Transfusion Medicine Overview

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Transfusion Medicine Overview

• Brenda J. Grossman, MD, MPH
• Medical Director, Transfusion Medicine Services
• Saint Louis University Hospital

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Overview

• Blood Donation and Component Preparation
• Pretransfusion testing
• Direct Antiglobulin Testing
• Transfusion Reactions
• Transfusion-transmitted Diseaes

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Blood Component Units Processed and Transfused ,
2001
National Blood Donor Resource Center, 2003
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Overview of Transfusion Medicine Services at SLUH

• Blood Donation and Apheresis Service
• Whole Blood and Plateletpheresis collection
• Therapeutic Cytapheresis
• Therapeutic Plasmapheresis
• Peripheral Blood Stem Cell Collection
• Transfusion Therapy
• Therapeutic Phlebotomy
• Blood Bank
• Compatibility Testing
• Acquiring Special Products
• Modifying Products
• Distribution of Products for Transfusion

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Volunteer Blood Donor Eligibility

• Age 17 or older
• Typically 110 lbs
• In good health
• Temperature 37.5C (99.5F)
• Pulse 50-100
• Blood Pressure 180/100
• Hb/HCT 12.5 g/dl / 38
• No skin lesions or signs of IV drug use

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Volunteer Donations

• Medical History
• Mini physical exam
• Hb determination
• Phlebotomy
• Eat and Drink

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And if we are lucky..
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Blood Collection and Manufacturing
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Centrifugation
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Plasma/Red Cell Separation
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Red Blood Cells

• Composed of RBC with reduced amount of plasma
• Primary indicationrestore or maintain
  oxygen-carrying capacity to meet tissue demands
• O2 content (Hb x 1.39 x sat) (pO2 x
  0.003)
• O2 delivery is dependent on C.O., Hb conc. and
  oxygen demand therefore do not use Hb level as
  sole indicator for transfusion
• Assess clinical status before transfusion

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Red Blood Cells

• Composed of RBC with reduced amount of plasma
• Primary indicationrestore or maintain
  oxygen-carrying capacity to meet tissue demands)
• O2 delivery is dependent on C.O., Hb conc. and
  oxygen demand therefore do not use Hb level as
  sole indicator for transfusion
• Assess clinical status before transfusion

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Red Blood Cells

• Plasma removed (less than 30cc remain)
• CPD/CP2D- 21 day shelf life
• CPDA-1-35 day shelf life
• AS-42 day shelf life
• Hct 80
• Stored at 1-6C
• Transport at 1-10C
• 1 unit should increase Hb by 1g/dL

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Contraindications and Precautions with RBC and WB
transfusions

• WB transfusion for normovolemic anemia
• Volume expansion
• Non-Symptomatic anemia
• Chronic anemia
• Nutritional anemia

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RBC TransfusionsAdministration Issues

• 170-260 microns removes fibrin clots, coagulated
  protein and cellular debris accumulated during
  storage
• Initial volume of Red Blood Cells or Whole Blood
  should be transfused slowly (1 mL/kg/hour) to
  monitor the recipient for any untoward reactions
• Entire red blood cell component must be
  transfused within 4 hours.

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Administration of RBC Components

• Blood Warming
• Maintain RBC at 37C
• A unit returned to blood bank that is gt 10C may
  not be reissued
• Only normal (0.9 USP) saline may be administered
  with blood components

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RBC TransfusionsSpecial RBC components

• RBC, Leukocyte Reduced
• RBC, Washed
• RBC, Irradiated
• RBC, CMV seronegative

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Platelet Rich Plasma Separation
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Plasma/platelet separation
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Plasma

• Indications
• Active bleeding with a proven coagulopathy
• Congenital deficiency of Factor II, V, X or XIII
• Emergency reversal of Warfarin
• TTP/HUS replacement
• Contraindication
• Volume expander
• Protein Supplementation
• Factor replacement for which factor concentrates
  available

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Fresh Frozen Plasma (FFP)

• Plasma placed at -18º C within 8 hours if
  collected in CPD, CP2D, CPDA-1 or within 6 hours
  if collected in ACD
• Expiration date 1 year if frozen
• Expiration date 24 hours after thawing
• Contains stable and labile coagulation factors at
  1U/mL
• 1 unit should increase clotting factors by 2 in
  a 70kg person

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Plasma Frozen with 24 hours of collection

• Plasma placed at -18º C within 24 hours of
  collection
• Essentially equivalent to Fresh frozen plasma

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Random Donor Platelets

• Sometimes called platelet concentrates
• Separated from WB by differential centrifugation
• Stored at 20-24C/ continuous agitation
• 5 day shelf-life
• Administered in pools of 4-6 units (50mL/unit)
• ? 5.5 X1010 platelets per unit in at least 90 of
  units
• In absence of decrease platelet survival, a unit
  should raise 5000-10000/µL

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Plateletpheresis donation

• 1-2 products
• Takes 2 hours
• No aspirin for 36 hours

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Platelet, Pheresis

• Prepared by apheresis
• Stored at room temperature/ continuous agitation
• 5 day shelf-life
• Administered as one unit/dose (? 200 mL-400mL)
• ? 3 X 1011 platelets/unit in at least 90 of
  units
• In absence of decrease platelet survival, a unit
  should raise 30,000-50,000/µL

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Platelet Components
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Blood Bank Storage
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Blood Bank

• Compatibility testing
• ABO/Rh
• Screening
• Crossmatching
• Antibody identification

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Pretransfusion Testing

• ABO Group and Rh Type
• Forward patients RBC and reagent antiserum
• Reverse-patients serum and reagent A and B RBC
• Antibody Screen (IAT)
• Patients serum and reagent O RBCs (2 or 3)
• Crossmatch
• Patients serum and donor RBC
• Immediate Spin vs. complete crossmatch

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ABO Group

• Most significant blood group system in
  transfusion
• A, B, AB, O
• All are formed from precursor molecule with H
  antigen

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Rh Type

• Second most significant blood group system in
  transfusion
• 85 Caucasian population Rh /15 Rh-
• Most immunogenic blood group
• Antibodies always result of a previous pregnancy
  or transfusion with incompatible antigens- IgG
• -80 of D negative person who receive D-positive
  blood will form antibodies
• May causes HDN and AHTR

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Antibody Screen (IAT)
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Direct Antiglobulin Test (DAT)
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What causes a positive DAT ?

• Autoantibody to intrinsic RBC antigens
• Alloantibodies in recipient circulation to
  transfused cells
• Alloantibodies in donor plasma to recipients RBC
• Alloantibodies in maternal circulation which
  cross the placenta and coat fetal cells
• Antibodies against certain drugs which bind RBC
  membrane (e.g. Pencillin)

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What causes a positive DAT ?(Contd)

• Adsorbed proteins which attach to RBC modified by
  drugs (e.g. cephlasporin)
• Complement components bound to RBC after drugs
  (e.g. quindine)
• Non RBC immunoglobulins in hypergamma patients or
  after IVIG
• Antibodies produced by passenger lymphocytes in
  transplant organs and HPC

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What does a positive DAT mean?

• Positive DAT does not necessarily mean shortened
  RBC survival
• -DAT can detect 100-500 molecules of IgG/ red
  cell
• -Positive DAT without clinical problems occur in
  11000-114,000 blood donors and in 1-15 of
  hospital patients

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What does a positive DAT mean?

• -Immune-mediated hemolysis is the shortening of
  RBC survival by immune mechanisms
• -If marrow can compensate, it may not result in
  anemia
• -Blood bank must rely on other lab data to
  determne if hemolytic anemia is occurring- e.g
  Hb, Retic count, RBC morphology, bilirubin,
  haptoglobin, LD levels
• -Serologic findings suggest only whether
  hemolysis has an immune basis.

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Determing the cause of positive DAT

• Complement only
• In vitro complement activation
• Drug
• Paroxymal Cold Hemglobinuria
• Donath Landsteiner test
• Ig G alone or with complement
• Elution to determine pattern of reaction

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Defining the cause of a DAT with elution

• Positive eluate
• Autoantibody usually panagglutin
• Alloantibody- RBC Ag specific
• Negative Eluate
• Drug
• anti-A or anti-B (unless test with A or B cells)

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Transfusion issues with Warm Autoantibodies

• May be difficult to rule out underlying
  alloantibodies
• Transfusion may stimulate autoantibody and
  increasing hemolysis
• Transfusion may suppress compensatory
  erythropoiesis
• Transfusion should not be withheld solely for
  serological incompatibility
• Patient should be carefully monitored throughtout
  transfusion
• If antibody shows strong specificity and ongoing
  active hemolysis then blood lacking the antigen
  may be selected

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Irradiation

• To prevent GVHD
• Severely compromised patients
• Blood relatives
• HLA matched products
• All cellular or non-frozen products except stem
  cells

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CMV Safe Blood

• CMV is a ubiquitous virus
• 60 of population harbors virus
• If transplant recipient and donor are negative
  for the virus then blood components must be
  CMV-safe
• Leukoreduction
• CMV testing

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Transfusion Reactions
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Categories of Transfusion ReactionsAcute

• Immunologic
• Hemolytic
• Febrile
• Allergic
• Anaphylactic
• TRALI

• Non-immunologic
• Circulatory Overload
• Hemolytic
• Physical
• Bacterial contamination
• Air embolus
• Metabolic reaction

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Categories of Transfusion ReactionsDelayed (gt 24
hours)

• Immunologic
• Alloimmunization
• RBC
• HLA
• Hemolytic
• GVHD
• Post-transfusion Purpura
• Immunomodulation

• Non-immunologic
• Iron overload
• Viral infections
• HCV
• HBV
• HIV
• HTLV
• Other organisms
• Malaria, Chagas, Babesiosis, etc.

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Protocol for ALL acute transfusion reactions

• STOP THE TRANSFUSION immediately
• Maintain IV assess with 0.9 NaCl
• Check blood component for patient ID
• Notify Blood Bank(BB)
• Send blood sample and urine to BB
• Keep blood unit in case culture becomes necessary
• Support patient as necessary

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Most common cause of an acute hemolytic
transfusion reaction is Clerical Error- Be very
careful with your patient identification
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Transfusion-transmitted Diseases
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Current Risk of Transfusion-Transmitted Diseases
Stramer Arch Pathol Lab MedVol 131, May 2007
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Other Infectious Risk
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Blood Bank Distribution
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Transfusion Service
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Questions?