Choosing Appropriate Blood Components and Derivatives

1
Choosing Appropriate Blood Components and
Derivatives
CLS 423 Clinical Immunohematology II

• For each case, decide which blood component or
  derivative would be most appropriate to
  transfuse.
• Then select the best product from the available
  inventory.

2
Case One

• Sam is being treated for Hodgkins Lymphoma.
• Below are the results from this mornings CBC
• WBC 4.0 K/µL
• RBC 2.64 M/µL
• Hgb 6.8 g/dL
• Hct 21
• Plt 133 K/µL

3
Based on the CBC results, which of the following
components would be appropriate to transfuse to
Sam?

• Click on the box in front of your choice
• Granulocytes
• FFP
• Packed RBCs
• Platelet Concentrates

4
Granulocytes

• Not indicated in Sams case.
• Patient is not neutropenic
• History does not indicate that the patient has an
  infection.
• Please choose another component
• FFP
• Packed RBCs
• Platelet Concentrates

5
FFP

• There have been no coagulation tests ordered
  there is no indication for plasma transfusion in
  this case.
• Please choose another component
• Granulocytes
• Packed RBCs
• Platelet Concentrates

6
Platelet Concentrates

• Sams platelet count is adequate.
• Transfusion is usually not indicated unless the
  platelet count is lt10 K/µL in a nonsurgical
  patient.
• Please choose another component
• Granulocytes
• FFP
• Packed RBCs

7
Packed RBCs

• Correct!
• Sam has a low hemoglobin and would benefit from a
  RBC transfusion.
• Sams Type and Screen results are
• A Rh Positive
• Antibody screen Negative using the gel method

8
Which of these packed RBC units would be
compatible with Sam?

• O Rh Positive
• A Rh Negative
• AB Rh Negative
• B Rh Positive
• Either O Rh Positive or A Rh Negative packed RBCs
  are group compatible with Sams A Rh Positive
  RBCs.

9
Which of the following attributes should be
considered for Sams RBCs?

• Irradiation
• Leukoreduction
• Washed
• Patients with Hodgkins Disease have a high risk
  of Transfusion Associated - Graft vs. Host
  Disease and should get irradiated cellular
  products.
• There is a strong chance that Sam will receive
  multiple transfusions, so leukoreduced units may
  be beneficial in preventing the formation of HLA
  antibodies and the complications associated with
  those antibodies.

10
Case Two

• Jill is having cardiac bypass graft surgery this
  afternoon.
• These are her morning CBC results
• WBC 6.2 K/µL
• RBC 3.85 K/µL
• Hgb 12.6 g/dL
• Hct 37
• Plt 40 K/µL
• These are her Type and Screen results
• O Rh Negative
• Antibody screen negative with tube (PEG) method

11
Which of these components should be transfused
in order to prepare Jill for surgery?

• Cryoprecipitate
• FFP
• Packed RBCs
• Platelet Concentrates

12
Cryo and FFP

• There is no indication that any coagulation
  factors are low and in need of replacement.
• Please select a different component
• Packed RBCs
• Platelet Concentrates

13
Packed RBCs

• Jills hemoglobin is acceptable. No RBC
  transfusion is necessary.
• Please select a different component
• Cryoprecipitate
• FFP
• Platelet Concentrates

14
Platelet Concentrates

• Jills platelet count is lt50,000/µL. Platelet
  transfusion may be necessary to raise her count
  before proceeding with surgery.

15
Which of these platelet units would be
appropriate to transfuse to Jill?

• A Rh Negative
• AB Rh Negative
• B Rh Negative
• O Rh Positive
• Any of these units could be transfused to Jill as
  there are no antigens on her Group O RBCs that
  could interact with the antibodies in the donor
  units plasma.

16
O Rh Positive Platelets

• This unit could be transfused to Jill
• HOWEVER since she is Rh Negative
• She may need an RhIG injection afterward to
  prevent the formation of anti-D.

17
Case Three

• Steve was involved in a motor vehicle accident.
• He received 12 units of O Rh Negative
  uncrossmatched packed RBCs in the emergency room.
• He is being prepped for a splenectomy.

18
Steves lab results

• WBC 12 K/µL
• RBC 3.80 M/µL
• Hgb 10.6 g/dL
• Hct 30.2
• Plt 20 K/µL
• PT 24 sec
• PTT 65 sec

19
Steves Type and Screen results
Anti-A Anti-B Anti-D A1 cells B cells Interpretation
0 3mf 2mf 4 0 ???
Screen IS 37 AHG CC Interpretation
I 0 0 0 3 ???
II 0 0 0 3 ???
III 0 0 0 3 ???
20
How would you interpret Steves Type and Screen
results?

• B Rh Positive, negative antibody screen
• What explains the mixed-field reactions with
  anti-B and anti-D?
• The transfusion of a large number of O Rh
  Negative packed RBCs units.
• When a large quantity of RBCs is transfused in
  less than 24 hours it is called ___________ .
• Massive transfusion

21
Which of these components should Steve receive?

• Cryoprecipitate
• FFP
• Packed RBCs
• Platelets

22
Packed RBCs

• At this time, Steves hemoglobin level is
  acceptable and transfusion of RBCs is not
  warranted as long as the patient is not actively
  bleeding.
• Transfusion trigger is typically set at a
  hemoglobin of lt7 g/dL
• If the patient is currently bleeding, additional
  RBC transfusions may be indicated.
• Please select a different component
• Cryoprecipitate
• FFP
• Platelets

23
Cryoprecipitate

• Although the patients PT and PTT are elevated,
  cryoprecipitate only contains a limited number of
  coagulation factors and will not fully correct
  the multiple factor deficiencies.
• There is a better component choice available.
• Please choose another component
• FFP
• Packed RBCs
• Platelets

24
FFP

• This will restore the multiple coagulation
  factors that were depleted as Steve bled.
• There is a second component that should be
  transfused at this time. Which one is it?
• Cryoprecipitate
• Packed RBCs
• Platelets

25
Platelets

• Steves platelet count is low, especially for a
  pre-surgical patient, so a platelet transfusion
  is indicated.
• Transfusion trigger lt50,000/µL

Continue
26
Platelets

• Steves platelet count is low, especially for a
  pre-surgical patient, so a platelet transfusion
  is indicated.
• Transfusion trigger lt50,000/µL
• There is a second component that should be
  transfused at this time. Which one is it?
• Cryoprecipitate
• FFP
• Packed RBCs

27
FFP

• This will restore the multiple coagulation
  factors that were depleted as Steve bled.

28
Which of these blood types would be suitable when
selecting FFP for Steve?

• B Rh Negative
• AB Rh Positive
• O Rh Negative
• A Rh Positive
• The antibodies in the plasma of these donors
  would not react with the antigens on Steves RBCs.

29
Case Four

• Jimmy is a 4 year old with Hemophilia A who is
  experiencing a bleed into his knee joints.
• Which of the following would provide the best
  treatment for Jimmie?
• Cryoprecipitate
• FFP
• Factor VIII concentrate
• Platelet Concentrates

30
Platelet Concentrates

• While Jimmie does have a bleeding problem,
  platelets will not correct for the coagulation
  deficiency found in Hemophilia A.
• Please choose a different product
• Cryoprecipitate
• FFP
• Factor VIII Concentrate

31
FFP

• FFP is ideal when the patient has multiple factor
  deficiencies.
• In this case, we are missing 1 specific factor
  there is a better choice.
• What is it?
• Cryoprecipitate
• Factor VIII Concentrate
• Platelet Concentrates

32
Cryoprecipitate

• This is not a bad choice, but there is a better
  (safer) product.
• Please choose another product
• FFP
• Factor VIII concentrate
• Platelet Concentrates

33
Factor VIII Concentrate

• This derivative product would provide the safest
  and most effective treatment for Jimmie.
• Processed to remove/destroy viruses
• Known quantity of Factor VIII

34
Case Five

• Sue is scheduled for a liver transplant today.
• She has a history of an anaphylactic transfusion
  reaction.
• The transfusion reaction workup revealed Sue has
  no IgA in her serum, and has formed anti-IgA.
• The surgeon has ordered 10 units of packed RBCs
  and 10 units of Plasma to be prepared for the
  transplant surgery.

35
Which of these RBC components would prevent Sue
from having another anaphylactic transfusion
reaction?

• Frozen/Deglycerolized RBCs
• Irradiated packed RBCs
• Leukoreduced packed RBCs
• Washed packed RBCs
• Washed packed RBCs are most suitable for
  prevention of anaphylactic transfusion reactions
• Deglycd units could substitute for washed, but
  are more expensive and generally are units that
  are difficult to find

36
Assuming Sue is A Rh Negative, which of the
following Plasma components could she safely
receive?

• A Rh Positive
• B Rh Negative
• O Rh Positive
• AB Rh Negative
• Only the A and AB plasma units lack antibodies
  that could react with the antigens on Sues Group
  A RBCs.
• Remember that Rh is not a consideration for
  plasma, as plasma is not a cellular component.

37
Which of these plasma products would be
appropriate for transfusion to Sue?

• Fresh Frozen Plasma
• IgA deficient plasma
• Irradiated plasma
• Washed plasma
• Only IgA deficient plasma can be transfused
  without causing an anaphylactic reaction.
• FFP will have labile coag factors present, but
  will also have IgA, unless specifically collected
  from an IgA deficient donor.
• Irradiation and washing are for cellular products
  only.

38
What is the difference between Plasma and Fresh
Frozen Plasma (FFP)?

• FFP must be frozen within 8 hours (if
  manufactured from a Whole Blood collection) or
  according to the FDAs guidelines (for an
  apheresis collection) in order to maintain
  adequate levels of the labile coag factors.
• Factors V and VIII
• Plasma can be prepared from FFP that did not meet
  the freezing timeline, or FFP that has been
  thawed and not transfused within 24 hours.
• Plasma has the stabile coag factors, but reduced
  levels of labile factors.
• In most cases, either FFP or Plasma are suitable
  for transfusion to restore multiple coag factor
  deficiencies.

39
Case Six

• George is a potential bone marrow transplant
  recipient.
• During treatment to ablate his marrow, he has
  been supported with multiple packed RBC and
  platelet concentrate transfusions.
• His last 3 platelet transfusions have not
  resulted in the expected increase in platelet
  count.

40
What term is given to this lack of response to
platelet transfusions?

• The patient is said to be refractory to platelets.

41
Transfusion of which of these components would
result the greatest improvement in the platelet
increment?

• ABO group specific Platelets, Pheresis
• HLA matched Platelets, Pheresis
• Irradiated platelets (apheresis or concentrates)
• Washed platelets (apheresis or concentrates)

42
Irradiated Platelets

• Although his immunosuppression may qualify George
  to receive irradiated cellular components, this
  will not improve his response to platelets in
  this case.
• Please choose another component.
• ABO group specific Platelets, Pheresis
• HLA matched Platelets, Pheresis
• Washed platelets (apheresis or concentrates)

43
Washed Platelets

• Washing cellular products removes plasma proteins
  that contribute to anaphylactic and severe
  allergic transfusion reactions.
• This will not improve Georges response to
  platelet transfusion.
• Please select another component
• ABO group specific Platelets, Pheresis
• HLA matched Platelets, Pheresis
• Irradiated platelets (apheresis or concentrates)

44
ABO Group Specific Platelets, Pheresis

• Transfusing Platelets, Pheresis will limit the
  number of donors that George is exposed to (in
  contrast to pools of platelet concentrates).
  This can be quite beneficial in preventing
  refractoriness.
• While providing platelets that are ABO group
  specific may improve Georges response to
  platelet transfusion, there is a better choice.
• What is it?
• HLA matched Platelets, Pheresis
• Irradiated platelets (apheresis or concentrates)
• Washed platelets (apheresis or concentrates)

45
HLA matched Platelets, Pheresis

• Transfusing Platelets, Pheresis will limit the
  number of donors that George is exposed to (in
  contrast to pools of platelet concentrates).
  This can be quite beneficial in preventing
  refractoriness.
• Platelet refractoriness is often caused by HLA
  antibodies in the recipient destroying the donor
  platelets. Using platelets that match at the
  HLA- A and B loci should result in improved
  platelet counts.
• A match all 4 antigens (2 As and 2 Bs) match.
• B match 3 of 4 antigens match 4th is either a
  duplicate (homozygous) or one in which the
  antibody cross-reacts with one of the patients
  antigens.
• C match 3 of 4 antigens match 4th is complete
  mismatch. This is not a good match and will
  probably not improve the platelet increment.

46
What component attribute could have prevented
formation of Georges HLA antibodies?

• Alcohol fractionation
• Leukoreduction
• Irradiation
• Washed
• Removal of WBCs by filtration will reduce
  exposure to HLA antigens and limit HLA antibody
  formation, preventing refractoriness.

47
Attributes

• Alcohol fractionation is used in preparing
  derivatives from plasma
• Irradiation prevents Transfusion Associated -
  Graft vs. Host Disease
• Washing removes plasma proteins in order to
  prevent anaphylactic and severe allergic reactions

48
Case Seven

• Maureen is undergoing a liver transplant.
• Near the end of her procedure, the surgeon would
  like to transfuse her with a bolus of fibrinogen.
• Which of these blood products should the surgeon
  order?
• Albumin
• Cryoprecipitate
• FFP
• Factor VIII concentrate

49
Albumin

• This is a plasma derivative that does not contain
  coagulation factors.
• Please choose another product
• Cryoprecipitate
• FFP
• Factor VIII concentrate

50
Factor VIII Concentrate

• This plasma derivative contains Factor VIII only.
• Fibrinogen is NOT in this product.
• Please choose a different product
• Albumin
• Cryoprecipitate
• FFP

51
FFP

• FFP contains multiple coagulation factors,
  including fibrinogen.
• However, there are more coag factors in this
  component than what the recipient requires.
• There is a better choice. What is it?
• Albumin
• Cryoprecipitate
• Factor VIII concentrate

52
Cryoprecipitate

• The most common use of cryoprecipitate is for
  replacement of fibrinogen!

53
If Maureen is AB Rh Positive, which of these
cryoprecipitate units would be the best choice
for her transfusion?

• AB Rh Negative
• A Rh Positive
• O Rh Positive
• B Rh Positive
• All of the above!
• Since there are no cells and extremely little
  plasma in cryoprecipitate, a recipient of any
  blood type can receive cryoprecipitate of any
  blood type.

54
Case Eight

• Mike is scheduled for prostate surgery.
• His surgeon has ordered four units of packed RBCs
  for him.
• These are his type and screen results

Anti-A Anti-B Anti-D A1 cells B cells Interpretation
2 0 4 W 4 ?????
Screen Cells IS 37 AHG CC Interpretation
I 0 0 0 3 ?????
II 0 0 0 3 ?????
III 0 0 0 3 ?????
55
Mike has an ABO Discrepancy

• What is the most likely cause?
• Please click the button in front of your choice.
• Cold alloantibody
• Cold autoantibody
• Rouleaux
• Subgroup of A with anti-A1

56
Rouleaux

• Not likely as none of the screen cells reacted at
  the IS phase.
• Since rouleaux is due to excess plasma proteins,
  all the reactions using the patients plasma
  should have been affected.
• Please make another choice
• Cold alloantibody
• Cold autoantibody
• Subgroup of A with anti-A1

57
Cold Alloantibody

• There should have been reactivity with one or
  more screen cells at the IS phase if this were
  the source of the discrepancy.
• Please make another selection
• Cold autoantibody
• Rouleaux
• Subgroup of A with anti-A1

58
Cold Autoantibody

• No reactivity with the screen cells at the IS
  phase rules out this possibility.
• Please make another selection
• Cold alloantibody
• Rouleaux
• Subgroup of A with anti-A1

59
Subgroup of A with anti-A1

• YES! How would you confirm this?
• Test the patients RBCs with anti-A1 lectin to
  prove that the patient lacks this antigen and
  could form an antibody to it.
• Repeat the reverse grouping using A2 cells to
  prove the reactivity with the A1 cells is
  directed at the A1 antigen and NOT against the A
  antigen.

60
Which of the following packed RBC units would be
appropriate for transfusion to Mike?

• A1 Rh Negative
• A2 Rh Positive
• A2B Rh Positive
• O Rh Positive
• O Rh Negative
• These units lack antigens that would react with
  Mikes antibodies (anti-A1 and anti-B).

61
Should Mikes surgeon order Plasma during
surgery, which of these Plasma units would be
acceptable?

• A1 Rh Negative
• A2 Rh Positive
• A2B Rh Positive
• O Rh Positive
• O Rh Negative
• These units do not contain antibodies that would
  react with the antigens on Mikes RBCs.
• Remember it is Mike who has anti-A1 in his
  plasma, not the plasma donor!

62
Case Nine

• Willie has anti-Jsb in his serum.
• If his physician wants to transfuse packed RBCs
  to Willie, which of these sources should be
  considered?
• Autologous blood
• Directed donors
• Designated Donors
• Frozen deglycerolized units

63
All of these!

• Jsb is a high prevalence antigen, so finding
  antigen negative blood will be difficult.
• If it is possible to plan ahead, Willie should be
  encouraged to donate autologous RBCs.
• These could be frozen for future use.
• Sometimes when one person in a family is negative
  for a high prevalence antigen, there are others
  in the family (i.e. siblings) who are also
  antigen negative. These individuals may be able
  to serve as Directed Donors.
• If the antiserum to type family members is not
  readily available, and the patients antibody is
  strong and you have an adequate quantity, you may
  screen potential donors with the patients serum
  and then have the donors who appear to be
  compatible tested for the antigen by a reference
  laboratory that does have the anti-serum.

64
Designated Donors

• The American Rare Donor program maintains a
  database of donors who are Rh null, Bombay
  phenotype, negative for high prevalence antigens,
  etc.
• Working with a reference laboratory, it may be
  possible to recruit a rare donor to make a
  donation for a specific recipient (liquid unit).
• When these rare donor units are not immediately
  transfused, they are frozen in glycerol if a
  liquid unit is not available, a frozen unit may
  be located.
• Frozen, deglycerolized units typically outdate 24
  hours after thawing.

65
The End

• How did you do?