BLOOD TRANSFUSSION

PEDIATRIC HEMATO-ONCOLOGY DIVISION MEDICAL FACULTY SUMATERA UTARA UNIVERSITY

 BLOOD: - THE BIGGEST ORGAN (GIGANTIC ORGAN) - BIOLOGICAL MULTIANTIGENIC MATERIAL - CIRCULATING IN CARDIOVASCULER SYSTEM - CONSISTS OF : 1. CORPUSCULAR COMPONENT : - RED BLOOD CELLS LIVING MATERIAL - WHITE BLOOD CELLS MULTI ANTIGENIC - PLATELETS 2. NON CORPUSCULAR COMPONENT: - PLASMA : FLUID, ELECTROLYTE, PROTEIN (ALBUMIN, TRANSFERIN, E1 - GLOBULIN, E2GLOBULIN, F- GLOBULIN, IMUNOGLOBULIN, CLOTTING FACTORS )
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 BLOOD TRANSFUSSION: BLOOD TRANSFERING PROCESS FROM DONOR TO RECIPIENT } ORGAN TRANSPLANTATION CONSIDER OF: - BENEFIT AND RISK ASPECT - IMMUNOHEMATOLOGY OF TRANSFUSSION - INFORMED CONSENT OBTAINED TO EVERY NON EMERGENT TRANSFUSION GAVE BLOOD SAVE LIFE GLOBAL BLOOD SAFETY INITIATIVE WHO 1989: ANY TRANSFUSION WHICH IS NOT INDICATED IS CONTRAINDICATED

 PRINCIPLE EVERY BLOOD TRANSFUSSION CONSISTS OF MINIMAL ANTIGEN VARIATION AND OPTIMAL DOSES BLOOD COMPONENTS TRANSFUSSION MORE RATIONAL THAN WHOLE BLOOD THE GOAL OF TRANSFUSSION ACHIEVED IF : * GOOD MANUFACTURING PRACTICE: DONOR SELECTION, RECORDED, BLOOD SAMPLING, STORED, COMPONENT PROCESSING INCLUDE QUALITY CONTAINT * GOOD HOSPITAL PRACTICE: INDICATION , REQUESTED VOLUME, CARED, EVALUATE PATIENT BEFORE AND AFTER 4 TRANSFUSSION

PRETRANSFUSSION TESTS

BLOOD TUBE CLEAR LABELS

BLOOD GROUP

COOMBS TEST
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 PROBLEMS BLOOD TRANSFUSSION: 1. INDICATIONS 2. CONTRAINDICATIONS 3. DOSES 4. BENEFIT 5. SIDE EFFECTS BLOOD COMPONENTS TRANSFUSSION : - FIRST IN 1960 - FROM WHOLE BLOOD SEPARATES: RED BLOOD CELLS, GRANULOCYTE, PLATELETS, FRESH FROZEN PLASMA, CRYOPRECIPITATE, ALBUMIN
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1. RED BLOOD CELL COMPONENTS - 640 Ag, CONSISTS OF 20 BLOOD GROUPS SYSTEM: ABO, CDE, MNS, P, LEWIS, KELL, DUFFY, LUTHERAN, KIDD, DIEGO. - BLOOD GROUP SYSTEM : * ABO: BY LANDSTEINER (1901) A,B,AB,O BASED ON SURFACE Ag OF ERYTROCYTE GROUP A B AB O GENOTYPE A/A or A/O B/B or B/O A/B O/O NATURAL Ab (SERUM) ANTI- B ANTI- A ANTI A & ANTI B
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* RHESUS : - LANDSTEINER & WIENER (1940) - BASED ON: Ag D ON ERITROCYTE SURFACE - INDONESIA : s100% Rh + - SERUM: NATURAL ANTIBODY (-) FROM BIRTH

RED BLOOD CELLS COMPONENTS

1. A. FRESH WHOLE BLOOD - DOSE: 6 x BW (kg) x (Hb - USE <1 DAY SEVERE BLEEDING CAUSED BY TRAUMA OR SURGERY
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1.B. PACKED RED CELL (PRC) - DOSE: 4 x BW (kg) x (Hb (Ht 3/2 OF WHOLE BLOOD (Ht 70-80%) - CHILD & INFANT: 10 ml/kgBB/DAY - 1 UNIT PRC : 225-350 ml WITH Ht 55-65% DOSES OF PRC Hb (g/dL) 7-10 5-7 <5, HEART FAILURE(-) <5, HEART FAILURE(s) <5, HEART FAILURE(+)

PRC EVERY 3-4 HOURS 10 ml/kgBB 5 ml/kgBB 3ml/kgBB 3ml/kgBB + FUROSEMIDE EXCHANGE TRANSFUSSION
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1C. PACKED RED CELLS LOW PLATELETS 1D. WASHED RED CELLS
> 85% LEUCOCYTE ARE REMOVED, AS WELL AS 99% OF THE ORIGINAL PLASMA

1E. FROZEN WASHED PACKED RED CELLS 1F. IRRADIATION RED BLOOD CELLS

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INDICATIONS FOR RED BLOOD CELLTRANSFUSION PACKED RED BLOOD CELLS 1. INFANT LESS THAN 4 MONTHS OLD Hb < 13 g/dl IN NEONATES < 24 HOURS Hb < 13 g/dl AND SEVERE PULMONARY DISEASE, CYANOTIC HEART DISEASE OR HEART FAILURE ACUTE BLOOD LOSS > 10% OF TOTAL BLOOD VOL PHLEBOTOMY LOSSES OF >5-10% OF TOTAL BLOOD VOL Hb < 8 g/dl IN STABLE NEWBORN

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PACKED RED BLOOD CELLS 2. PATIENTS 4 MONTHS OF AGE SIGNIFICANT PREOPERATIVE OR POST OPERATIVE ANEMIA ACUTE BLOOD LOSS WITH HYPOVOLEMIA UNRESPONSIVE TO CRYSTALLOID OR COLLOID 3. CHRONIC CONGENITAL OR ACQUIRED ANEMIA UNRESPONSE TO MEDICAL THERAPY AND Hb < 8 g/dl AND SYMPTOM OF ANEMIA 4. CHRONIC TRANSFUSION THALASSEMIA, SICKLE CELL DISEASE
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WHOLE BLOOD (SELDOM USED) 1. 2. 3. MASSIVE TRANSFUSION OR ACUTE BLOOD LOSS , USUALLY ASSOCIATED WITH TRAUMA CARDIOVASCULAR BY PASS SURGERY EXTRACORPOREAL MEMBRANE OXYGENATION

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GUIDELINES PRC TRANSFUSION FOR ONCOLOGY PATIENT 1. 2. 3. 4. STABLE, ASYMPTOMATIC CHILD WITH Hb < 7g/dl AND LOW RETICULOCYTE COUNT SYMPTOMATIC ANEMIA AND Hb < 10 g/dl Hb < 8 g/dl IN PATIENT BEGINNING INDUCTION OR INTENSIFICATION COURSE OF CHEMOTHERAPY ACUTE BLOOD LOSS > 10% OF TOTAL BLOOD VOL, OR ONGOING LOSS AND Hb < 8 g/dl IN A CHILD UNABLE TO PRODUCE RED CELLS Hb < 7g/DL PRIOR TO GENERAL ANESTHESIA RECEIVING RADIATION THERAPY Hb > 10 g/dl
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5. 6.

2. PLATELETS TRANSFUSSION
INDICATIONS 1. PREMATURE OR SICK INFANTS - STABLE INFANT WITH PLATELET COUNT < 50x109 /L - DISTRESSED INFANT WITH PLATELET COUNT < 100x109 /L 2. CHILDREN - PLATELET COUNT < 10x109 /L , IF FEBRILE, INFECTED OR BLEEDING - PLATELET COUNT < 50x109 /L WITH ANTICIPATED INVASIVE PROCEDURE: - LUMBAR PUNCTURE - QUALITATIVE PLATELET DEFECT - SURGERY

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3. ONCOLOGY NON BLEEDING PATIENT WITH PLATELET COUNT < 10x109 /L INDUCTION CHEMOTHERAPY BRAIN TUMORS PLATELET COUNT MAINTAIN AT > 30x109 /L LUMBAR PUNCTURE WITH PLATELET COUNT < 3050x109 /L BLEEDING PATIENT WITH NORMAL COAGULATION STUDIES, PLATELET COUNT < 50x109 /L SURGICAL PROCEDURE WITH PLATELET COUNT < 100x109 /L INTRAMUSCULAR INJECTION , PLATELET COUNT < 20x109 /L
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DOSAGE
1 UNIT PLATELET /10kg INCREASED PLATELET 4050X109/L PHERESIS PLATELET HARVESTED FROM SINGLE DONOR , CONTAIN > 30x109/L PLATELET, EQUAL TO 6-8 UNITS OF RANDOM PLATELET THE VOLUME IS 250-300 ml

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3. GRANULOCYTE TRANSFUSSION
- FROM LEUCOPHERESIS, FILTER NYLON - ABO / Rh COMPATIBLE, HLA MATCHED - GAVE AS SOON AS POSSIBLE BECAUSE CIRCULATING HALF LIFE IS 6-10 HOURS , SLOW INFUSSION IN 2-4 HOURS - 1 UNIT : 1,0x1010 CELLS, IN ADDITION TO OTHER LEUCOCYTES, PLATELETS, AND 20-50 ml RBC - RESUSPENDED IN APPROXIMATELY 200-300 ml OF ANTICOAGULATED PLASMA
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INDICATIONS 1. NEONATAL BACTERIAL SEPSIS 2. BACTERIAL OR FUNGAL SEPSIS, CULTURE POSITIVE, UNRESPONSIVE TO ANTIMICROBIAL THERAPY, ANC< 100/ L DOSAGE 1 UNIT GRANULOCYTE ADMINISTEREDAT 150 ml/m2/HOUR UNITS ARE GIVEN DAILY UNTIL ANC >100/ L AND THE INFECTION IS RESOLVING
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4. PLASMA AND PLASMA PRODUCTS

WHOLE BLOOD FRESH PLASMA FRESH FROZEN PLASMA CRYOPRECIPITATE FVIII CONSENTRATE FIBRINOGEN VWF F XIII CRYOSUPERNATAN ALBUMIN PLASMAPHERESIS

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TYPE & INDICATION OF PLASMA PRODUCTS 1. FRESH FROZEN PLASMA - DOSES: 15-20 ml/kgBW FFP IN 1 HOUR - CONSISTS OF : - FACTORS II,V,VII,VIII,IX,X,XI - PROTEIN C, S AND ANTITHROMBIN III - ELECTROLYTES, ALBUMIN, IMMUNOGLOBULIN, PROTEIN COMPLEMENT - 1 BAG FFP : 200 UNITS F.VIII - SHOULD NOT BE USED IF COAGULOPATHY CAN BE CORRECTED WITH SPECIFIC TREATMENT : VIT K, CRYOPRECIPITATE, FACTOR CONCENTRATE
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2. CRYOPRECIPITATE
CONSISTS OF : FVIII, F.XIII, FIBRINOGEN, F.VON WILLEBRAND DOSAGE : 1 U/ 6 kg BW

3. ALBUMIN
INDICATION HIPOPROTEINEMIA - EXCHANGE PLASMA PROTEIN FLAME BURN - EXCHANGE PLASMA VOLUME
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INDICATIONS
FRESH FROZEN PLASMA 1. BLEEDING/INVASIVE PROCEDURE WITH CLOTTING FACTOR DEFICIENCY 2. TREATMENT OF ANTITHROMBIN III, PROTEIN C&S DEFICIENCY, OR F.XI DEFICIENCY (HEMOPHILIA C) 3. BLEEDING DURING MASSIVE TRANSFUSION CRYOPRECIPITATE 1. BLEEDING/INVASIVE PROCEDURE WITH F.VIII, F.XIII DEFICIENCY, VON WILLEBRAND DISEASE, HYPOFIBRINOGENEMIA 2. SUPPORTIVE TREATMENT OF DIC

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TRANSFUSSION REACTION 1. ALLERGIC REACTION

URTICARIA, WHEEZING, ANGIOEDEMATOUS REACTIONS ANAPHYLACTOID REACTION : DYSPNEA, PULMONARY/LARYNGEAL EDEMA, BRONCHASPASM TRANSFUSION RELATED ACUTE LUNG INJURY TREATMENT : STOP TRANSFUSION, ANTIHISTAMINE, CORTICOSTEROID, EPINEPHRINE. FEVER, CHILLS DURING TRANSFUSION TREATMENT : STOP TRANSFUSION, EVALUATE VITAL SIGN AND BLOOD PRODUCT, TREATING THE SYMPTOMS.

2. FEBRILE NON HEMOLYTIC REACTIONS

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3. ACUTE HEMOLYTIC TRANSFUSION REACTION

FEVER, CHILLS, URTICARIA, DYSPNEA, CHEST PAIN, ABDOMINAL OR LOWER BACK PAIN, TACHYCARDIA, SHOCK LAB: ANEMIA, DIC, HEMOGLOBINEMIA, HEMOGLOBINURIA, POSITIVE COOMBS` TEST TREATMENT : IMMEDIATE CESSATION OF TRANSFUSION, ADMINISTRATION OF FLUID, STEROID,MANITOL, AND MAINTAIN CARDIOVASCULAR STABILITY AND URINE OUTPUT

4. DELAYED TRANSFUSION REACTION

SYMPTOMS OCCUR IN 2-14 DAYS AFTER TRANSFUSION UNEXPLAINED FEVER, POSITIVE DIRECT COOMBS`TEST AND ANEMIA
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5. ALLOIMMUNIZATION 6. GRAFT VERSUS HOST DISEASE 7. MICROBIAL CONTAMINATION 1. VIRUS: - HEPATITIS B,C,D,E AND A - HIV - EBV - HTLV I / II - HERPES VIRUS - CMV - PARVO VIRUS 2. BACTERIA : - T. PALLIDUM - M. LEPRAE - S. TYPHOSA - BRUCELLA ABORTUS - RICKETTSIA RICKETSII

3. PARACYTES - P.VIVAX, MALARIAE, FALCIPARUM,OVALE -TRYPANOSOMA CRUZI -MICROFILARIAE -AFRICAN TRYPANOSOMIASIS -T. GONDII -BABESIA MICROTI -L. DONOVANI
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DRUG USED IN TREATMENT OF NON HEMOLYTIC TRANSFUSION REACTION

1 DIPHENHYDRAMI USE : TREATING PRURITUS AND RASH NE DOSE : 12.5-50 MG IV OVER 10-20 MIN (1 MG/KG/DOSE, MAX 50 MG) USE : SEVERE INFECTIONS: BRONCHOSPASM, 2 EPINEPHRINE HYPOTENSION, SHOCK (1:1000 AQUEOUS) DOSE : 0,01 ML/KG SQ (SINGLE DOSE MAX 1 MG). (1 MG/ML) REPEAT Q 15 MIN X 3-4 DOSES AS NEEDED 3 EPINEPHRINE USE : FOLLOWING STABILIZATION WITH (1:200 AQUEOUS) EPINEPHRINE (1,5 MG/0,3 ML) DOSE : 0,005 ML/KG SQ (MAX SINGLE DOSE 0,15 ML). REPEAT Q 8-12 H PRN
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FOR HYPOTENSIVE PATIENTS, A BOLUS 20 ML/KG OF NORMAL SALINE SHOULD BE ADMINISTERED SIMOULTANEOUSLY WITH EPINEPHRINE AND STEROIDS 5 NARCOTICS USE : SPECIFIC AND EFFECTIVE TREATMENT FOR RIGORS DOSE : 0,1 MG/KG MORPHINE IV (MAX DOSE 10 MG) 6 ACETAMINOPHEN USE : TO PREVENT OR REVERSE TEMPERATURE ELEVATIONS IN MILD TO MODERATE FEBRILE REACTIONS DOSE : 10-15 MG/KG PO (MAX DOSE 800 MG) 7 STEROIDS USE : IN MODERATE TO SEVERE REACTIONS : URTICARIA, FEVER, SHAKING, CHILLS, DIAPHORESIS, OR PALLOR DOSE : 1-2 MG/KG OF METHYLPREDNISOLONE (OR EQUIVALENT DOSE OF DEXAMETHASONE/ HYDROCORTISONE) 28 IV PUSH

4 FLUIDS

PREVENTION 1. BLOOD SCREENING: HBsAg ANTI HIV 1/2 SIFILIS ANTI HCV 2. BLOOD BAG IDENTITY A. RE-TEST ABO / Rh BLOOD GROUP B. LABEL ON BLOOD BAG AND EASY TO READ, CONSISTS OF : - NO. BLOOD BAG -BLOOD GROUP - BLOOD TYPE/ COMPONENT -SCREENING TEST - BLOOD VOL / COMPONENT - STORED TEMP. / EXPIRED DATE
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