to have significant pre- operative platelet deficiency Not indicated in: — Idiopathic autoimmune thrombocytopenic purpura (ITP) —Thrombotic thrombocytopenic purpura (TTP) — Untreated disseminated intravascular coagulation (DIC) — Thrombocytopenia associated with septicaemia, until treatment has commenced or in cases of hypersplenism

58. Dosage 1 unit of platelet concentrate/10 kg body weight: in a 60 or 70 kg adult, 4–6 single donor units containing at least 240 x 10 9 platelets should raise the platelet count by 20–40 x 10 9 /L Increment will be less if there is: — Splenomegaly — Disseminated intravascular coagulation — Septicaemia

59. Administration After pooling, platelet concentrates should be infused as soon as possible, generally within 4 hours, because of the risk of bacterial proliferation Must not be refrigerated before infusion as this reduces platelet function 4–6 units of platelet concentrates (which may be supplied pooled) should be infused through a fresh standard blood administration set Special platelet infusion sets are not required Should be infused over a period of about 30 minutes Do not give platelet concentrates prepared from RhD positive donors to an RhD negative female with childbearing potential Give platelet concentrates that are ABO compatible, whenever possible

60. Complications Febrile non-haemolytic and allergic urticarial reactions are not uncommon, especially in patients receiving multiple transfusions

61. PLATELET CONCENTRATES (collected by plateletpheresis) Description Volume 150–300 ml Platelet content 150–500 x 10 9, equivalent to 3–10 single donations Platelet content, volume of plasma and leucocyte contamination depend on the collection procedure Unit of issue 1 pack containing platelet concentrates collected by a cell separator device from a single donor

62. Infection risk Same as whole blood Storage Up to 72 hours at 20°C to 24°C (with agitation) unless collected in specialized platelet packs validated for longer storage periods; do not store at 2°C to 6°C

63. Indications Generally equivalent to the same dose of platelet concentrates prepared from whole blood If a specially typed, compatible donor is required for the patient, several doses may be obtained from the selected donor Dosage 1 pack of platelet concentrate collected from a single donor by apheresis is usually equivalent to 1 therapeutic dose

64. Administration Same as recovered donor platelets, but ABO compatibility is more important: high titre anti-A or anti-B in the donor plasma used to suspend the platelets may cause haemolysis of the recipient’s red cells

65. That’s all, folks!