Apex: Transfusion

Erythrocytes contain ___________________ on their cell membranes (determines blood type)

Antigenic glycoproteins.

_________________ contains the opposite antibodies of erythrocytes

Plasma

If an antigen is expressed on the erythrocyte, then there _____________________ be an antibody against that specific antigen in the plasma

will NOT

If an antigen is NOT expressed on the erythrocyte, then there ________________ be an antibody against that specific antigen in the plasma

Will

The most clinically important antigens are:

the ABO and Rh systems

Name the following for Recipient Type O:
1) Recipient RBC Antigens
2) Recipient Plasma Antibodies
3) Campatibility with Donor Cells

1) None
2) Anti-A and Anti- B
3) O

Name the following for Recipient Type A:
1) Recipient RBC Antigens
2) Recipient Plasma Antibodies
3) Campatibility with Donor Cells

1) A
2) Anti-B
3) A, O

Name the following for Recipient Type B:
1) Recipient RBC Antigens
2) Recipient Plasma Antibodies
3) Campatibility with Donor Cells

1) B
2) Anti-A
3) B,O

Name the following for Recipient Type AB:
1) Recipient RBC Antigens
2) Recipient Plasma Antibodies
3) Campatibility with Donor Cells

1) A, B
2) None
3) A, B, AB, O

Name the following for Recipient Type Rh+:
1) Recipient RBC Antigens
2) Recipient Plasma Antibodies
3) Campatibility with Donor Cells

1) D
2) None
3) Rh + or Rh -

Name the following for Recipient Type Rh-:
1) Recipient RBC Antigens
2) Recipient Plasma Antibodies
3) Campatibility with Donor Cells

1) None
2) Anti-D if sensitized
3) Rh-

A person who is Rh - can be sensitized by exposure to ___________________ or __________________-

Rh + blood during transfusion or pregnancy

How can a Rh - mother become sensitized

A Rh- negative mother can be sensitized by her Rh positive fetus. Transfer occurs across the placenta, usually several days after delivery

The Rh- mother recieves ________________ the prevent sensitization

Rhogam

What occurs if the Rh - mother becomes sensitized

If the mother becomes sensitized and develops antibodies, a subsequent pregnancy with a Rh+ fetus may result in erythroblastosis fetalis

Name some other RBC antigen systems

Duffy
Lewis
Kell
M
N
P
(These are less antigenic

Erythrocyte universal donor

O negative

Plasma Universal donor

AB positive

Erythrocyte universal acceptor

AB positive

Plasma universal acceptor

O Negative

Running a blood type tests for:

ABO and RH-D antigens

How long does it take to run a blood type

5 minutes

With this test, recipient blood is mised with anti-A, Anti-B, and Anti Rh-D antibodies

Blood type test

There is a ___________% chance of incampatibility reaction after blood type testing

0.2%
(Specific units are not assigned to the pt)

A Blood Screening tests for

most clinically significant antibodies

how long does it take to run a blood screening

45 minutes

Recipient plasma is mixed with commercially prepared O RBCs that contain known antigens

Blood screen

With a blood screen, there is a ___________% chance of incompatibility reation after this test

0.06%
(Specific units are not assigned to the pt)

What does a blood crossmatch test for?

compatibility between recipient plasma and the actual blood unit to be transfused

How long does it take to run a blood crossmatch

45 minutes

Simulates tranfusion in a test tube

Blood crossmatch

With a blood crossmatch, there is a _______% chance of incompatibility reaction after this test

0.05%
(specific units are assigned to the pt)

In the setting of acute hemorrage, what is the recommended order of administering uncrossmatched blood (from most to least favorable options)

1) Type-Specific partially crossmatched blood
-tests for ABO compatibility as well as a few antibodies
2) Type-Specific uncrossmatched blood
-Tests for ABO compatibility only
3) Type O Netagive Blood
-This blood does not contain A, B or RH antigents and i

When can O+ be used for emergency transfusion?

Because 85% of the population is RH D Positive, O positive can be used for emergency transfusion if the pt is not a woman of child bearing age and has not recived a previous tranfusion

Components in Packed red blood cells

RBCs

Indications for packed red blood cells

RBC replacement (increased CaO2)

Key points about RBC

-Hgb> 10 g/dL: transfusion rarely required
- Hgb < 6 g/dL: transfusion often required
-Decision to transfuse is guided by pt factors
- Large transfusion - dilutional coagulopathy

Components in whole blood

-RBCs
-WBCs
- Plasma
-Platelet debris
-Fibrinogen

Indications for Whole Blood

-RBC replacement (increase CaO2)
- Blood volume replacement

Key points on whole blood

Rarely used in the OR

Components in Fresh frozen plasma

-All coagulation facotrs
-Fibrinogen
-Plasma proteins

Indications for FFP

-Coagulopathy (PT or PTT >1.5x control)
-Warfarin reversal ( acute need)
- Antithrombin III deficiency
- Massive transfusion
- DIC
- C1 esterase deficiency (heredity angioedema)

Key points about FFP

-Dose: warfarin reversal = 5-8 mL/kg
-Dose: Coagulopathy = 10-20 ml/kg (increase factor concentration by 20-30%, factor 7 has t1/2 3-6 hours)
-Complete infusion within 24 hrs of thawing

Components of platelets

Platelets

Indications for platelets:

1) Thrombocytopenia (<50,000/ uL):
-Invasive procedures, neuraxial blockade, or most surgeries
2) Thrombocytopenia (<100,000/uL):
-Eye and neurosurgery
3) Qualitative plt defect

Key points about platelets

1) Dose= 1 pack per 10 kg/body weight
2) stored at room temp for 5 days
-highest risk of bacterial contamination

Components of cryoprecipitate

- Fibrinogen
-factor 8
-Factor 13
-vWF

Indications for cryoprecipitate

1) fibrinogen deficiency (<80-100 mg/dl)
2) vWB disease
3) hemophilia

Key points about cryoprecipitate

1) Dose = 5 bag pool increase fibrinogen by 50 mg/dL
2) administer through a filter
3) complete infusion within 6 hours of thawing

Blood loss should be replaced with crystalloid and/or colloid sonutions until:

the risk of anemia is greater than the risk of transfusion

The 2006 ASA task force guidelines state transfusions are usually unnecessary if hbg is greater than ___________ g/dL, but should usually be administered if the hbg is less than __________-

10
6
(the decision to trasfuse when hbg is between 6-10 g/dL should be based on the pt's response to anemia)

Pts with significant CAD should be transfused when hct falls below ________%

28-30%

If a 70 kg pt has a hgb of 12 g/dL and acutely loses 1 L of blood, What is the new hbg value BEFORE resuscitation?

12 g/dL. Even though the pt has lost 1/5th of his blood volume, the amount of hbg per deciliter of blood has not changed
(if you resuscitate the pt with a crystalloid and/or colloid soultion and return him to a euvolemic state, his hemoglobin will drop as

Estimated blood volume of neonate: premature

90-100 ml/kg

Estimated blood volume neonate: full term

80-90 ml/kg

Estimated blood volume for infant

80 mL/kg

Estimated blood volume for adult

70 ml/kg

MABL calculation

MABL = EBV x (Starting Hgb - Target Hgb)/Starting Hgb

One unit of PRBC containes approximately ____________ mL with a hematocrit of ______%

300 mL
70%

Transfusion of one unit of PRBCs raises Hgb by _________ g/dL and Hct by _____%

1 g/dL
2-3%

Erythrocytes do not contain _____________, so they rely on ___________ to convert glucose to ATP

mitochondria
anaerobic metabolism
(this is beneficial, so the RBC does not consume the oxygen that it is supposed to deliver to the tissues)

Blood is stored at 1-6 degrees C to:

extend its lifespan by slowing the rate of glycolysis

Additives to blood that increase its shelf life

-citrate
-phosphate
- dextrose
-adenine
(CPDA)

______________ is an anticoagulant that inhibits calcium (factor IV). After transfusion of multiple units, this can cause hypocalcemia

citrate

______________ is a buffer that combats acidosis

phosphate

_____________ is the primary substrate for glycolysis

_Dextrose

______________ is a substrate that helps RBCs re-synthesize ATP. It extends storage time from 21-35 days

Adenine

Newer blood preservities (Adsol, Nutricel, and optisol) extend storage time to _________ days

42 days

List the physiochemical changes that occur during RBC storage (RBC storage lesion)

1) Decreased 2,3 DPG - shifts the oxyhemoglobin dissociation curve to the left (left = love = decreased O2 release)
2) Decreased ATP - shift to anaerobic metabolism
3) Decreased pH (increased lactic acid)
4) Increased postassium (caution in neonates and r

What is leukoreduction

-removes WBC's from RBC and platelets

Leukoreduction reduces the risk of:

HLA alloimmunization
Febrile nonhemolytic transfusion reactions
CMV transmission

What is "Washing" for component processing

-wasing the blood products with saline to remove any remaining plasma (and antigens) in the donor RBC's (RBC's antigens are not removed)

Washing prevents:

anaphylaxis in IgA deficient patients

What is irradiation of the blood product

This process exposes units to gamma radiation and this disrupts WBC DNA in the donor cells

What does Irradiation prevent

Prevents graft vs host disease in immunocompromised pts

What is graft vs host disease

a rare (devastating) event. Donor leukocytes attack recipient bone marrow, leading to pancytopenia, fever, hepatitis, and diarrhea. Gamma radiation destroys donor leukoctyes. Radiated blood is particularly useful in immunocompromised pts

Populations who benefit from irradiated cells:

leukemia
lymphoma
hematopoietic stem cell transplants
DiGeorge syndrome

List the viral complications that can be transmitted via blood products from most common to least:

1) Cytomegaloviris (1-3% of all transfusions)
2) CMV with leukoreduced products ( 0.023% of all transfusions)
3) Hepatitis B (1 in 366,500)
4) Hep C (1 in 1,657,700)
5) HIV (1 in 1,800,000)
6) Human T cell lymphotrophic viris (HTLV) (1 in 3,300,000)

Is bacterial contamination more likely with PRBC or platelets?

Platelets (1 in 15,000 vs 1 in 35,000 with RBC)

_________________ is the most common infection complication of transfusion

CMV (leukoreduction greatly reduces this risk, so immunocompromised pts should recieve leukoreduced blood)

In up to 85% of infections, hep C can progress to:

cirrhosis, hepatocellular carcinoma, liver failure and death

Why is bacterial contamination more common with platelets than PRBC or FFP

Plt are stored at room temp (bacterial contamination can lead to sepsis)

_______________ is perhaps the most devastating complication that results from traunsfusion

Hemolytic reaction

What is a hemolytic reaction

complement is activated in the recipient's blood and plasma antibodies attack the antigens present on the donor blood cell membranes

_______________ is the most lethal hemolytic reaction

ABO incompatibility

_______________, _______________, and ______________ are the most catastrophic complications of intravascular hemolysis

Renal failure, DIC, and hypotension

S/S of acute hemolytic reaction observed under anesthesia

-Hemoglobinuria (usually the presenting sign(
-Hypotension
-Bleeding

What s/s of acute hemolytic reaction are masked by anesthesia?

-fever
-chills
-chest pain
-dyspnea
-nausea
-flushing

What do you see renal failure (acute tubular necrosis) with acute hemolytic reaction?

-free hbg in the form of acid hematin precipitates inside the renal tubules. This cuases a mechanical obstruction
-Acidic urine increases precipitation

Why is DIC seen with acute hemolytic reaction

-erythrocyin is released from the RBC and it activates the intrinsic clotting cascade. This leads to uncontrolled fibrin formation and consumes the body's supply of platelets and factors I, II, V, and VII

Why do you see hemodynamic instability with an acute hemolytic reaction

-free hgb activates the kallikrein systen. The final product of this pathway is bradykinin - a potent vasodilator

Treatment for acute hemolytic reaction

1) Stop the transfusion
2) Maintain UO >75-100 mL/hr with:
-IV fluids
-Mannitol 12.5-25 g
-Furosemide 20-40 mg if IVF and mannitol fail to provide an adequate response
3) alkalinize the urine with sodium bicarbonate
4) Send urine and plasma hemoglobin sam

__________________ is a form of non-cardiogenic pulmonary edema that occurs following transfusion. It is the most common cause of transfusion related mortality in the united states

transfusion related actue lung injury (TRIAL)

Which populations are at higher risk for TRAIL:

1) Critically ill (highest risk)
2) Anyone susceptible to acute lung injury: sepsis, burns, or post CPB

What is TRAIL probably caused by?

Human leukocyte antigens (HLA) and neutrophil antibodies present in the donor plasma

Describe the pathophysiology behind TRALI

Donor antibodies - neutrophil activation in the lungs - endothelial injury - capillary leak - pulmonary edeam - impaired gas exchange - hypoxemia - acidosis - death

____________ and _____________ contain the highest concentration of neutrophil antibodies

FFP and platelets (higher risk of TRALI)

Where the blood producst come from also affects the risk of TRALI. These donor groups impart the highest risk:

1) multiparous women (highest risk)
2) history of blood transfusion
3) history of organ transplant

Diagnostic criteria for TRALI

1) Onset < 6 hours following transfusion
2) Bilateral infiltrates on frontal CXR
3) PaO2/FiO2<300 mmHg or SpO2 <90% on RA
4) normal pulmonary artery occlusion pressure (no left atrial HTN or volume overload)

Management of TRALI

Managment is supportive and uses a lung protective strategy:
-Maximaize PEEP
-Low TV
-Avoid overhydration

Indications for FFP

...