transfusion sarah lim

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1. Transfusion Medicine
2. • Blood components • Compatility Testing • Transfusion reactions
3. WHOLE BLOOD centrifuge pRBC PLATELET RICH PLASMA centrifuge PLATELET POOR PLASMA freeze FFP thaw CRYOPRECIPITATE PLATELETS
4. RBC • 250 to 300 ml volume per bag • Hct 70 to 80 % • 1 U should increase Hb by 1 – 1.5 g/dL • Most commonly used solution for storage: CPDA-1 o Citrate as an anticoagulant, phosphate as a buffer, dextrose as energy source, adenosine as a precursor for ATP • Increased storage time leads to: o Decreased 2,3 DPG → left shift in O2 dissociation curve o Increase in K
5. Platelets • 1 U generally contains 50 – 70 mL of plasma • Expected to increase platelet count by 5000 to 10 000 • Stored at 20 – 24 deg to preserve clotting function o risk of bacterial growth and contamination
6. FFP • Contains all plasma proteins and most clotting factors • Indications: o Treatment of isolated factor deficiencies, warfarin reversal, correction of coagulopathy associated with liver disease • 1 U generally increases level of each clotting factor by 2 – 3% in adults • Initial therapeutic dose: ~ 10 – 15 mL/kg
7. Cryoprecipitate • Created by controlled thaw of FFP • 1 plasma unit generates 10 – 20 mL of cryo • Contains: fibrinogen, vWF, factor 8, factor 13 • Single adult dose = 5 bags of cryo
8. Compatibility Testing • Includes ABO and RhD typing, antibody screening for IgG non-ABO antibodies, RBC crossmatch o Crossmatch mimics the transfusion: donor red cells are mixed with recipient serum • Non-ABO antibodies: Rh, Kidd, Kelly, Duffy, etc • Duration: 45 – 60 minutes o Longer if antibodies present • In emergency situation: Type O Rh-negative
9. Immune Mediated Transfusion Reactions • Febrile non-hemolytic • Allergic reactions o Acute hemolytic o Delayed hemolytic • TRALI • Transfusion associated GVHD • Posttransfusion purpura
10. Febrile Non-hemolytic Reaction • Pathophys: recipient alloimmunization to HLAs from donor WBC and release of leukocyte-derived cytokine • Presentation: within 4 hours of transfusion • Symptoms: fever, chills, rigors, anxiety, headache • Treatment: often self-limited, can be prevented or treated with anti-inflammatory or antipyretic medication
11. Acute Hemolytic Reaction • Pathophys: ABO incompatibility → IgM mediated antibody- antigen complexes → complement activation → hemolysis • Presentation: acutely • Symptoms: o Bradykinin release → fever, hypotension, hemodynamic instability o Histamine release → bronchospasm, urticaria, dyspnea, flushing, anxiety • Treatment: supportive, maintenance of adequate UOP to avoid renal failure associated with hematuria • Diagnosis: lab analysis of free Hb levels, low haptoglobin, increased bilirubin, direct antiglobulin (Coombs) test
12. Delayed Hemolytic Reaction • Pathophys: antibodies to RBC antigen such as Rh, Kell, Kidd, Duffy • Presentation: 3 – 10 days after transfusion • Symptoms: milder than AHTRs, mild fever, rash • Treatment: generally self limiting, hydration
13. Transfusion-related Acute Lung Injury • Pathophys: Donor antileukocyte or anti-HLA antibodies → damage to endothelial lining of lung capillaries → extravasation of WBCs and leakage • Presentation: within 6 hours of blood component therapy o Majority of cases due to platelets and FFP • Symptoms: non-cardiogenic pulmonary edema, acute bilateral infiltrates, hypoxemia (PaO2/FiO2 < 300, O2 sats < 90% on RA), no left atrial HTN • Treatment: supportive
14. Transfusion associated GVHD • Pathophys: donor lymphocytes grafted in recipient attack host cells they recognize as foreign • Presentation: 4 – 21 days after, but clinical suspicion should last up to 6 weeks • Symptoms: progress rapidly, fever, rash, liver dysfunction, diarrhea, pancytopenia • Treatment: high mortality. Best to prevent with irradiation and leukoreduction of blood components
15. Post-transfusion purpura • Pathophys: development of platelet alloantibodies that destroy recipient’s own platelets • Presentation: 5 – 10 days posttransfusion • Symptoms: severe thrombocytopenia, purpura • Treatment: intravenous IG, plasmapheresis
16. Nonimmune Mediated Transfusion Reactions • TACO
17. TACO • Pathophys: new or worsening hydrostatic pulmonary edema • Presentation: within 6 hours of transfusion • Symptoms: signs of volume overload, left atrial hypertension • Treatment: responds to diuretic therapy and afterload reduction
18. References • Miller. Basics of Anesthesia. 7th edition. • Barash. Clinical Anesthesia. 7th edition. • Morgan & Mikhail. Clinical Anesthesiology. 5th edition.