Transfusion Therapy

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Transfusion Therapy

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Outline

• Blood provision
• About blood products
• Blood Groups and Compatibilities 
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products
• Blood administration

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Blood Safety
Donor education recruitment screening
Storage Distribution Transportation
Bedside use
Blood collection
Testings
1. Appropriate Use of Blood component 2.
Hemovigilance System 3. Look back
NAT Prestorage LR (CMV ,Alloimmune,FNHTR) Pathogen
reduction Donor Retest
Monitor of temperature Inspection Storage time
Skin disinfection compliance with SOP C.U.E
Donor suitability
Quarantined, Retrieve Donor remark
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Blood provision

• Pretransfusion sample
• Collector
• Venipuncture will only be performed by an
  appropriately trained pathology collector,
  medical officer, registered nurse or anaesthetic
  or theatre technician, or a trainee in direct
  supervision of one of the above. Patients must be
  identified before sample collection
• Ask the patient (or parent) to state their name,
  date of birth and address (outpatients)
• Inspect the patient ID bracelet (inpatients) and
  confirm that these details match those on the
  request form

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Blood provision

• Pretransfusion sample
• Specimen labelling
• must be labelled at the bedside before leaving
  the patient
• specimens must have the following identifiers
• Full Name (Surname and First name)
• Date of birth
• UR number (if known)
• Date and time of collection
• Collectors signature or initial on the request
  form
• labelling of tubes in advance of collection is
  not acceptable due to the risk of patient
  specimen mismatch

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Blood provision

• Pretransfusion testing
• Group and Screen
• Determines the ABO and Rh(D) group
• Antibody screen to detect red cell antibodies
• Checking for previous transfusion and blood group
  records

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Blood provision

• Issue of blood products from the blood bank
• Blood products should only be picked up when the
  transfusion is ready to commence in order to
  ensure appropriate storage of blood products.
• Blood products must not be stored in ward areas
  or domestic fridges.
• If the transfusion cannot commence within 30
  minutes, the product must be returned to blood
  bank for storage

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About blood products

• Blood products
• Blood Groups and Compatibilities 
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products

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Blood Groups and Compatibilities

• Many blood groups including ABO, Rh, Kidd, Kell,
  Duffy, MNS and Lewis
• The most important of these are ABO and RhD
• Transfusion with ABO incompatible blood can lead
  to severe and potentially fatal transfusion
  reactions
• RhD is highly immunogenic and can lead to red
  cell hemolysis in certain settings

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Blood Groups and Compatibilities
ABO Blood Groups
 Blood Group ABO antigens present onthe red cell surface ABO antibodies presentin the plasma
 Type O  nil  anti-A and anti-B
Type A  A antigen  anti-B
Type B  B antigen  anti-A
 Type AB  A and B antigens  nil
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Blood Groups and Compatibilities

• Rhesus D (RhD) Antigen
• More than 40 different kinds of Rh antigens
• The most significant Rh antigen is RhD.  When RhD
  is present on the red cell surface, the red cells
  are called RhD positive.
• Antibodies to RhD develop only after an
  individual is exposed to RhD antigens via
  transfusion, pregnancy or organ transplantation. 
• As a general rule, RhD negative individuals
  should not be transfused with RhD positive red
  cells, especially RhD negative girls and women of
  childbearing age.

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Blood Groups and Compatibilities
   Blood Compatibility - Are they Compatible?    Blood Compatibility - Are they Compatible?    Blood Compatibility - Are they Compatible?
 Patient Type  Compatible Red Cell Types  Compatible Plasma Types(FFP Cryoprecipitate)
A A, O A, AB
B B, O B, AB
O O O, A, B, AB
 AB AB, A, B, O AB
 RhD Positive  RhD Positive RhD Negative RhD Positive RhD Negative 
 RhD Negative  RhD Negative RhD Positive RhD Negative 
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Blood Groups and Compatibilities

• Avoiding ABO Incompatible Transfusions
• Most ABO incompatible transfusions occur as a
  result of improper patient identification at the
  time of collection of the pre-transfusion sample
  or administration of the blood product.
• The pre-transfusion check is carried out at the
  bedside by 2 members of clinical staff to ensure
  the right blood is transfused to the right
  patient.
• Positive patient identification prior to blood
  sample collection and labelling the specimen tube
  at the bedside is critical for accurate sample
  collection

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About blood products

• Blood products
• Blood Groups and Compatibilities 
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products

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??????(Blood Component Therapy)
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8hr???
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8hr???
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Buffy coat
20-24?C, 6hr ???
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6-8hr???
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?? CPDA-1 35? 1º6 ?
?????? CPDA-1 35? 1º6 ?
??????? 35? 1º6 º
??? 3-5? 20 º24?(??)
??? 24?? 20 º24?
?????? 1? -20???
???? 5? -20???
????? 1? -20???
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????????????

• ???????????,???????,????????????????
• ?????????????

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???? (Fresh Whole Blood)

• ??
• ?????3????????????
• ????100 ml,??150 ml,???35 ml,??????????????,??????
  ?,Ht 32-42?
• ??285 ml
• ?? / ??4?,35?

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???? (Fresh Whole Blood)

• ??????????Hb 0.5g / dl,?????2, 3 -
  DPG???????,???????????
• ???
• ?????
• ???????
• ?????????

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?? (Stored Whole Blood)

• ???????100 ml,??150 ml,???35 ml,??????120??,Ht
  32-42 ????factor ?? ? ??????,?????????,?????
• ??285 ml
• ??/??4?,35?
• ??????????Hb 0.5 g / dl,????????????,????????

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?? (Stored Whole Blood)

• ???
• ??????????????????1000 ml??????????30
  ?,?????,???? ??(kg)x 70 ml?
• ????3?????????????????? ?????????,????,???????????
  ????,???????packed RBC?FFP?? platelet
  concentrate?
• 1000ml?????,????packed RBC?

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??????(Packed RBC)

• ????????100 ml,??40 ml,??????40
  ??,?????????,?????
• ??150 ml
• ?? / ??4?,35 ?
• ????????? Hb 0.5 g / dl,????????????

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??????(Packed RBC)

• ???
• 1. 500 ml?????
• 2. ????????????? (???)?
• ????(iron?folate????B12?) ?
• ?????
• 3. Hb lt 9 g / dl ?,???????????
• ???,????,?????????
• ?,angina ????????????
• 4. Hb lt 8 g / dl ?,??????????

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???????? (Washed RBC)

• ????
• ???? 90 ml,?????? (????? WBC 1 x 108,??????
  WBC?90),??????? ,??????????
• ??130 ml
• ?? / ??4?,24??

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???????? (Washed RBC)

• ????????? Hb 0.5g / dl
• ???
• 1. ??????(????????,
• IgA ???)
• 2. ???????????????
• 3. ??????????(PNH)

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???????????(Frozen Deglyceride RBC)

• ????
• ????90 ml,???,????,???????,????????????
• ??120 ml
• ?? / ??
• - 65?,10?,????? 4 ?,24??

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???????????(Frozen Deglyceride RBC)

• ????????Hb 0.5 g / dl
• ???
• 1. ?????????
• 2. ?????????????????
• 3. ??????????(PNH)

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????????????(Leukocyte-Poor RBC)

• ????
• ?2U???????(?SAGM),???????(filter)???????????,
  ??WBClt5x106?
• ??200350 ml/? (2U)
• ??/??16?,???42?

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????????????(Leukocyte-Poor RBC)

• ??
• ?????? Hb 0.5g / dl
• ??? Febrile nonhemolytic transfusion reaction,HLA
  alloimmunization,CMV,HTLV-????
• ???? GVHD

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????????????(Leukocyte-Poor RBC)

• ???
• 1. ?????,?chemotherapy,thalassemia,aplastic
  anemia,dyserythropoiesis????
• 2. ??TA-GVHD?
• 3. ???????CMV??,?????? ?,??????,????????????(?
  WBC lt 1 x 107)
• 4. ??????????,??????

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??????(Fresh Frozen Plasma)

• ????
• ?250ml?????8?????????,???????,???????????,???V?
  VIII????????
• ??90-120 ml
• ?? / ??-18?,1?,
• ? 30 37???????

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??????(FFP)????

• 1. Anti-thrombin ???
• 2. Coagulation factor ?????????IX?X?XIII ???
• 3. Coumadin??????
• 4. DIC,TTP,hemolytic-uremic syndrome
• 5. ??????????????
• 6. ??????????????
• 7. ?????????

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Transfusion audit of fresh-frozen plasma in
southern Taiwan

• The indications for FFP included the following
• surgery and invasive treatment of patients who
  had activated partial thromboplastin time (APTT)
  and prothrombin time (PT) elevated to 15 times
  the normal level, with a bleeding tendency
• disseminated intravascular coagulation (DIC)
• plasma exchange for thrombotic thrombocytopenic
  purpura (TTP)
• massive transfusion with coagulopathy
• exchange transfusion for newborns

Vox Sanguinis (2006) 91, 270274
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The change in red blood cell (RBC)-to-plasma
ratio and inappropriate requests for fresh frozen
plasma (FFP), before and after the intervention
Transfusion audit of fresh-frozen plasma in
southern Taiwan
Vox Sanguinis (2006) 91, 270274
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Internal Medicine Journal 2005 35 283288
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Internal Medicine Journal 2005 35 283288
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????(Frozen Plasma)

• ???????????? 90??,?factor ???,??????????
• ??100-150ml
• ?? / ??-18?,??
• ????????????
• ???
• ??????????(warfarin) ??????
• ???????????

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????(FP)
Practice Guidelines for Blood Transfusion 2007
American National Red Cross
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????(FP)
Practice Guidelines for Blood Transfusion 2007
American National Red Cross
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????(Cryoprecipitates)

• ?????
• ?????8???????????????-80????????????????,?1-6?????
  ???????????????,???????1???????-20????
• ?????45IU?factor VIII,125mg?????,40IU
  von-Willebrand??,fibronectin 23mg?20-30IU factor
  XIII
• ??1520 ml
• ?? / ??-20?,1?

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????(Cryoprecipitates)

• ???
• 1. Coagulation factor ? ??
• 2. Von Willebrands disease
• 3. DIC,Sepsis
• 4. Hypofibrinogenemia (fibrinogen?100 mg /
  dl,????,??150 mg / dl)

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??????(Platelet Concentrate)

• ????,????
• (a) ????????,?1????
• ???? 23 x 1010,????????????
• (b) ??????(???12???????) ,???
• ??? 3 x 1011,????????????
• ??(a) 30 40 ml (b) 200 300 ml
• ?? / ??2024???????,5 ?
• ??(a) ?????????? 2500 /µl
• (b) ?????????? 60000 /µl

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?????? (Platelet Concentrate)

• ???
• 1. ??? lt 10,000 20,000 /µl,
• ???,?? ???,???????
• 2. ??? lt 80,000 -100,000 /µl,
• ?????? ??
• 3. ??? lt 50,000 /µl,
• ?????????
• 4. ??? lt 50000 /µl,
• ?????,????5?

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?????? (Platelet Concentrate)

• ???
• 5. ?????DIC,????????
• ???,ITP????????
• 6. ???????????
• 7. ???????????(uremia)
• 8. ??????????????????

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Platelet transfusion

• Blood Group? ? Principles

Patients ABO Group Platelet Product Group Platelet Product Group Platelet Product Group
Patients ABO Group First Choice Second Choice Third Choice
O O    
A A B O
B B A O
AB AB B or A O
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Platelet transfusion

• Platelet Administration
• Use a fresh administration set for platelets. Do
  not transfuse though a standard filter straight
  after red cells as platelets will get caught up
  in fibrin strands /debris etc.
• Platelet transfusion must be completed within 4
  hours of spiking pack. Occasionally platelets are
  given over 30 minutes, but this may contribute to
  an increased risk of some reactions (fever/chill)
  and fluid overload.
• In patients receiving multiple other fluids etc
  give at a rate of 3ml/kg/hr over 2-3 hours.

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?????? (White Blood Cells Concentrate)

• ????6???,???(2024C)?????????????buffy coat??
• ??1?? - 250ml??????,??2030ml,?1x109
  ???,???????????
• ?? / ??
• 2024?,24??,?6???
• ?????

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?????? (WBC Concentrate)

• ??
• ?? neutropenia ??????????????
• ???????????????,
• 1. ??????? ( neutrophils lt 500 /µl)?
• 2. ???? 24??,??3??????????
• 3. ?????? myeloid series ?????
• 4. ?????????????

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?????? (WBC Concentrate)

• ????
• 1.??????????????,???? ?,?????????????????
• 2.????????,?????????,??????????????????,??????????
  ???
• 3.?????????????,??????????
• 4.?????????

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Volumes and rates for transfusion of blood
products
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About blood products

• Blood products
• Blood Groups and Compatibilities 
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products

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Blood product modifications

• Irradiation of blood products
• by gamma irradiation of cellular blood products
  (whole blood, red blood cells, platelets,
  granulocytes)
• using a dedicated blood irradiator with a long
  half-life gamma emitting source
• to prevent Transfusion Associated Graft-Versus
  Host Disease (TA-GVHD)
• occurs 10-14 days post transfusion
• fever, skin rash, hepatitis, diarrhea and
  pancytopenia
• fatal in more than 90 of cases

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Blood product modifications

• Irradiation of blood products
• Irradiation of RBCs and whole blood
• results in reduced post transfusion red cell
  recovery and increases the rate of efflux of
  intracellular potassium ? no clinically
  significant effect on red cell pH, glucose, 2,3
  DPG levels or ATP
• Packs irradiated within 14 days of collection
  expire 28 days after collection
• Packs irradiated more than 14 days after
  collection expire either 5 days after irradiation
  OR at original expiry of pack, whichever comes
  first
• In patients where hyperkalemia is a concern, red
  cells should be transfused within 24 hours of
  irradiation. Examples include large volume
  neonatal transfusion such as exchange
  transfusion, ECMO or rapid large volume
  transfusion

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Blood product modifications

• Irradiation of blood products
• Irradiation of platelets
• has not been shown to cause any clinically
  significant change in platelet function.
• Platelets may be irradiated at any stage during
  their 5 day storage life.
• Irradiation of granulocytes
• conflicting evidence of irradiation damage to
  granulocytes.
• Granulocytes should be transfused as soon as
  possible after collection and irradiation.

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Blood product modifications

• Irradiation of blood products
• Labelling

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About blood products

• Blood products
• Blood Groups and Compatibilities 
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products

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Blood product modifications

• Leucocyte depletion - 1
• Removal of white cells from cellular blood
  products (whole blood, red blood cells,
  platelets) to a level of lt1 x 106 per pack
• Why?
• Reduces alloimmunisation and platelet
  refractoriness
• Reduces frequency of recurrent febrile reactions
• Reduces the risk of CMV transmission
• Reduces the risk of potential immunomodulatory
  effects

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Blood product modifications

• Leucocyte depletion - 2
• Which patients?
• Immunocompromised patients
• Hematology/Oncology patients
• Malignancy
• Transplant recipients (bone marrow and solid
  organ)
• Severe Combined Immune Deficiency Syndrome
  (SCIDS), Common Variable Immune Deficiency (CVID)
• Patients requiring chronic transfusion
• Patients less than 12 months of age
• Intrauterine and exchange transfusions

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Blood product modifications

• Leucocyte depletion - 3
• Which filter should I use?

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Blood product modifications

• Leucocyte depletion - 4
• Fresh Frozen Plasma (FFP) and cryoprecipitate
  have extremely low numbers of viable cells and do
  not require leucocyte depletion - they should be
  administered via a standard filter.

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Accumulation of extracellular sVEGF (ng/unit) in
WB and SAGM blood during storage for 35 days at
4C.
Transfusion, Vol. 39, No. 10, 1078-1083, October
1999
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Outline

• Blood provision
• About blood products
• Blood Groups and Compatibilities 
• Blood Component Therapy
• Blood product modifications
• Irradiation of blood products
• Leucocyte depletion of blood products
• Blood administration

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Blood administration

• Patient preparation
• Pretransfusion check
• Blood Transfusion Record
• Transfusion Tag
• Care and monitoring of transfused patients 

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Blood administration

• Patient Preparation
• appropriate IV access
• written order for transfusion
• benefits/risks of transfusion discussed
• an opportunity to have any questions answered

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Blood administration

• Pretransfusion check - 1
• Safe transfusion
• a final patient identity check at the patient
  bedside before blood administration
• to ensure the right blood is given to the right
  patient. 
• Signing the blood transfusion record
• the check has been completed prior to transfusion
• no discrepancy was identified

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Blood administration

• Pretransfusion check - 2
• Check blood product for any signs of leakage,
  clumps or abnormal color
• Patient identification
• ? Check name, DOB and UR on the Blood
  Transfusion Record and pack tag/label and on the
  patient's wristband. Are they identical?
• Blood product identification
• ? Check the pack number on the Blood Transfusion
  Record, pack tag/label and the product. Are they
  identical?

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Blood administration

• Pretransfusion check - 3
• Blood Group
• ? Check the blood group (ABO and RhD) on the
  Blood Transfusion Record (this form reports
  compatibility), pack tag/label and the
  product. Do they match?
• Check expiry date on the pack
• Check medical orders
• product type, special requirements (eg
  irradiation, leucocyte depletion)
• administration requirements (eg volume, rate)
• Complete documentation
• sign, date, time the Blood Transfusion Record
• file in the patient's medical record

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Blood administration

• Blood Transfusion Record

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Blood administration

• Transfusion Tag

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Blood administration

• Care and monitoring
• temperature, pulse, respiratory rate and blood
  pressure should be measured and recorded
• before the start of each pack of blood or blood
  product
• at 15 minutes after commencement
• hourly during transfusion
• at the completion of each pack
• may require more frequent observations
  particularly in unstable or unconscious patients

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Blood administration

• Care and monitoring
• more frequent vital signs should be taken if the
  patient has an unstable underlying condition or
  the patient becomes unwell or shows signs of
  a transfusion reaction
• Patients should be observed during the first 15
  minutes of transfusion as some life-threatening
  reactions may occur after the infusion of only a
  small amount of blood.
• Where possible, patients should be informed of
  possible symptoms of a transfusion reaction and
  should inform staff immediately if they feel
  unwell during transfusion.

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General Transfusion Practices
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How to manage blood transfusion?

• Pretransfusion-IV route and sampling
• Manage Blood transfusion

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