Blood transfusions

This material is intended to support the didactic lecture series provided by The Department of Medicine for Intermediate Cycle II

Learning Objectives
Be familiar with different concepts of blood donation Know indications for blood products Know ABO system and antibodies Complications of blood transfusion

Whole Blood (Donor Screening)

Cellular components

Fresh plasma

(Packed) Red cells

Platelets

Cryoprecipitate

Fresh frozen plasma

Factor VII concentrate

Fibrinogen concentrate

Albumin

Immunoglobulins

INDICATIONS (core)

1. WHOLE BLOOD: Large Acute Blood Loss 2. PACKED RED CELLS (LEUKOCYTE DEPLETED) : Usually Hb < 8g/l (SAG-M = Saline, Adenine, Glucose, Manitol are added to the red cells) 3. PLATELET CONCENTRATION : Keep Platelet Count > 10x10^9L (or >50x50 10^9L for surgical procedures) 4. FRESH FROZEN PLASMA (Octaplas): Replacement of Coagulation Factors (if bleeding (Solvent Detergent) or prior to surgical procedures): Liver Disease, Mass Transfusion , DIC, TTP 5. PROTHROMBIN COMPLEX (Octaplex) (Contains Factors II, VII, IX, X): Emergency Reversal of Warfarin 6. CRYOPRECIPITATE enriched in fibrinogen, vWF, VIII, XIII. For treating haemophilia A, von Willebrands disease, DIC

Packed red cells

Store at 4C Transfuse within 35 days of collection, otherwise cell lysis can result in hyperkalaemia Transfuse within 7 days of collection in renal failure or hepatic failure to reduce solute load Each unit will raise Hb by 1 g/dL approximately Donor blood should be the same ABO and Rh group as recipient Donor blood should be crossmatched prior to infusion Donor blood should be free from any irregular group antibodies

INDICATIONS (additional)

CRYOPRECIPATE (RICH IN I AND VIII) - Was used to make Factor VIII - In DIC when Fibrinogen Low (Replaced by Fibrinogen Concentrate) ALBUMIN - Replacement fluid in Plasmapheresis (Except TTP) - Plasma Volume Expander in Hypoalbuminemia States INTRAVENOUS IMMUNOGLOBINS - Hypogammaglobinemia - Immune Thrombocytopenic Purpura - Anti D Immunoglobulin

TRANSFUSION OF RED BLOOD CELLS

Red Cell Antigens: Blood Recipients who lack a particular blood group antigen may produce antibodies reacting to that antigen and may lead to a transfusion reaction if red cells bearing the antigen are transfused ABO and Rhesus (Rh) are of major clinical significance

BLOOD GROUP ANTIBODIES (core)

Naturally Occurring Antibodies: occur in plasma of subjects lacking the corresponding antigen and who have not been transfused or pregnant. Anti-A and Anti-B are usually IgM and react primarily at 4C Immune Antibodies: occur in response to introduction (transfusion or in pregnancy) of red cell antigens which the recipient lacks. Usually IgG and react optimally at 37C. Only IgG antibodies can cross placenta to fetus.

ABO SYSTEM (core)

Group OAnti-A and Anti-B Group AAnti-B Group BAnti-A Group ABNo naturally occurring antibodies RH SYSTEM Rh D negative 15% of population

TESTING FOR BLOOD GROUP AND ANTIBODY SCREEN 1. Indirect anti-globulin/indirect Coombs test for antibody screen 2. Blood of same ABO and RhD blood group is selected. 3. Cross-match of patients serum against donor red cells using indirect Coombs test

Acute complications of blood transfusions (CORE)

Pyrogenic reactions (to plasma proteins or due to HLA Antibodies) Febrile non-haemolytic transfusion reactions
Due to antibodies stimulated by previous transfusions angainst antigens on donor cells Get fever and chills STOP transfusion, give paracetamol, give steroids, give washed blood

Allergic reactions to white cells, platelets or proteins (Anaphylactic transfusion reactions )

Due to reaction between donor plasma proteins and recipient IgE antibodies Get urticaria, itching, wheezing and rarely, anaphylaxis Give adrenaline, antihistamines, steroids Due to Abo incompatability, often due to incorrect patient/product resulting in complement activation Get muscle pain, back pain, fever, nausea, vomiting, chest pain, wheezing, dyspnoea, anxiety, ARDS, renal failure, DIC, shock Repeat crossmatch and grouping process for donor and recipient blood, direct Coombs test. STOP transfusion, hydrate aggressively, transfuse with compatible blood products

Haemolytic Reactions - (Immediate or Delayed)

Citrate toxicity in massive transfusion. Preven by giving 10mL of 10% Ca2+ gluconate for every 2 units of blood Hyperkalaemia when blood old, get this from cell lysis Circulatory overload minimise the amount of saline given with blood Reactions due to infected blood bacterial infections can cause prompt reaction if blood infected. Treat as would sepsis Urticarial transfusion reactions Post-transfusion purpura Air Embolism Thrombophlebitis Clotting abnormalities after massive blood transfusions

Acute haemolytic transfusion reaction Clinical manifestations Fever Flank pain, and Red or brown urine (haemoglobinuria) DIC Positive DAT (Direct antiglobulin test)

Febrile non-haemolytic transfusion reaction

Clinical manifestations: Occur one to six hours after transfusion of red cells or platelets
Fever mild dyspnoea

Delayed complications of blood transfusions (CORE)

Delayed Hemolytic transfusion reaction delay up to 5-10 days
Due to extravascular haemolysis due to alloantibodies that are not detectable by indirect antiglobulin test Get anaemia, fever Avoid further transfusion

Iron overload if get many transfusions get secondary haemochromotosis Transfusion associated graft versus host disease 4 to 25 days post
Due to transfused T-cells reacting against the recipient Generally associated with host immunocompromise Get fever, diarrhoea, liver impairment, pancytopaemia. 90% mortality Prevent with gamma irradiation of blood components

LATE COMPLICATIONS OF BLOOD TRANSFUSION (CORE)

Transmission of disease: Hepatitis A HBV <1:82,000 HCV <1:3000,000 HIV <1:5000,000 CMV Bacteria 1:100,000 of sepsis Other - Treponema Pallidum, Brucella, Salmonella, Parasites, Malaria, Toxoplasma, Microfilaria Transfusional overload Immune sensitization (e.g. to Rh D Antigen)

HAEMOVIGILANCE (CORE)

- 2002 /98/EC Directive

1. 2. Avoid inappropriate transfusion and reduce risks of transfusion Traceability: Every blood product component must be fully traceable to the donor as well as the recipient 3. Clerical Error: Check > 70 steps for administration of blood products 4. Strict labelling of blood samples 5. Strict completion of blood transfusion request 6. Correct prescription of blood product 7. Laboratory SOPs 8. QA Schemes 9. Computerized Records 10. Correct identification of blood product for correct patient 11. Ongoing Education and Audit