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BLOOD TRANSFUSION

Sheilla Khonada
(406162056)

Pembimbing:
dr. Erniody, Sp.An, KIC, M.Kes

Kepaniteraan Klinik Ilmu Anestesiologi Rumah Sakit Husada


4 Desember 2017 – 6 Januari 2018
Fakultas Kedokteran Universitas Tarumanagara
Principles of • Patient with acute blood loss should receive effective
resuscitation (IV replacement fluids, O2 and other

Clinical
medication) immediately & the need for transfusion is
estimated thereafter.

Transfusion
• The patient’s hemoglobin (Hb) value, although important,
should NOT be the sole deciding factor in the decision to
transfuse blood  should be supported by the need to
Practice relieve clinical S&S and to prevent significant
morbidity/mortality.
• Clinicians should be aware of the risk of transfusion
transmissible infections.
• Transfusion should be prescribed only when the benefits
are likely to outweigh the risks.
• Clinicians should clearly record the REASON for ordering a
transfusion (clinical diagnosis).
• Trained staff should monitor a patient undergoing
transfusion and respond immediately there are signs of an
adverse effect.

Clinical Transfusion Practice (World Health Organization)


Safe Blood Blood for transfusion is considered safe when it is:
• Donated by a carefully selected, healthy donor
Criteria • Free from infections that could be harmful to the
recipient
• Processed by reliable methods of testing, component
production, storage and transportation
• Transfused only upon need and for the patient’s health
and wellbeing

Clinical Transfusion Practice (World Health Organization)


Blood Donor • General appearance: the prospective donor shall appear
to be in good physical and mental health.

Recruitment • Age: donors: between 18-60 years of age.


• Hemoglobin: Hb shall be >= 12.5 g/dL for males and >=
11.5 g/dL for females.
• Weight: min. 45 kg.
• Blood pressure: systolic and diastolic pressures normal
(systolic: 100‐140 mm Hg, diastolic: 60‐90 mm Hg is
recommended), WITHOUT the aid of anti‐hypertensive
medication.
• Temperature: oral temperature shall not exceed
37.5oC/99.5oF.
• Pulse: HR between 60-100 bpm and regular.
• Donation interval: the interval between blood donations
shall be 3 to 4 months.

Clinical Transfusion Practice (World Health Organization)


Blood • The donor should NOT be fasting before donation.
• If the last meal was taken >4 hours previously, the
Collection donor should be given something to eat and drink
before donation.
• Blood flowing into the bag is mixed with anticoagulant
in a ratio 1:7 (anticoagulant : blood).
• Total collection volume is from 405‐495 mL (usually, a
volume of 450 mL blood is donated)  approximately
12% of total blood volume, or 10.5 mL/kg body weight.

Clinical Transfusion Practice (World Health Organization)


Blood Components Clinically Available
• Red cell concentrate
Blood Products
• Plasma • Whole blood
• Platelet concentrate • Red cell concentrates
• Cryoprecipitate, prepared from fresh – Packed red cells (PRC)
frozen plasma; rich in Factor VIII and
– Leukocyte-reduced red cells
fibrinogen
– Washed red cells

A plasma derivative is made from human – Frozen red cells


plasma proteins prepared under • Plasma component derivatives
pharmaceutical manufacturing conditions,
such as: – Fresh-frozen plasma (FFP)
• Albumin – Immunoglobin preparations
• Coagulation factor concentrates – Cryoprecipitate
• Immunoglobulin – Platelets

Welsby IJ, Hathaway JA. Blood and Blood Component Therapy. In:
Longnecker DE, Brown DL, Newman MF, et al. Anesthesiology. 2nd Ed. New
York: McGraw-Hill Companies; 2012: 1438-53.
Indications
• To increase the oxygen capacity of blood by giving red cells.
• To restore the blood volume to maintain effective tissue

for Blood
perfusion.
• To replace platelets, coagulation factors and other plasma

Transfusion
proteins.

Blood may be needed in the following circumstances:


• Blood loss:
– Bleeding
– Trauma
• Inadequate production:
– Diseases such as thalassemia, leukaemia
Excessive destruction of cells:
– Disease
– Mechanical

Transfusion of blood and products should be undertaken only to treat a


condition that would lead to significant morbidly or mortality that
cannot be prevented or managed effectively by other means.
Clinical Transfusion Practice (World Health Organization)
Class of
Hemorrhagic
Shock

• Blood transfusion should be given in grade 3-4 hemorrhagic shock!


• Cross-matching and ABO rhesus typing requires approximately 90
minutes

Setyohadi B, Arsana PM, Suryanto A, et al. EIMED PAPDI:


Kegawatdaruratan Penyakit Dalam (Emergency in Internal
Medicine). Jakarta: Interna Publlishing ; 2011: 146-9.
Transfusion • One unit of whole blood/PRC  increase Hb by 1g/dL
in an adult or Hct by 3% (Hb of unit must be >75%).
Trigger • Perioperative transfusion: 8g/dL for patient

(Adults)
undergoing cardiovascular surgery, orthopedics and
acute GI bleeding.
• Chronic anemia: 7g/dL in adults (target of 7-9 g/dL)
• Acute blood loss: 30% of volume of blood.

• Blood volume in adult (man): 70 mL/kg


• Blood volume in adult (woman): 65 mL/kg
• Blood volume in pediatrics: depending on age

Clinical Transfusion Practice (World Health Organization)


Indications for • It’s unnecessary for most children to maintain
Blood Transfusion: hemoglobin levels of 8 g/dL or greater (a level
Pediatrics frequently desired for adults).
• The most important measures in the treatments of
• Hb <= 4 g/dL or Hct 12% acute hemorrhage  control the hemorrhage (if
blood loss is modest, restore circulating blood volume
• Hb 4-6 g/dL (or Hct 13-18%) if any of
following clinical features are present: & tissue perfusion with crystalloid or, less often,
– Clinical features of hypoxia colloid solutions).
– Acidosis (usually causes dyspnea) • If the estimated blood loss is >25% of the circulating
– Impaired consciousness blood volume (>15 mL/kg of an estimated 60 mL/kg
– Hyper-parasitemia (>20% malarial total estimated blood volume) and the patient’s
parasites) condition is unstable despite intravenous fluids, RBC
transfusions may be indicated; given with plasma
Restrictive transfusion trigger  Hb 7 transfusions at a 1:1 ratio of RBC : plasma volumes.
g/dL (target of 8.5-9.5 g/dL)

Nelson’s Textbook of Pediatrics, 26th Ed, Chapter 470: Red Blood Cell
Transfusions and Erythropoietin Therapy
Red Cell The laboratory performs:

Compatibility • ABO and RhD grouping on patient and donors.

Testing • Antibody screening on patient.


• Cross matching between serum of patient and red cells
of donor.

Clinical Transfusion Practice (World Health Organization)


Emergency • In emergency situations where bleeding occurs
profusely and cross-matching & ABO rhesus typing
Transfusion haven’t been done, the first blood bag given to the
patient should be of O+ blood group (Kemenkes 2010).
• While blood transfusion with the first bag is done,
cross-matching and rhesus typing is done in the
hospital (the next blood bag given should be of the
same blood group and compatible rhesus with the
patient).

Setyohadi B, Arsana PM, Suryanto A, et al. EIMED PAPDI:


Kegawatdaruratan Penyakit Dalam (Emergency in Internal
Medicine). Jakarta: Interna Publlishing ; 2011: 146-9.
Check Points for Blood bag should be checked for:

Signs of Deterioration • Any sign of hemolysis in the plasma indicating that the blood has
been contaminated, allowed to freeze or to warm.
in Blood and Plasma • Any sign of hemolysis on the line between the red cells and
plasma during storage.
• Any sign of contamination, such as a change of color in the red
cells, which often look darker/purple/ black when contaminated.
• Any clot, which may mean that the blood was not mixed
properly with the anticoagulant when it was collected or might
also indicate bacterial contamination due to the utilization of
citrate by proliferating bacteria.
• Any sign that there is a leak in the bag or that it has already been
opened.
The blood unit must be discarded if:
• It has been out of the refrigerator for longer than 30 minutes, or
• The seal is broken, or
• There is any sign of hemolysis, clotting or contamination.
Clinical Transfusion Practice (World Health Organization)
ABO Compatibility of Blood Products

ABO-Compatible Blood Products


Recipient Recipient
Blood Group Alloantibodies Packed Red
Whole Blood FFP Cryoprecipitate Platelets
Cells

A Anti-B A A or O A or AB Any Any

B Anti-A B B or O B or AB Any Any

AB Nil AB O, A, B, and AB AB Any Any

Anti-A and
O O O A, B, AB, or O Any Any
anti-B

Welsby IJ, Hathaway JA. Blood and Blood Component Therapy. In:
Longnecker DE, Brown DL, Newman MF, et al. Anesthesiology. 2nd Ed. New
York: McGraw-Hill Companies; 2012: 1438-53.
Whole Blood Red Cell Platelet Fresh Frozen
Concentrates Concentrates Plasma (FFP)
1 (PRBC) (PC)
2 3 4

Cryoprecipitated
anti-haemophilic
factor (Cryo-AHF)

Clinical Transfusion Practice (World Health Organization)


1 Whole Blood: Old vs New

New WB is metabolically more active than stored blood.


Older stored WBs develop lesions and accumulates
potentially injurious substances (increased toxicity).
Use of older stored blood is associated with a significantly
increased risk of death. Older blood possesses more risk of
causing:
- MODS & pneumonia (OR 2.26)
- Cardiac surgery death (OR 1.25)
- Trauma patients death (OR 1.18)
- Non-cardiac surgery & non-traumatic patients death (OR
1.12)
However, recent researches stated that there is no
therapeutical difference between old and new blood.

Wang D, Sun J, Solomon SB. Transfusion of older stored blood and risk of
death: a meta-analysis. Transfusion. 2012 Jun; 52(6): 10.
Content
WB PRBC Platelet FFP Cryoprecipitate
450 mL WB in 63 mL 150‐200 mL red blood Prepared from units Plasma prepared from WB, Prepared from FFP by
anticoagulant‐preservati cells from which most of whole blood that from the primary centrifugation collecting the precipitate
ve solution (7:1) of the plasma has have not been of WB into PRBC and plasma, or formed during
been removed (250 allowed to cool from a secondary centrifugation controlled thawing at
mL). below +20°C. of platelet rich plasma. +4°C & re‐suspending in
10‐20 mL plasma. It’s
stored at –25°C or colder
for up to 1 year after the
date of phlebotomy.
Hb will be approximately Hb concentration will A single donor unit The plasma is rapidly frozen to – Cryo‐AHF contains
1.2 g/dL and be approximately 20 consists of 50‐60 25°C or colder within 8 hours of about half the Factor VIII
haematocrit (Hct) g/100 mL (not less mL plasma that collection  contains normal and fibrinogen as a pack
35‐45% with no than 45 g per unit) and should contain ≥55 plasma levels of stable clotting of fresh WB: e.g. Factor
functional platelets or Hct 55‐75%. x 109 platelets. factors, albumin, Ig & Factor VIII VIII: 80‐100 IU/ pack;
labile coagulation at level of at least 70% of fibrinogen: 150‐300 mg/
factors (V and VIII) when normal fresh plasma. pack.
stored at +2°C to +6°C.

Clinical Transfusion Practice (World Health Organization)


Infection Risk
WB PRBC Platelet FFP Cryoprecipitate
Capable of transmitting Same as for whole Bacterial Capable of transmitting any As for plasma, but a
an agent present in cells blood. contamination affects agent present in cells or normal adult dose
or plasma which was about 1% of pooled plasma which was undetected involves at least 6 donor
undetected during units. by routine screening TTIs, exposures.
routine screening for including HIV, hepatitis B and
TTIs, i.e. HIV, hepatitis B C, syphilis and malaria.
& C, syphilis and malaria

Clinical Transfusion Practice (World Health Organization)


Storage
WB PRBC Platelet FFP Cryoprecipitate
Between +2°C and +6°C Same as for whole May be stored till 5 days Stored at –25°C or colder for At –25°C or colder for up
in an approved blood blood. at +20°C to +24°C (with up to 1 year. Before use, it to 1 year
bank refrigerator, fitted agitation). PCs require should be thawed in the blood
with a temperature continuous agitation transfusion center between
monitor and alarm. during storage, on a +30°C and +37°C.
platelet shaker and in an
incubator that maintains
the required storage
temperature.

Clinical Transfusion Practice (World Health Organization)


Dosage
WB PRBC Platelet (PC) FFP Cryoprecipitate
ADULT: ADULT: ADULT: ADULT: ADULT:
12-20 mL/kg Around 10-15 mL/kg, or 1 1 unit PC/10 kg 15 mL/kg 10-15 U
blood bag, reassess Hb (1 unit can increase 5,000-
post-transfusion 10,000 platelets)
PEDIATRIC: PEDIATRIC: CHILDREN < 30 KGS: PEDIATRIC PEDIATRIC:
Rarely used, 10-15 mL/kg, given 5-10 mL/kg 10-15 mL/kg Various, ranging from 2 mL of
usually using slowly (in 2-4 hours), cryoprecipitate per kg to 1 unit of
leukocyte-reduced reassess Hb post- LARGER CHILDREN: cryoprecipitate (15-20 mL) per 7
cells transfusion 3-4 pooled whole blood- kg
(prestoraged leukocyte- derived PC/1 apheresis unit
reduced RBCs)
1 unit of PRBC should 1 unit of apheresis platelet  1 unit will raise fibrinogen level
increase Hb by 1 g/dL & increase platelet count by 30- by 5-10 mg/dL (0.15 to 0.29 umol
Ht by 3% 60 x 109/L (adult), and 50-100 x per L), with the goal of
109/L (neonates). maintaining a fibrinogen level of
at least 100 mg/dL (2.94 umol/L).

Clinical Transfusion Practice (World Health Organization)


Administration
WB PRBC Platelet (PC) FFP Cryoprecipitate
• Must be ABO and Similar to WB • Platelet concentrates • Should be ABO compatible. • ABO compatible
RhD compatible administration after pooling should be • Infuse as soon as possible product should be
with the recipient. infused ASAP (risk of after thawing. used.
• Never add bacterial proliferation). • Labile coagulation factors • After thawing, infuse
medication to a A unit should be infused rapidly degrade; use within 6 as soon as possible.
unit of blood. over a period of <= 30 hours of thawing. • Must be transfused
• Complete minutes. Do not give • FFP may be beneficial if PT within 6 hours of
transfusion within platelet concentrates and/or partial thawing.
4 hours of prepared from RhD (+) thromboplastin time (PTT)
commence-ment. donors to an RhD (-) >1.5 times normal.
female with childbearing • FFP for volume expansion
potential. Give platelet carries a risk of infectious
concentrates that are disease transmission and
ABO compatible, other transfusion reactions
whenever possible. (e.g. allergic) that can be
avoided by using crystalloid
or colloid solutions.

Clinical Transfusion Practice (World Health Organization)


Indication
WB PRBC Platelet (PC) FFP Cryoprecipitate
• Red cell • Acute sickle cell crisis Treatment of bleeding due to: (Next Page) As an alternative to Factor VIII
replacement in (stroke prevention) • Thrombocytopenia. concentrate in the treatment of
acute blood • Acute blood loss • Platelet function defects. inherited deficiencies of:
loss with >1.500 mL or >30% of • Prevention of bleeding due • von Willebrand Factor (von
hypovolemia. blood volume to thrombocytopenia as in Willebrand’s disease).
• Exchange • Patients with bone marrow failure. • Factor VIII (haemophilia A).
transfusion. symptomatic anemia • As a source of fibrinogen in
• Patients with HF with acquired coagulopathies; e.g.
Hb <= 5 g/dL (each DIC.
bag should be • Can be used in isolated Factor
administered slowly XIII deficiency.
in 4 hours with prior • Ameliorate platelet dysfunction
furosemide 40 mg associated with uraemia.
given) • Used topically as a fibrin sealant.

Anemia symptoms: fatigue, weakness, dizziness, reduced exercise


tolerance, shortness of breath, changes in mental status, muscle
cramps, angina, or severe CHF.
Clinical Transfusion Practice (World Health Organization)
Contraindications
WB PRBC Platelet (PC) FFP Cryoprecipitate
Risk of volume • Idiopathic autoimmune
overload in thrombocytopenic purpura
patients with: (ITP).
• Chronic • Thrombotic
anemia. thrombocytopenic purpura
• Incipient (TTP).
cardiac failure. • Untreated DIC.
• Thrombocytopenia
associated with
septicemia, or in cases of
hypersplenism.

Clinical Transfusion Practice (World Health Organization)


Nelson’s Textbook of Pediatrics, 26th Ed, Chapter 470: Red Blood Cell
Transfusions and Erythropoietin Therapy
Sharma S, Sharma P, Tyler LN. Transfusion of Blood and Blood Products:
Indications and Complications. Am Fam Physician. 2011 Mar 15; 83(6): 719-
24.
Indications for • Active bleeding & thrombocyte count <50,000/uL, or any
Transfusion of thrombocyte functional defect (uremia, known storage
pool defect, or following cardiac bypass surgery)
Platelets in Adults • Active bleeding caused by myelosupression effect
(cytostatic drugs) & thrombocyte <10,000 uL (or
(Indonesia) <20,000/uL if with fever or minor bleeding)
• Intracranial bleeding or those who will undergo
neurosurgery with thrombocyte count <100,000/uL.

NOTE:
 In dengue fever thrombocytopenia, platelet transfusion
refers to management of dengue fever guideline.
 Avoid thrombocyte transfusion in: 1) thrombotic
thrombocytopenic purpura (TTP), 2) idiopathic
thrombocytopenic purpura (ITP), and 3) heparin-induced
thrombocytopenia.
Setyohadi B, Arsana PM, Suryanto A, et al. EIMED PAPDI:
Kegawatdaruratan Penyakit Dalam (Emergency in Internal
Medicine). Jakarta: Interna Publlishing ; 2011: 146-9.
Nelson’s Textbook of Pediatrics, 26th Ed, Chapter 470: Red Blood Cell
Transfusions and Erythropoietin Therapy
4 Fresh Frozen Plasma (FFP) Conditional indications:
• Massive blood transfusion.
• Acute DIC if there are coagulation
Definite indications: abnormalities (PT or aPTT > 1.5x normal
• Replacement of a single coagulation factor deficiency, values) and patient is bleeding.
where a specific or combined factor concentrate is • Liver disease, with abnormal coagulation
unavailable or contraindicated. and bleeding - prophylactic use to reduce
• Immediate reversal of warfarin effect where prothrombin time (PT) to 1.6‐1.8 x normal
prothrombin complex concentrate is unavailable. for liver biopsy.

• Thrombotic thrombocytopenic purpura. • Cardiopulmonary bypass surgery – use in


the presence of bleeding but where
• Inherited coagulation inhibitor deficiencies where
abnormal coagulation is not due to
specific concentrate is unavailable.
heparin. Routine perioperative use is not
• C1 esterase inhibitor deficiency where specific indicated.
concentrate is unavailable.
• Severe sepsis, particularly in neonates
(independent of DIC).
Clinical Transfusion Practice (World Health Organization) • Plasmapharesis.
The Blood Cold Chain from Collection to Transfusion

Clinical Transfusion Practice (World Health Organization)


Suggested Rates of Adults Rate
Transfusion Whole blood 150-200 mL/hour
PRBC 100-150 mL/hour
Transfusion rate depends on clinical Platelets/plasma 150-300 mL/hour
circumstances and may vary from 3‐5
mL/kg/hour to greatly increased rates for
individuals in hypovolemic shock. Paediatric Patients Rate
Whole blood/PRBC 2-5 mL/kg/hour
Platelets/plasma 1-2 mL/minute

Clinical Transfusion Practice (World Health Organization)


Duration Times for Transfusion
Time limits for transfusion
• There is a risk of bacterial proliferation or loss of function in blood products once they have been
removed from the correct storage conditions.
• Transfusion of a unit of blood should be completed within a maximum period of 4 hours after removal
from the blood fridge: discard the unit if this period is exceeded.
• If blood has been out of the blood bank refrigerator for more than 30 minutes and is not transfused, then
the unit must be returned to the laboratory, where it will be disposed of.

Blood products Start transfusion Complete transfusion


≤ 4 hours
Whole blood / PRBC Within 30 minutes of removing from refrigerator
Discard unit if this period is exceeded
Platelet concentrate Immediately Within 30 minutes
FFP As soon as possible Within 30 minutes
Cryoprecipitate As soon as possible Within 30 minutes

Clinical Transfusion Practice (World Health Organization)


Monitoring the Transfusion
• It is essential to take baseline observations and to ensure that the patient is monitored during the
transfusion  to detect any adverse event as early as possible.
• It’s essential to encourage the patient to notify a nurse or doctor immediately if he or she becomes
aware of any discomfort such as shivering, flushing, pain or shortness of breath or begins to feel
anxious.
• For each unit of blood transfused, monitor the patient:
 Before starting the transfusion (baseline observation).
 15 minutes after starting the transfusion.
 At least every hour during transfusion.
 Carry out a final set of observations 15 minutes after each unit has been transfused.

Clinical Transfusion Practice (World Health Organization)


Documentation of The Transfusion
• Monitor the patient before, during and on • Record in the patient’s notes:
completion of the transfusion.
– Type and volume of each unit transfused.
• At each of these stages, record the following
information on the patient’s chart: – Unique donation number of each unit transfused.

– Patient’s general appearance. – Blood group of each unit transfused.


– Temperature. – Time at which the transfusion of each unit
– Pulse. commenced.

– Blood pressure. – Signature of the individual responsible for


administration of the blood.
– Respiratory rate.
– Record the time of completion of the transfusion.
• Make note of the following:
– Time the transfusion started. – Record the details of transfusion reaction.

– Time the transfusion was completed. • Identify and respond immediately to any adverse
– Volume and type of blood products transfused. effect, by stopping the transfusion. Severe
– Unique donation number of all products transfused.
reactions most commonly present during the first 15
minutes of a transfusion.
– Any adverse effect.

Clinical Transfusion Practice (World Health Organization)


TRANSFUSION
ADVERSE
REACTIONS
Classification of Transfusion Reactions

Clinical Transfusion Practice (World Health Organization)


• Acute
Classification of – Immune-mediated
Transfusion •

Acute hemolytic transfusion reaction (AHTR)
Transfusion-related acute lung injury (TRALI)
Reactions • Febrile non-hemolytic transfusion reaction
• Urticarial reaction
• Anaphylactic
– Non Immune-mediated
• Non-immune hemolysis
• Bacterial contamination
• Volume overload
• Metabolic
• Embolic
• Delayed
– Immune-mediated
• Delayed hemolytic transfusion reaction (DHTR)
• Posttransfusion purpura
• Graft versus host disease
– Non immune-mediated
• Tranfusion-transmitted infection
• Iron overload
Welsby IJ, Hathaway JA. Blood and Blood Component Therapy. In:
Longnecker DE, Brown DL, Newman MF, et al. Anesthesiology. 2nd Ed. New
York: McGraw-Hill Companies; 2012: 1438-53.
Sahu S, Hemlata, Verma A. Adverse events related to
blood transfusion. Indian J Anaesth. 2014 Sep-Oct;
58(5): 543-51.
Sahu S, Hemlata, Verma A. Adverse events related to blood transfusion. Indian J Anaesth. 2014 Sep-Oct; 58(5): 543-51.
Tranfusion Hemolytic
transfusion
Bacterial
contamination TACO
Reactions reaction & septic shock

Anaphylactic Delayed
TRALI
reaction complications

• Delayed hemolytic transfusion


reaction
• Post-transfusion purpura
• Transfusion associated graft-
versus-host disease (TA-GVHD)
• Delayed complications:
transfusion transmitted
infections

Clinical Transfusion Practice (World Health Organization)


1. Hemolytic
• Result of mismatched blood transfusion (incompatible red cells) 
causing acute intravascular hemolysis (a small volume (5-10 mL) of
incompatible blood can cause severe reaction  larger volume
Transfusion increases the risk)

Reaction • Most common cause: ABO incompatible transfusion, causes are:


– Errors in blood request form
– Taking blood from the wrong patient into a pre-labeled sample tube
– Incorrect labeling of blood sample tube send to blood transfusion center
– Inadequate checking of blood label against patient’s identity
• Ab in patient’s plasma against other red cell antigens present on
transfused blood (Kidd, Kell, Duffy blood group system) can also
cause acute hemolysis
• SS
– In conscious patient  within minutes of transfusion (usually when
>10mL blood has been given)
– In unconscious/anesthetized patient, hypotension & uncontrollable
bleeding from transfusion site may be the only sign of incompatible
transfusion
• It’s essential to monitor patient from commencement of transfusion
up to completion!

Clinical Transfusion Practice (World Health Organization)


2. Bacterial • May affect up to 0.4% of red cells & 1-2% of platelet
concentrates

contamination • Routes of contamination:

and septic shock – Bacteria from donor’s skin entering blood unit during collection
(usually staphylococci)
– Bacteremia present in blood donor during collection (Yersinia)
– Improper handling during blood processing
– Defect or damage to the blood bag
– Thawing FFP or cryoprecipitate in water-bath (often contaminated)
• Contaminants:
– Pseudomonas grows at +2oC to +6oC & can survive/multiply in
refrigerated red cell units
– Staphylococci grow in warmer conditions & able to proliferate in PCs
stored at +20oC to +24oC
• Signs/symptoms  appear rapidly after commencement, but
may delayed for a few hours. Severe reaction  sudden onset of
high fever, rigors, and hypotension
• Tx: Urgent supportive care + high dose IV AB
Clinical Transfusion Practice (World Health Organization)
3. Transfusion • Is acute pulmonary edema caused by left atrial

Associated
hypertension or volume overload occuring within 6
hours following a blood transfusion.
Circulatory • May occur when:
Overload (TACO) – Too much fluid is transfused
– Transfusion is given too rapidly
– Renal function is impaired
• Particularly likely to happen in patients with:
– Chronic severe anemia
– Underlying cardiovascular disease

Clinical Transfusion Practice (World Health Organization)


Clinical Transfusion Practice (World Health Organization)
4. Anaphylactic • Rare complication, but risk increased by rapid
transfusion (esp with FFP)  rare very severe
reaction anaphylaxis may be caused by IgA deficiency (may be
caused by any blood product)
• Cytokines in plasma may occasionally cause
bronchoconstriction & vasoconstriction in recipients
• Occurs within minutes of starting transfusion, is
characterized by:
– Cardiovascular collapse
– Respiratory distress
– No fever!
• Anaphylaxis is likely to be fatal if not managed rapidly
and aggressively.

Clinical Transfusion Practice (World Health Organization)


5. Transfusion Related Acute Lung
• Occurs in the first 6 hours following
Injury (TRALI)
transfusion in patients without signs
of previous left ventricle
hypertension.
• Usually is caused when donor plasma
contains Ab against patient’s
leukocytes
• SS:
– PE: Rapid failure of pulmo function
usually presents within 1-4 hours of
starting transfusion
– Chest X-ray: Diffuse opacity
• Tx: no spesific therapy, only intensive
respiratory & general support in ICU
6. Delayed 1. Delayed hemolytic transfusion reaction

complications of • SS (appearing 5-10 days after transfusion):

transfusion – Fever
– Anemia
– Jaundice
– (Occasionally) hemoglobinuria
Severe life-threatening delayed hemolytic transfusion
reactions with shock, renal failure, and DIC are rare.

Clinical Transfusion Practice (World Health Organization)


6. Delayed 2. Post-transfusion Purpura
• Rare but potentially fatal complication of PRC/Platelet, caused
complications of by Ab directed against platelet-specific antigens in recipient.

transfusion • Most commonly seen in multigravida female patients


• SS:
– Signs of bleeding
– Acute, severe thrombocytopenia 5-10 days after transfusion
(platelet count <100 x 109/L)
• Management (platelet < 50 x 109/L) (occult bleeding at 20 x 109/L)
– High dose corticosteroids
– High dose IV IG, 2g/kg or 0.4 g/kg for 5 days
– Plasma exchange
– Monitor patient’s platelet count
– If available, give platelet concentrates negative for platelet-spesific
antigen against which Abs are directed
– Unmatched platelet transfusion is generally ineffective, recovery of
platelet count occurs after 2-4 weeks

Clinical Transfusion Practice (World Health Organization)


6. Delayed 3. Transfusion associated graft-versus-host disease (TA-
GVHD)
complications of • Is usually a fatal condition, occuring in:

transfusion – Immunodeficient (bone marrow transplants)


– Immunocompetent patients transfused from individuals
with whom they have compatible HLA tissue type (usually
blood relatives, particularly 1st degree)
• SS (10-12 days after transfusion):
– Fever
– Skin rash and desquamation
– Diarrhea
– Hepatitis
– Pancytopenia
• Tx: Supportive (no specific therapy)
• Prevention: Don’t use 1st degree relatives as donors
(unless gamma irradiation of cellular blood components is
carried out to prevent proliferation of transfused
Clinical Transfusion Practice (World Health Organization)
lymphocytes)
6. Delayed 4. Delayed complications: transfusion transmitted

complications of
infections
• Infections of:
transfusion
– HIV, Hep B and C, syphilis (Treponema pallidum), malaria
– Cytomegalovirus (CMV)
– Other TTIs: Human parvovirus B19, brucellosis, Epstein-
Barr virus, toxoplasmosis, Chagas disease, infectious
mononucleosis, Lyme’s disease
• May occur days, weeks/months after transfusion  it’s
essential to record all transfusions accurately in
patient’s case notes & consider transfusion in the DD.

Clinical Transfusion Practice (World Health Organization)


Recognizing & Management of Acute Tranfusion
Reactions
Category 1: Mild Reactions

Signs Symptoms Possible Cause


Localized cutaneous: Pruritus Hypersensitivity (mild)
Urticaria
Rash

Immediate management of Category 1: Mild reactions


• Slow the transfusion
• Administer antihistamine IM
• If no clinical improvement within 30 minutes / if signs and symptoms worsen, treat as Category 2. If
improved, restart transfusion slowly.

Clinical Transfusion Practice (World Health Organization)


Recognizing & Management of Acute Tranfusion
Reactions
Category 2: Moderately severe reactions

Signs Symptoms Possible Cause


Flushing Anxiety Hypersensitivity
Urticaria Pruritus
Rigors Palpitations
Fever Mild dyspnea
Restlessness Headache
Tachycardia

Clinical Transfusion Practice (World Health Organization)


Recognizing & Management of Acute Tranfusion
Reactions
Immediate management of Category 2: Moderately severe reactions

• Stop the transfusion and keep IV line open with normal saline in another site.
• Return the blood unit with transfusion administration set, freshly collected urine and new blood
samples (1 clotted and 1 anticoagulated), drawn from a vein opposite to the transfusion site, to the
blood transfusion center for laboratory investigations.
• Administer antihistamine IM and oral or rectal antipyretic. Avoid aspirin in thrombocytopenic patients.
• Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. bronchospasm,
stridor).
• If clinical improvement occurs, restart transfusion slowly with new blood unit and observe carefully.
• If no clinical improvement within 15 minutes or if signs and symptoms worsen, treat as Category 3.
• Collect urine for next 24 hours for evidence of hemolysis and send for laboratory investigations

Clinical Transfusion Practice (World Health Organization)


Recognizing & Management of Acute Tranfusion
Reactions
Category 3: Life-threatening reactions

Signs Symptoms Possible Cause


Rigor Anxiety Acute intravascular haemolysis
Fever Chest pain (mismatched blood transfusion)

Restlessness Pain along transfusion line Bacterial contamination and septic


shock
Hypotension (fall of 20% in systolic Respiratory distress/shortness Fluid overload
BP)
Tachycardia (rise of 20% in heart Loin/back pain Anaphylaxis
rate)
Hemoglobinuria Headache Transfusion related lung injury (TRALI)
Unexplained bleeding (DIC) Dyspnea

Clinical Transfusion Practice (World Health Organization)


Recognizing & Management of Acute Tranfusion
Reactions
Immediate management of Category 3: Life-threatening reactions
• Stop the transfusion and keep IV line open with normal saline in another site.
• Infuse normal saline to maintain systolic BP.
• Maintain airway and give high flow oxygen by mask.
• Give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by slow intramuscular injection.
• Give IV corticosteroids and bronchodilators if there are anaphylactoid features.
• Give diuretic: e.g. furosemide 1 mg/kg IV or equivalent.
• Check a fresh urine specimen visually for signs of hemoglobinuria.
• Notify the superior or senior doctor attending the patient, and the blood center immediately.
• Send blood unit with transfusion set, fresh urine sample and new blood samples (1 clotted and 1 anticoagulated),
drawn from a vein opposite the infusion site, with the appropriate request form to the blood transfusion center for
investigation.
• Start a 24‐hour urine collection and record all intake and output. Maintain fluid balance chart.
Clinical Transfusion Practice (World Health Organization)
Recognizing & Management of Acute Tranfusion
Reactions
Immediate management of Category 3: Life-threatening reactions
• Assess for bleeding from puncture sites or wounds. If there is clinical or laboratory evidence of
• DIC, give platelets (adult: 4‐6 units) and either cryoprecipitate (adult: 12 units) or FFP (adult: 3 units).
• Reassess. If hypotensive:
– Give further saline.
– Give inotrope, if available.
• If urine output falls or there is laboratory evidence of acute renal failure (rising K+, urea, creatinin):
– Maintain fluid balance accurately.
– Give further diuretic: e.g. furosemide 1 mg/kg IV or equivalent.
– Consider dopamine infusion, if available.
– Seek expert help: the patient may need renal dialysis.
• If bacteremia is suspected (rigor, fever, collapse, no evidence of a hemolytic reaction), start a broad‐spectrum
antibiotic IV.
Clinical Transfusion Practice (World Health Organization)