Blood Components Therapy

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Blood Components Therapy

• Brian Poirier, M.D.
• University of California, Davis Medical Center

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Topics

• Whole Blood
• Packed Red Blood Cells
• Plasma
• Platelets
• Special Transfusions/Modifications

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Modern Hemotherapy

• Administer that component of blood that the
  patient needs to prevent morbidity or mortality.
• The need may be due to lack of production,
  increased destruction or blood loss.

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Whole Blood Donation
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Transfusion criteria for whole blood (Hct 40
if available)

• Overt bleeding with clinical signs of hypovolemia
• Exchange transfusion of a neonate (if RBCs
  reconstituted with FFP not available)

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Bristol, England, 1941
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Packed Red Blood Cells
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Transfuse red blood cells

• to increase oxygen-carrying capacity in anemic
  patients
• Do NOT transfuse red blood cells
• For volume expansion
• In place of a hematinic
• To enhance wound healing
• To improve general well-being

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RBC concentrates to raise Hgb level of
average-size adult 1g/dL
Anticoag/preservative Hct Flow rate Dating
CPDA-1 70-80 Slow 35 days
AS-5 (Optisol -mannitol) 45-59 Rapid 42 days
AS-3 (Nutricel -no mannitol) 45-59 Rapid 42 days
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RBC transfusion trigger 7 vs. 9.5 or 10 g/dL

• 7 g/dL is as effective as 10 g/dL in adults
• 9.5 g/dL or 10 g/dL in PICU patients without
  cardiovascular disease (similar morbidity and
  mortality)
• Hebert PC et al. A multicenter, randomized,
  controlled clinical trial of transfusion
  requirements in critical care. N Engl J Med
  1999340409-17.
• Lacroix J et al. Transfusion strategies for
  patients in pediatric intensive care units. N
  Engl J Med 20073651609-19.

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Properties of Stored RBCs

• Supernatant
• Citrate
• Potassium
• free hemoglobin
• pH low
• RBC
• 2,3 DPG low
• spherocytic change

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UCDMC Massive Transfusion Guideline (MTG) Pack

• 6 units of pRBC
• 3 FFP Jumbo (or 6 regular)
• 1 Plateletpheresis
• Kept thawed at 4C for up to 5 days

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Washed Red Cells

• All Plasma and 85 of White Blood Cells are
  removed by washing.

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Indications for Washed Red Cells

• Urticarial transfusion reaction to several
  consecutive red cells transfusions.
• Anaphylactoid reaction to packed red cell
  transfusion (suspect IgA antibodies in an IgA
  deficient patient).

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Frozen, Thawed Deglyceralized Red Cells

• White cells and plasma are removed from the
  product

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Indication for Frozen, Thawed Deglyceralized Red
Cells

• Predeposition of autologous blood for elective
  surgery to occur gt42 days after donation.
• Patient with rare or multiple antibodies that
  need antigenically rare blood from the local
  blood bank or the rare donor file.
• Patients with HLA antibodies where febrile
  reaction occurred with transfusion of washed red
  cells.
• History of anaphylaxis to packed red cells or
  washed red cells.

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Irradiated Blood Products

• Recommended dose is between 1,500 and 5,000 cGy.
• 3,000 rads destroy the spindle apparatus of the
  lymphocytes so that they cannot divide. No
  functional impairments develop in the cells
  including phagocytosis by granulocytes.
• Leukemic patients, all lymphoma patients,
  immature infants, children with neuroblastoma
  receive irradiated products

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Indications for Irradiated Blood Products
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Autologous Blood

• Encourage physicians to use this product.
• The patient cannot develop diseases from it.
• If multiple units will be needed the patient will
  be placed on iron therapy.
• Criteria for transfusion remain the same.

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Fresh Frozen Plasma
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Male Donors
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Plasma

• Contains all the coagulation factors, albumin and
  fibrinogen.
• FFP (and FP24) Stored at -18C for up to 1 year.
• Once thawed, must be used within 24 hours, or may
  be stored at 1-6C for 5 days (as thawed plasma).

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Plasma usual dose to increase clotting factor
levels is 15-20 mL/kg body weight
Component Volume
FFP (single donor) 180-250 mL
FP24 180-250 mL
Jumbo FFP (single donor) 400 mL
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Indications for Plasma

• Prolonged PT and/or PTT (³ 1.5x ULN or INR gt2) or
  coagulation factor assay 25 with active
  bleeding or impending surgery
• Bleeding with coagulopathy and specific
  concentrate unavailable
• Plasma exchange for TTP/HUS
• Emergency reversal of Coumadin (Warfarin) effect

(Adapted from NIH Consensus conference)
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Plasma Transfusion

• Do NOT transfuse plasma
• For volume expansion
• As a nutritional supplement
• Prophylactically following cardiopulmonary bypass

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Plasma for TTP

• ADAMTS13 is present in similar amounts in FFP,
  Cryo-poor plasma, and Plasma 24h and storage at
  1-6C for up to 5 days does not significantly
  diminish its activity, e.g., for TTP.
• Scott EA et al. Comparison and stability of
  ADAMTS13 activity in therapeutic plasma products.
  Transfusion 200747120-5.

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Properties of Stored Plasma

• Citrate Anticoagulant
• Coagulation Factors
• Degradation of V and VII with prolonged storage
  (4C), 10 7 days respectively

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Cryoprecipitate
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Cryoprecipitate unit (bag)

• Volume 10-25 mLIncreased levels of- Factor
  VIII (³ 100 U)- Fibrinogen (200-300 mg)- Von
  Willebrands factor- Factor XIII
• - ADAMTS13
• Usual dose 10 bags/adult
• N.B. once thawed, keep at room temp

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Indications for Cryoprecipitate

• No longer recommended for mild hemophilia A.
• It is better to use heat treated factor VIII
  since HIV is destroyed by heat.
• D.I.C
• Von Willebrands disease
• Massive intra-abdominal clotting in liver
  lacerations
• Fibrin glue (cryoprecipitate is mixed with
  thrombin and applied directly to blood vessels)

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Platelets
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PLATELET AGITATION AT ROOM TEMPARATURE
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Platelets

• A platelet pack contains 5.5 x 1010 platelets and
  can raise the platelet count 10,000 mm3
  maximally.
• A plateletpheresis contains 3 x 1011 platelets
  and can raise the platelet count 30,000 mm3.

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Properties of Stored Platelets

• Citrate
• Cytokines/Vasoactive Substances

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Indications for Platelets

• Prevention or arrest of bleeding in
  thrombocytopenic patients
• Maintain a platelet count 10,000 20,000 mm3 in
  medical cases
• Maintain a platelet count 50,000 100,000 mm3 in
  surgical cases
• GI bleeder who has taken aspirin

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Indications for Platelets

• Non-bleeding patient with count of lt10,000/mm3 or
  1x109/L
• Platelet count lt 50,000/mm3 or 5x109/L and
• - Bleeding due to thrombocytopenia and/or
• - Surgical/invasive procedure imminent
• Documented abnormal platelet function with
  bleeding or surgical/invasive procedure imminent

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Platelet transfusion

• Do NOT transfuse platelets
• To patients with immune thrombocytopenic purpura
  (unless there is life-threatening bleeding)
• Prophylactically following cardiopulmonary bypass

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ABO Compatible Blood Components

• Blood Compatible Compatible
• Type RBCs FFPs
• A A, O A, AB
• B B, O B, AB
• AB AB, A, B, O AB
• O O A, B, AB, O

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Editorial Platelet ABO matters. RM Kaufman
Transfusion 2009495-7.

• PLT recovery is not the only problem with
  ABO-incompatible PLTs
• In ABO minor-incompatible PLTs, anti-A/B is
  passively transfused and, rarely, causes acute
  hemolysis
• PLT ABO incompatibility major or minor should
  be avoided whenever possible

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ABO Compatibility Study

• Julmy F, Amman RA, Taleghani BM, et al.
  Transfusion efficacy of ABO major-mismatched
  platelets (PLTs) in children is inferior to that
  of ABO-identical PLTs. Transfusion 200949 21-33.

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Julmy F et al. (cont.)

• ABO major-mismatched PLTs, (e.g., A1 to O or B),
  result in lower 1 hr post counts (21 vs. 32)
• ABO major-mismatched PLTs more often unsuccessful
• Platelets expressing A1 on their surface are
  cleared in O or B recipients
• A2 PLTs, expressing no detectable A, were as
  successful as ABO identical PLTs

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Julmy et al. (cont.)

• Conclusions
• In children, ABO major-mismatched PLT
  transfusions result in inferior efficacy, except
  for A2 PLTs
• ABO minor-mismatched PLTs showed comparable
  efficacy to identical PLTs

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Other Products andSpecial Considerations
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Granulocyte Transfusions
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Granulocyte Transfusions

• Severely neutropenic patients (Absolute
  Neutrophil count lt500/mm3) with sepsis
  (especially if Gram negative bacteria)
• - Unresponsive to 24-48 hrs. of appropriate
  antibiotics
• - Reasonable chance of marrow recovery soon
• - Progressive cellulitis
• Neonatal sepsis with transient granulocytopenia

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Leukocyte-Depleted Components Advantages

• Sensitization to wbc
• Febrile reactions (and some TRALI)
• Risk of cell-associated viruses, e.g., CMV (and
  bacteria)
• ? Response to platelet transfusions

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No benefit of leukocyte reduction for
HIV-infected patients

• Specifically, there was no difference in
  survivalin HIV-1 related serious events, norin
  the rate of transfusion reactions.

Collier AC et al. Leukocyte-reduced red blood
cell transfusions in patients with anemia and
human immunodeficiency virus infection. The
Viral Activation Transfusion Study A randomized
controlled trial. JAMA 2001 2851592-1601.
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CMV seronegative (cellular) components

• Intrauterine transfusions.
• Premature infants (lt1200 g) born to CMV
  seronegative mothers.
• CMV seronegative transplant candidates receiving
  CMV negative tissues/organs.
• CMV seronegative pregnant women.
• CMV seronegative, HIV-infected patients.

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Alternatives to standard allogeneic transfusions

• Hemodilution
• Intraoperative autologous transfusion
• Perioperative blood salvage
• Lower transfusion trigger
• Pharmacologic therapies
• Pathogen inactivated components
• Red cell substitutes

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The ideal red cell substitute

• Delivers oxygen (and maybe enhances delivery)
• Does not transmit disease
• Does not have immunosuppresive effects
• Available in abundant supply
• Universally compatible

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Characteristics of HBOC(Hemoglobin-based Oxygen
Carriers)
Product PolyHeme Hemopure Hemospan
Company Northfield Biopure Sangart
Volume (mL) 500 250 250 or 500
Hb Conc 10 g/dL 13 g/dL 4.2 g/dL
Hb Mass (g) 50 30 10 or 20
P50 (mmHg) 26-32 38 6
Met Hb lt8.0 lt15.0 lt0.5
Tetramer 1.0 3.0 1.0
Shelf-life gt1 year 3 years gt1 year
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Blood substitutes increase risk of death

• 16 trials of hemoglobin-based blood substitutes
  3,711 patients
• 30 increase in risk of death
• 3 fold chance of heart attack
• Natanson C et al. JAMA May 21, 2008

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• Scientists take step toward converting A and B
  Red Blood Cells to Universal O
• Bacterial enzymes can remove A B antigens at
  room temperature in neutral pH B. fragilis
  enzyme removes B antigen
• E. meningosepticum enzyme targets A antigen
• Liu QP et al. Bacterial glycosidases for the
  production of universal red blood cells. Nat
  Biotechnol 2007251-11.

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Thank You!
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