Transfusion%20Medicine

1
Transfusion Medicine

• Cassandra D. Josephson, MD

2
Disclosure Information

• Bioarray/Immucor - consultant
• Octapharma consultant
• Biomet- consultant

3
American Board of Pediatrics Pediatric
Transfusion Medicine Objectives

• Collection and storage characteristics of blood
  products
• Type and cross match testing
• Indications for transfusion
• Selection of appropriate blood conponents
• Computation of dose, rate of delivery, modifying
  conditions
• Complications of blood and blood product
  transfusions

4
Collection and Storage Characteristics of Blood
Products
5
Anticoagulants and Blood Preservatives

• Citrate, phosphate, dextrose (CPD, CP2D, CPDA-1)
• Shelf life 21 days , volume 250 ml
• Shelf life 35 days usually yield Hct 70, volume
  250 ml
• Adsol (AS-1, AS-3, AS-5)
• Additive solution licensed in US (1980s) contains
  mannitol, phosphate buffer, adenine, NaCl and
  dextrose
• Increases red cell shelf life to 42 days
• Preserves metabolism of red cells with slower K
  leak
• Addition of 100 ml AS dilutes RBC so Hct 50 -
  60
• Volume usually 350 mls
• 10 ml/kg of CPDA-1 unit raises Hgb 2 gm/dL and
  AS raises Hgb 1.5 g/dL

6
Whole Blood

• Volume of 500 ml /- 10
• Final Hematocrit 35-40
• After 24 hours, platelet function is lost
• Factors V and VIII decrease to 5-30 by day 21
• Cytokines accumulate and contribute to
  WBC-related complications

7
Red Blood Cells
Cryopreserved
Liquid

• Glycerol is a cryoprotectant, allows for long
  term frozen storage of rare pRBCs (eg.frozen,40
  glycerol, store _at_ -65oC for 10
  yrs. )
• Glycerol washed away after thawing
• 90 leukoreduced
• Platelets and CMV destroyed
• Must be transfused within 24 hrs.
• Indicated for anemic pts with rare blood types or
  multiple alloantibodies

• Shelf-life/volume depends upon anticoagulant
  preservative solution
• After whole blood donation unit is spun down and
  pRBCs go to bottom of unit
• Platelet-rich plasma is removed (supernatant) and
  additive solution is added to pRBCs if necessary

8
Age of RBCs Storage Lesion

• During liquid preservation of pRBCs the following
  metabolic changes occur
• a. extracellular K concentration rises
• b. extracellular free Hgb rises
• c. intracellular 2,3 DPG falls and
  reaches zero by 14 days of storage
  and then returns to normal levels 24
  hours after transfusion
• d. intracellular pH falls

9
Age of RBCs

• Cardiac arrhythmia and neonatal deaths have
  occurred subsequent to transfusion of stored (35
  day old) RBC prompting recommendation to use
  younger RBC for transfusions of neonates lt 5 days
  old.
• Events above occurred with transfusion of large
  volume pRBC gt 20 ml/kg, stored in CPDA-1.
• K leak is slower with AS stored RBCs thus, many
  think that transfusion of gt 5 days old is safe
  for neonates, as long as the volumes are 10 -20
  ml/kg aliquots.

10
Platelets

• 1. Whole-blood derived platelets
  Platelet ConcentratesRandom Donor Platelets
  (RDP)
• 2. Apheresis platelets Single Donor
  Platelets (SDP)
• Both types are stored at room temperature for up
  to 5 days with constant
  agitation
• 1 units of SDP 6-8 units of RDPs
• 1 RDP unit 50 -60 ml
• 1 SDP unit 300 600 ml

11
Whole blood derived platelets Random Donor
Platelets (RDP)
Leukoreduction by filtration after product made
Stored at 22-24oC with agitation X 5 days
Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
200946
12
Platelet collection by apheresis
Single Donor Platelets (SDP)
Josephson photo 2007
3 X 1011 plts (104-106 WBC)
Leukoreduction performed during apheresis process
13
Major Plasma-Containing Products Transfused
Apheresis Platelet
Cryoprecipitate
Healthy platelets
Josephson photos 2007
14
Fresh Frozen Plasma (FFP) and F24 Plasma

• Production FFP frozen within 8hrs of
  collection at lt-18 o C from
  CPD, CP2D or CPDA-1 whole blood or frozen within
  6 hrs from ACD plasma
• F24 plasma frozen
  within 8 24 hrs after collection
• Viral testing only, no viral inactivation
• Volume 150 300 ml per unit
• Contents contains all factors
• 1 IU/ml of clotting
  factors (labile and nonlabile)
• Thaw FFP thaw _at_ 30-37 o C store _at_ 1-6 o C for
  24 hrs
• F24 Thaw _at_ 30 -37 o C store _at_
  1-6 o for 5 days
• Expiration FFP 12 MOS _at_ -18 oC or 7 yrs _at_ -65o
  C
• F24 12 mos. _at_ -18 oC

15
Pooling of single-donor FFP

• Pooling allows for
• Dilution effects
• for enveloped and non-enveloped viruses,
  anti-HLA/HNA antibodies, histamine, allergens
• Immune neutralization 
• Binding of antibody to antigen within the pool
• allows inactivation of viruses (e.g. HAV, HEV)
  and neutralization of antibodies (e.g.
  anti-HLA/HNA antibodies)
• Standardized content of clotting factors and
  inhibitors
• Counteracts donor-to-donor variability

Manufacturing plasma pool consists of 630-1,520
single-donor FFP units from U.S. donors
16
Cell Filtration (1 micron)
Removal of cells, cell debris, and associated
intracellular pathogens through filtration,
bioactive lipids/cell bound antibodies
Fresh frozen plasma
Octaplas
Retains factors essential to hemostasis
17
Cryoprecipitate

• Production Cold insoluble portion of plasma that
  remain after FFP has been allowed to thaw at
  1-6ºC. Separated from
  plasma and refrozen.
• Viral Testing no viral inactivation processes
• Volume 10 -20 mL (may need diluent if amount of
  plasma is less than
  15 mL)
• Contents 80-100 units factor VIII
  150-250 mg fibrinogen
• 80 units of von Willebrand Factor
  (40 -70 of the original
  amount in the unit) 40-60
  units of factor XIII (20
  -30 of the original amount)
  30-60 mg fibronectin
• Thaw 37oC waterbath store 6 hrs _at_ Room
  Temperature
• Pool 4 hours _at_ 20 -24oC
• Preparation Time 10 20 minutes

18
Granulocyte Collection

• Collected by apheresis techniques from volunteer
  donors.
• Transfuse within 6-10 hours of collection,
  without leukoreduction filter for optimal
  beneficial effect.
• WBCs should be stored at room temperature with as
  little agitation as possible.
• Donor WBC mobilization can be stimulated with
  dexamethasone alone or with dexamethasone plus
  G-CSF.
• Dex G-CSF donor stimulation can yield
  neutrophil collection ranges between 3 to 10 x
  1010 neutrophils.
• Ideal WBC product dose is 1 x 109 neutrophils/kg
  or 15 ml/kg.
• WBC transfusions with low or high neutrophil
  counts has not consistently been demonstrated to
  increase the survival rates of neutropenic septic
  neonates or children.

19
Plasma-Derived Factor Products

• Humate-P, Alphanate, Koate DVI, Activated
  prothrombin complex concentrates (FEIBA)
• Viral inactivation techniques are intended to
  eliminate potential replication of
  contaminating viruses
• Techniques include
• a. Physical heat, pressure,
  pasteurization, nanofiltration
• b. Chemical treatments solvent/detergent
  combinations to disrupt membrane of enveloped
  viruses (eg. HIV, HBV, HCV)
• These processes will not treat non-enveloped
  viruses such as parvovirus B19 and HAV.
• Indications, ½ life, dosing per
  Hemophilia lecture

20
Albumin
(plasma-derived product)

• Derived from donor plasma
• Prepared by cold alcohol fractionation
• Pasteurized by heating to 60º C for 10 hours
• destroys viruses
• 5 or 25 solution
• 5 is oncotically and osmotically equivalent to
  plasma
• Indications
• Hypovolemia with hypoproteinemia
• Thermal injury, nephrotic syndrome, shock
• Contraindications
• Long-term therapy for chronic or nutritional
  hypoalbuminemia

21
Intravenous Immunoglobulin
(plasma-derived product)

• Plasma-derived product that has undergone viral
  inactivation processes (S/D, heat) and the pooled
  plasma has been tested for infectious diseases
  (eg. HIV).
• Side effects rash, chills, headache, aseptic
  meningitis, hives, chest tightness, dizziness,
  weakness, sweating, vomiting

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Blood Component/Derivative Storage
Blood Component Storage Temperature Storage Duration Storage Conditions
Whole Blood 1-6ºC 35 days CPDA-1
Packed Red Blood Cells 1-6ºC 35 days 42 days CPDA-1 additive solution (AS)
Platelets (apheresis or whole blood derived) 22ºC 5 days Gas exchange/ constant agitation/ plasma
Frozen Plasma (FFP and F24) - 18ºC/thawed 1 year/24hrs. plasma frozen in 8 or 24 hrs
Cryoprecipitate - 18ºC/thawed 1 year/24hrs. precipitate frozen
Plasma-derived factor products 1-6ºC or 22ºC depending on manufacturer as per manufacturer Lyophilized and mixed with diluent
Modified table from Handbook of Pediatric
Transfusion Medicine, Hillyer, Strauss, Luban.
Elsevier Publishing, 200428, 31,35
23
Type and Crossmatch Testing

• Erythrocytes Routine pre-transfusion testing
  required.
• ABO is the only system that the reciprocal
  antibodies are present in the sera/plasma of most
  individuals with no previous exposure
• Platelets Testing of patients ABO type is
  necessary, but no cross matching is
  done unless patient is in an immune refractory
  state. For children, goal is to transfuse ABO
  type specific or compatible platelets due to
  their small plasma volume.
• Frozen Plasma/Cryo. ABO type is necessary, no
  cross matching
  performed. Goal to transfuse ABO type specific/
  compatible plasma.

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ABO Blood Group

• A or B antigens on RBCs - glycolipids

Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
200998
25
ABO Antibodies

• Anti-A and antiB can generally be detected in
  serum after the first few months of life.
• Antibody production reaches the adult level at
  5-10 years of age.
• IgM is the major class of antibody produced in
  group A and group B people small amounts of IgG
  are also present.
• IgG is the dominant class of antibody in group O
  people (anti-A,B), and is responsible for ABO HDN
• Both classes agglutinate RBCs best at room
  temperature or below, and activate complement at
  37C.

26
ABO Testing
Forward Group (Cells) Anti-A Anti-B Forward Group (Cells) Anti-A Anti-B Reverse Group (plasma) A1 cells B cells Reverse Group (plasma) A1 cells B cells Group
0 0 4 4 O
4 0 0 4 A
0 4 4 0 B
4 4 0 0 AB
Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
2009
27
Routine Rh (D) Pre-Transfusion Testing

• - The Rh (D) antigen is the most immunogenic RBC
  antigen
• Anti-D results from exposure through transfusion
  or pregnancy (miscarriage) to Rh(D)
• - Once exposed gt 80 of Rh(D) negative recipients
  will produce an alloantibody to Rh(D)

Relative Immunogenicity of Different Blood Group
Antigens
Martin, S. (1994). Fundamentals of Immunology for
Blood Bankers. In D. Harmening (Ed.), Modern
Blood Banking and Transfusion Practices (p.55).
Philadelphia, PA F.A. Davis Company
28
Direct Anti-globulin Testing

• DAT Patients RBCs are mixed with anti-human
  globulin IgG (Coombs reagent)
• The IgG reagent antibody binds to IgG antibody or
  complement (C3) that adhered to RBC surface
  resulting in RBC agglutination
• DAT can be positive in
• a. alloimmunization if donated red blood
  cells are coated with alloantibodies
• b. autoimmunization if the patients
  own red blood cells are coated with antibody.

29
Whats the DAT?

• (Direct Anti-globulin Test)

Complement (C3)
Anti-RBC Ab
C3
anti-IgG/ complement
C3
C3
C3
pos
neg
neg
Adapted from Transfusion Medicine and Hemostasis,
Hillyer, Shaz, Zimring, Abshire. Elsevier
Publishing 2009
30
Antibody Screening Indirect
Anti-globulin Testing (IAT)

• Indirect anti-globulin test is the screen in a
  type and screen order.
• Patients serum/plasma is mixed with RBCs of
  known specificity in the presence of Coombs
  reagent.
• A positive screen suggests a clinically
  significant IgG antibody is present in the
  patient that must be resolved prior to releasing
  pRBCs from the blood bank. This will likely
  delay routine transfusion or routine surgery.
• If necessary exceptional release of type
  specific and unscreened blood can be issued or if
  required more urgently emergency release (O -)
  pRBCs can be issued from the blood bank without
  any prior testing of the patient or crossmatching
  of the product with patient serum/plasma.

31
Red Blood Cell Membrane Antigens

• What antigens do we routinely identify on patient
  and recipient red blood cells?
• What does alloimmunization mean?
• What does phenotypic matching mean?

Blood Banking and Transfusion Medicine 2nd ed.
Hillyer, Silberstein, Ness, Anderson, Roback
p54 2007
32
Blood Typing, Screening, and Crossmatching

• Type and Screen Order should be placed when a
  patient may need a transfusion of pRBCs, but it
  is not immediately required
• Type and Crossmatch Order should be placed when
  an immediate pRBC transfusion is necessary.

33
Indications for Transfusion

• Plasma
• Cryoprecipitate
• Coagulation factor concentrates
• IvIg
• Therapeutic pheresis
• Irradiated blood and blood components

• Whole Blood
• Packed red blood cells
• Cryopreserved red cells
• Autologous erythrocytes
• Directed donors
• Platelets
• Granulocytes

34
Whole Blood Transfusion Indications

• Purpose simultaneous replacement of
  intravascular volume and RBCs
• Indications
• a. Neonatal exchange transfusion
  (eg. hyperbilirubinemia)
• b. Fresh whole blood for support of
  infants after cardiopulmonary bypass
  surgery
• c. Often used for autologous
  transfusion

35
RBC Exchange Transfusion in Neonates for
Hemolytic Disease of
the Newborn (HDN)
ABO, Rh, or other minor RBC antigens

• If ABO HDN is diagnosed then would select O RBCs
  with Rh matching of the recipient for exchange
  transfusion.
• The RBCs must to be leukoreduced, /- irradiated,
  not CMV negative, if infant is gt 1500 grams.
• The plasma used for whole-blood reconstitution
  should be compatible with patients ABO type (ie.
  A recipient A FFP or F24).
• The hematocrit goal should be 55-60 for the
  reconstituted whole blood.
• To calculate the double volume manual exchange
  transfusion volume weight of patient in kgs x
  80-100 ml/kg total blood volume.
• Never remove more than 15 of blood volume of
  infant when performing the manual exchange
  transfusion.
• If giving intrauterine transfusions to treat this
  irradiation of all cellular products is required
  to prevent transfusion-associated graft versus
  host disease.

36
RBC Exchange Transfusion in Neonates for
Hemolytic Disease of the Newborn
(HDN) ABO, Rh,
or other minor RBC antigens

• If RhD HDN is diagnosed then would select RhD
  negative RBCs for exchange transfusion that are
  ABO type specific or compatible with infant.
• The RBCs must to be leukoreduced, /- irradiated,
  not CMV negative if infant is gt 1500 gms.
• The plasma used for whole-blood reconstitution
  should be compatible with patients ABO type (ie.
  A recipient A FFP or F24).
• The hematocrit goal should be 55-60 for the
  reconstituted whole blood.
• To calculate the double volume manual exchange
  transfusion volume weight of patient in kgs x
  80-100 ml/kg total blood volume.
• Never remove more than 15 of blood volume of
  infant when performing the manual exchange
  transfusion.
• If giving intrauterine transfusions to treat this
  irradiation of all cellular products is required
  to prevent transfusion-associated graft versus
  host disease.

37
Packed Red Blood Cell Transfusion Indications
Indications 1. Improve oxygen carrying capacity
to maintain adequate Hgb and
relieve symptomatic anemia (eg. CHF)
2. Maintain adequate
pre-operative hgb gt 8 g/dL.
3. Chronic transfusion- sickle cell dz.,
thalassemia major, severe
hereditary spherocytosis, myelodysplasia,
etc.) Product pRBCs (Unit usually contains Hct
of 65 - 80) Dose Depends upon desired Hct,
rate of RBC destruction or blood loss.
Transfuse 5cc/kg , 10 cc/kg, or 15 cc/kg
Dose Hct(desired - actual) x total blood
volume (70-80cc/kg)
Hct pRBC unit Expected
post-transfusion Hgb without ongoing losses,
10 ml/kg of pRBC stored in AS raises Hgb
1.5 g/dL
38
Specialized Red Blood Cell Donation and
Indications

• Directed Donors
• Test requirements impossible for emergent
  transfusion
• Relative should not be used as blood component
  donors for potential HSCT recipeints one way HLA
  mismatch could result in rejection
• Recognize first time donors can exhibit higher
  rates of infectious disease markers (eg. HIV,
  HBV, HCV) than repeat volunteer donors

• Autologous
• Useful in older children for ortho surgery,
  scoliosis repair, marrow-donor harvest, or other
  conditions
• For patients with rare blood group types or with
  compatibility problems

39
Platelet Transfusion Indications

• With thrombocytopenia
• 1. Plt count 5 10,000/µL with failure of
  plt. production
• 2. Plt count lt 30,000/µL in neonates with
  failure of plt. production
• 3. Plt count lt 50,000/µL in stable
  premature infant with
• a. Active bleeding
• b. Before invasive procedure with
  failure of plt production
• 4. Plt ct. lt100,000/µL in sick premature
  infant with
• a. Active bleeding
• b. Before an invasive procedure in
  patient with DIC
• Without thrombocytopenia
• 1. Active bleeding with qualitative plt.
  defect.
• 2. Unexplained excessive bleeding in
  patient undergoing CPB
• 3. Patient undergoing ECMO with
• a. Plt count lt 100,000/µL
• b. Higher plt counts and bleeding

Technical Manual 17th ed. Roback, Combs,
Grossman, Hillyer, 2012
40
Platelet Refractory State

• Definition failure to obtain an adequate
  increase in
• platelet count following
  platelet transfusion
• Non-immune causes
• a. Active bleeding
• b. Fever, sepsis, DIC
• c. Splenomegaly
• d. Amphotericin, other anti-microbials
• Immune causes
• a. HLA antibodies
• b. Platelet specific allo- and
  auto-antibodies
• c. Drug dependent antibodies

Modified from Manno C. ASPHO Transfusion Medicine
slide set 2006
41
Identifying plt refractory patients a tool

• CCI (posttransfusion plt count -
  pretransfusion plt count) X (1.7)
• (Number of
  platelets transfused) X (10-11)
• 1.7 (m2) represents the body surface area of an
  average-size adult
• CCI should be 30-50,000
• CCI lt 7500 with a post-transfusion sample drawn
  within 15 - 60 minutes of infusion may indicate
  refractoriness

Corrected Count Increment Calculation
42
Identifying Platelet Refractory Patients Testing

• Platelet antibody test ELISA test to detect
  antibodies against HLA and platelet-specific
  antigens (special coag lab)
• Flow cytometric HLA antibody test cell-based or
  bead-based (HLA lab)
• Indirect antibody/crossmatch test patients
  plasma mixed with platelets from different donors
  and observed for agglutination of RBC indicator

43
Platelet refractory state prevention

• Trial to Reduce Alloimmunization to Platelets
  (TRAP) Trial found that reduced exposure to
  recipients of white cells in platelet
  transfusions is the most important factor in
  reducing HLA-antibody formation with subsequent
  platelet refractoriness.
• Exposure to HLA-antigens on WBC is more
  immunogenic than HLA-antigens on platelets

NEJM 1997
44
Treatment of Patient with Immune Platelet
Refractoriness
HLA Antibodies HLA-matched or x-match compatible platelets
Platelet Allo-antibodies Antigen-match or x-match compatible platelets
Auto-antibodies IvIg, steroids, splenectomy
Manno C. ASPHO Transfusion Medicine slide set 2006
45
Granulocyte Transfusion Indications

• Neonates and children with neutropenia or
  granulocyte dysfunction with bacterial sepsis and
  lack of responsiveness to standard antimicrobial
  therapy
  (neutrophil band count lt 3 x 109/L)
• Bacterial sepsis, no response to antibiotics,
  (neutrophil band count lt 5 x 109/L)
• Neutropenic neonates or children with fungal
  disease not responsive to standard therapy

46
FFP or F24 Transfusion Indications

• Congenital or acquired coagulation factor
  deficiency with active bleeding or prior to an
  invasive procedure when the specific concentrate
  is not available
• Massive blood transfusion with coagulopathy
• Multiple acquired coagulation defects (eg. liver
  disease and DIC)
• Deficiency of antithrombin III, protein C or
  protein S when a concentrate is not available
• Plasma exchange for thrombotic thrombocytopenic
  purpura (TTP)
• Rapid reversal of warfarin effect

47
Non-Indications for Frozen Plasma

• Volume expansion
• Nutrients
• Immunodeficiency (use fractionated Ig)
• Wound healing
• Reconstitution of RBCs (except for neonatal RBC
  exchange)

48
Cryoprecipitate Transfusion Indications

• Congenital or acquired hypofibrinogenemia
• Factor XIII deficiency (1unit/10-15kg q 2 wk)
• Topical hemostatic or adhesive agent (fibrin
  glue) combined with thrombin
• Wound or bone healing (fibronectin)
• Uremic bleeding unresponsive to dialysis or
  desmopressin (DDAVP)
• Hemophilia A vWD only when virus-inactivated
  concentrates are unavailable

49
Non-indications for Cryoprecipitate

• Deficiency of Factors II, V, VII, X or XI
• Hemophilia A (Factor VIII deficiency)
• Hemophilia B (Factor IX deficiency)
• vWD responsive to DDAVP
• Sole treatment of DIC
• Dont use for any deficiency in which
  viral-inactivated concentrate is available or in
  which the factor is not present in cryo.

50
Therapeutic Apheresis Indications

• Plasma exchange
  ABO
  incompatible HSCT
  Category II
  Autoimmune hemolytic anemia Cold/Warm
  Category III Aplastic Anemia
  pure red cell aplasia
  Category III Thrombotic
  thrombocytopenic purpura (TTP)
  Category I Pediatric
  autoimmune neuropsych. Disorders
  Category I associated
  with strep infection Sydenhams
  chorea Severe PANDAS, severe SC
  
  Sepsis
  
  Category III
• Leukapheresis Hyperleukocytosis
  
  Leukostasis
  
  Category I Prophylaxis
  
  Category III
  
• Erythrocyte exchange transfusion
  Sickle cell disease
  
  Category I
  Life and organ
  
  Category II
  Prevention of iron overload
  Category II
  

Szczepiorkowski ZM et al. J Clin Apheresis
25(3)83-177 2010
51
Intravenous
Immunoglobulin (plasma-derived
product)

• Indications
• - Primary immunodeficiency disorders (eg.
  Severe combined immunodeficiency, agamm
  aglobulinemia, common variable immune
  deficiency, ataxia telangiectasia, etc.)
• - Kawasaki disease
• - ITP with hemorrhage
• - Guillain-Barre syndrome with ascending
  paralysis
• - Post-bone marrow transplant

Modified from Manno C. ASPHO Transfusion Medicine
slide set 2006
52
Selection of Appropriate Blood Products and
Special Processing
53
Irradiation

• Dose 25 Gy
• Prevents TA-GVHD in patients at risk by rendering
  long-lived T cells that are in product incapable
  of proliferating
• Blood from relatives should be irradiated

Josephson photo 2007
Modified from Manno C. ASPHO Transfusion Medicine
slide set 2006
54
Transfusion Associated Graft
versus Host Disease

• Immunocompromised patients cannot effectively
  eliminate donor lymphocytes
• Rarely, immunocompetent patients do not see
  closely HLA-matched donor lymphocytes as foreign
• Donor T-cells proliferate, attack host (marrow
  also unlike GvHD) - gt90 fatal
• Completely eliminated by 25 Gy g-irradiation of
  units prior to transfusion

55
Indications for g-irradiation
Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing 2009
56
Leukoreduction
To mitigate/prevent

• Febrile non-hemolytic transfusion reactions
• Transfusion-transmitted CMV
• HLA-alloimmunization

Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
2009
57
Washing

• Why wash?
• remove plasma proteins that cause allergic
  reactions
• remove high levels of extracellular K from RBC

Manno C. ASPHO Transfusion Medicine slide set 2006
58
Washed RBC and Platelets

• RBC are washed only in
• normal saline solution (NSS)
• removes 99 of extracellular fluid (residual
  plasma)
• 20 of RBC mass may be lost
• must be transfused within 24 hours

• Platelets can be washed with NSS or buffered
  saline
• removes 95 of plasma and retains 90 platelets
• must be transfused within 4 hours

Manno C. ASPHO Transfusion Medicine slide set 2006
59
Selection of appropriate blood type

• Red Cell Alloantibody Patients selection of
  appropriate blood products
• Red Cell Autoantibody Appropriate selection of
  blood products

60
Racial distribution of several clinically-signific
ant RBC antigens
Manno C. ASPHO Transfusion Medicine slide set 2006
61
Alloantibodies Commonly Detected in Transfused
SCD Patients
Manno C. ASPHO Transfusion Medicine slide set 2006
62
Computation of Dose and Rate of Delivery
63
Pediatric Blood Dosing

• Know patients weight in kilograms
• pRBCs 5, 10, 15 ml/kg
• Platelet concentrate (RDP) 10 ml/kg
• If give 0.1-0.2 units/kg it will raise
  post-tx plt count by 50 100,000/µL in
  patient with hypoproliferative thrombocytopenia
  induced by chemotherapy.
• Platelet pheresis (SDP) 10 15 ml/kg
• 1/4
  pheresis neonates
  1/2 pheresis lt 15 kg
  1 pheresis gt 15 kg
• Frozen Plasma 10 ml/kg will raise factor levels
  15 20
• Cryoprecipitate 1-2 units/10 kg (unit 10
  -20mls) rise in
  fibrinogen of 60 -100 mg/dL

64
Manufacturing Aliquots
Josephson photos 2007
65
Complications of blood and blood product
transfusions

• Transfusion reactions acute and delayed
• etiology
• pathogenesis
• recognition
• management
• prevention
• Transfusion-transmitted disease

66
Complications of Transfusion
Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
2009
67
Methodologies to reduce adverse
reactions
Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
2009361
68
Processing for unusual transfusion requirements
Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
2009
69
Transfusion-related acute lung injury (TRALI)

• Leading cause of mortality secondary to
  transfusion reported to the FDA
• Non-cardiogenic pulmonary edema
• Indistinguishable from ARDS
• Dyspnea, tachycardia, cyanosis, infiltrates,
  fever, but NO cardiac decompensation
• Resolves with supportive Rx in 48-96 hrs
• Abs in donor plasma that agglutinate recipient
  neutrophils (inverse less often)
• multiparous women donors often implicated

Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
2009
70
Transfusion-Associated Circulatory Overload
(TACO)

• Expansion of intravascular volume
  post-transfusion leading to cardiac
  decompensation, pulmonary edema
• 0.1-1 of transfusions primarily in elderly,
  infants, pts with impaired cardiac function
• Headaches, chest tightness, agitation, dyspnea,
  orthopnea, cyanosis
• ?O2 sat, bilateral infiltrates
• ?fluids, diuretics, O2

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Hemolysis ?
No
YES
Acute
Delayed
Fever
No Fever

• FNHTR
• Bacterial contamination
• TRALI
• TA-GvHD

• Anaphylactic
• Medicated FNHTR
• Urticarial
• Hypotensive
• Bacterial
• Circulatory overload

Intravascular lysis
Extravascular lysis
IgM
IgG

• Non-immune
• Heating
• Solution added to RBCs

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Acute Hemolytic Transfusion Reaction Clinical
Evaluation
Transfusion Medicine and Hemostasis, Hillyer,
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Hemolytic transfusion reactions

• Usually Ab-mediated
• AHTR intravascular hemolysis IgM Ab
• ABO incompatibility (PP1, Pk, Vel, Lew, Jk)
• w/in 24 hours of tx (usually mins)
• DHTR extravascular hemolysis IgG Ab
• 1. Primary New Ab weeks post-tx
• 2. Anamnestic ? Ab titer gt 3 days post-tx
• -- Kidd, Duffy

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Clinical management

• 1. STOP TRANSFUSION keep IV access
• 2. Monitor vital signs, urine output
• 3. Evidence of a severe reaction?
• AHTR, septic shock, anaphylaxis
• 4. Perform nursing clerical check
• 5. Return product to BB with new samples

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Clinical management (cont)

• Hypotension
• Saline, Dopamine
• DIC
• Monitor PT, PTT, fibrinogen, FSP, platelet counts
• Heparin
• Transfuse as needed (FFP, platelets)
• Renal failure
• Monitor urine output
• Monitor BUN, creatinine, electrolytes
• Treat hypotension to prevent renal ischemia
• Furosemide
• Dialysis

Transfusion Medicine and Hemostasis, Hillyer,
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Bacterial contaminants
Transfusion Medicine and Hemostasis, Hillyer,
Shaz, Zimring, Abshire. Elsevier Publishing
2009336,337
77
Window Period Donations and HIV Risk
NAT
Manno C. ASPHO Transfusion Medicine slide set 2006
78
Current Estimated Residual Risk of other
Infectious Agents



Parvovirus 140,000
T. Cruzi 125-35,000
Malaria lt 11,000,000
Manno C. ASPHO Transfusion Medicine slide set
2006 Dodd RY. Current Opinions
Hematology, 2007 Hillyer CD, Shaz BH, Zimmring J,
Abshire TA, Transfusion Medicine and Hemostasis,
2008
79
Methods To Reduce the Window Period

• Genomic amplification testing (GAT) or nucleic
  acid testing (NAT)
• NAT is required in the US
• Detects viral DNA or RNA earlier than antibody
  testing
• Identification of infected donors 10-15 days
  after HIV exposure and 41-60 days after exposure
  to HCV

Manno C. ASPHO Transfusion Medicine slide set 2006
80
Estimated risk of collecting blood during the
infectious window period (repeat donors)
Agent Window Period Risk
Rate of Infectious
Donations HBV 59 days
1200,000 -488,000 HCV, plus NAT 10
days 11,935,000 HIV,
plus NAT 11 days
12,135,000
Adapted from Dodd R.Y., Notari, E.P., Stramer
S.L. Transfusion Vol 42. Aug. 2002
81
Infectious and Non-Infectious Serious Hazards of
Transfusion Therapy

• Pathogen transmissions and infections
• Parasites
• Bacteria
• Viruses (especially HIV, HBV, and HCV)
• Prions e.g. variant Creutzfeldt-Jakok disease
  (vCJD)
• Transfusion related complications1
• Allergic reactions
• Anaphylactoid and anaphylactic reactions
• Transfusion-related acute lung injury (TRALI)
• Haemolysis (anti-ABOs IgM and IgG, irregular
  antibodies)
• Alloimmunisation (e.g. anti-D, anti-K, anti-HLA,
  anti-HNA)
• Transfusion-associated circulatory overload
  (TACO)/fluid overload
• Reactions due to additives (e.g. citrate
  toxicity)
• 
  Severity is mild to fatal

Circular of Information Task Force.  Circular
of Information for the Use of Human Blood
and Blood Components. Rockville, MD AABB,
2009
82
Proven transfusion-relevant viruses
Virus Family Characteristics Appearance
HIV Retro EnvelopedRNA
HBV Hepadna EnvelopedDNA
HCV WNV Flavi EnvelopedRNA
CMV EBV Herpes EnvelopedDNA
HTLV-I/II Retro EnvelopedRNA
HAV Picorna Non-envelopedRNA
Parvovirus B19 Parvo Non-envelopedDNA
HEV Hepe Non-envelopedRNA
83
Assumed transfusion-relevant viruses
Proven pathogenic transmissible by blood or
organs
Virus Family Characteristics Appearance
CHIKV()/ Toga EnvelopedRNA
HHV-8 Herpes EnvelopedDNA NA
Dengue/ Flavi EnvelopedRNA
SARS-CoV? Corona EnvelopedRNA
Influenza A/H5N1/H1N1?/(Wild Bird Flu/Swine flu) Orthomyxo EnvelopedRNA
LCMV Arena EnvelopedRNA
SFV? Retro EnvelopedRNA NA
Transmission unlikely except in extreme cases of
viraemia (WHO).
84
Viruses capable of compromising blood safety
Proven highly pathogenic representing
bioterrorism
Virus Family Characteristics Appearance
Variola major(Smallpox) Pox EnvelopedDNA
Ebola virus(Viral haemorrhagic fever) Filo EnvelopedRNA
Marburg virus (Viral haemorrhagic fever) Filo EnvelopedRNA
Lassa virus (Viral haemorrhagic fever) Arena EnvelopedRNA
85
West Nile Virus

• In 2002, the 23 cases of WNV transmission through
  blood transfusion were described
• In 2004, WNV transmitted through organ donation
  (1), breast milk (1) and the placenta (1)
• Mandatory NAT testing introduced in 2003
• 2003 1.5/10,000
• 2004 0.4/10,000

NAT stopped 1000 donors from potentially
transmitting WNV
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Cytomegalovirus Safety

• CMV resides in WBC and is transmissible by blood
• 70-80 of blood donors in the southeastern U.S.
  are CMV
• Testing for presence of anti-CMV antibody is not
  part of routine donor screening
• Clinical manifestations in those at risk include
• Pneumonia
• Hepatitis
• Retinitis
• Multi-organ failure

Modified from Manno C. ASPHO Transfusion Medicine
slide set 2006
87
Cytomegalovirus Safety

• CMV safe
• Leukoreduced products are considered to be as
  safe as CMV seronegative
• Both are associated with significantly less CMV
  transmission than unscreened, untested products

88
Indications for CMV Safe Blood

• Infants (gt 1500 gm)
• Solid organ transplant patients
• BMT patients
• Other immunodeficiencies

89
Pathophysiology of Coagulopathy
in Trauma/Massive Transfusion

• Coagulopathy is secondary to
  
• a. DIC
• b. hypothermia
• c. dilution of coagulation factors/plts
• d. hypocalcemia
• e. acidosis
• Tissue factor generation and ultimately a
  DIC-like pattern with altered fibrinolysis
• Tissue hypoperfusion leads to activation of
  protein C and systemic anticoagulation

90
Thank You!!!
Josephson photos 2006
91
Recommended Reading

• Hillyer CD, Shaz BH, Zimmring J, Abshire TA.
  Transfusion Medicine and Hemostasis.
• Academic Press, San Diego, 2009.
• Hillyer CD, Luban N, Strauss RG (eds).
  Handbook of Pediatric Transfusion Medicine.
• Academic Press, San Diego, 2004
• Dodd RY. Current risk for transfusion-transmitte
  d infections. Current Opinions in
• Hematology. 2007
• Slichter SJ, Kaufman R, Assmann SF, McCullough
  J, Triuluzi D, Strauss RG, Gernsheimer TB,
• Ness PM, Brecher ME, Josephson CD, Konkle B,
  Woodson RD, Ortel T, Hillyer CD, Skerrett
• DL, McCrae K, Sloan SR, Uhl L, George JN,
  Buchannan G, Manno C, McFarland JG, Hess JR,
• Leissinger C, Granger S. Effects of Platelet
  Dose on Transfusion Outcomes (The PLADO
• TRIAL, A Transfusion Medicine/Hemostasis
  Clinical Trials Network Study). N Engl J Med
  
• 2010362600-13.

92
Recommended Reading

• Hillyer, CD, Josephson, CD, Blajchman MA, Vostal
  JG, Epstein JS, Goodman JL. Bacterial
  contamination of blood components risks,
  strategies, and regulation. Education Program in
  American Society of Hematology 575-892003.
• Josephson CD, Abshire TC. Plasma-derived
  products for haemophilia A, B, and von
  Willebrand Disease Clinical Use of Plasma and
  Plasma Fractions. Best Pract Res Clin Hematol
  20061935-49.
• Josephson CD, Mullis NC, Van Demark C, Hillyer
  CD. Significant number of apheresis-derived
  group O platelet units have high titer
  anti-A/A,B Implications for Transfusion Policy.
  Transfusion 200444805-08.
• Josephson CD. Neonatal and Pediatric Transfusion
  Practice. In Roback J. Technical Manual. 16th
  ed. Bethesda, AABB Press, 2008 23639-663.
• Josephson CD, Hillyer CD. Blood Components Used
  in Pediatric Medicine. In Hillyer CD, Luban N,
  Strauss RG (eds). Handbook of Pediatric
  Transfusion Medicine. Academic Press, San Diego,
  2004 pp.27-42.
• Szczepiorkowski ZM, Shaz BH, Bandarenko N,
  Winters JL. The New Appraoch to Assignment of
  ASFA Categories-Introduction to the Fourth
  Special Issue Clinical Applications of
  Therapeutic Apheresis. J Clin Apheresis 2010.