RATIONAL USE OF BLOOD AND BLOOD COMPONENTS

PLATELET TRANSFUSION

อ นพ วโรจน จงกลวฒนา

CLINICAL GUIDELINE

แพทยเรยนรเกยวกบ Transfusion Therapy ไดอยางไร

KNOWLEDGE GAPS: Physician

Karp JK et al. Transfusion 2011;51:2470-79

KNOWLEDGE GAPS: Physician

• Education on transfusion indications and risks in medical school is minimal

• Undergraduate medical education curriculum consists of 1-2 hrs of didactic lecture for TM

• Physicians learn from their physician mentors…. who learned from their physician mentors.... who learned from their physician mentors…. who learned from their physician mentors….

• Practice is often by Tradition…Not evidence-based

Karp JK et al. Transfusion 2011;51:2470-79

VARIATION IN TRANSFUSION PRACTICE

CABG Surgery (1st time CABG) – STS institutions • RBC Transfusion Rate = 10-90% • FFP Transfusion Rate = 0-95% • Platelet Transfusion Rate = 0-90% Orthopedic Surgery (Total hip arthroplasty) • RBC Transfusion Rate = 7-71% Knowledge gap exists for best practice & appropriate blood use

Bennett-Guerrero E ;JAMA 2010;304(14):1568-75 Jans O, et al. Vox Sang 2011;100:374

OVERUTILIZATION

• Risk of Adverse Event ความเสยงตอการเกดปฏกรยา • Unnecessary Cost คาใชจายทสงขน โดยไมจาเปน • Blood Availability for those who need it

ไมมเลอดเหลอทจะใหแกผ ปวยทจาเปนจรงๆ

The Appropriate Use of Blood and Blood Components Physician Handbook 1st edition 2011

Replacement Therapy

Replace when there is an evidence /clinical of deficiency

ปญหาเลอดออกของผปวย ไมได เกดจากการขาดสวนประกอบของ

เลอดเสมอไป Blood products Indication for replacement

Red cell products Anemia, blood loss

Fresh frozen plasma Coagulopathy

Platelet products Thrombocytopenia

Cryoprecipitate AHF Hemophilia A

การใหเลอดเปนเพยงการเตมสงทผปวยขาด

PLATELETS

• Platelets are cytoplasmic fragments produced by megakaryocytes in the bone marrow

• Platelets are classified as cells • Platelets are discoid in shape • Platelets do not have nucleus • Average life span : 10 days • 70% in circulation, 30% in spleen

Platelet

• เกรดเลอดเปน cellular

components

• สเหมอน plasma อาจจะมส

แดงของ red cell ปนเปอน

บาง

• เมอนาสองกบแสง จะสามารถ

มองเหน swirling effect

WBD Platelet Products

PRP Technique Buffy Coat Technique

Plasma/Red Cells Level Buffy Coat

Buffy Coat Depleted Red Cell Concentrate

Platelet Poor Plasma

Platelet pool from buffy coated method

LPRC FFP

LPPC

Platelet content in each unit

• Platelet conc. – 7-10 x 1010 / unit – 4.0 x 1011 (pool 5 unit)

• Single Donor Platelet

– 3.0- 4.0 x 1011

• LPPC – 3.5 x 1011

Therapeutic doses

Basic requirements for Platelets storage

• Platelets should be stored at 22-24oC ( controlled temperature ): aging process slows down at 22-24 C as compare to 37 C

• Continuous gentle agitation must be maintained on a flat bed agitator

• pH should be above 6.2 • Plasma 50-60 mL is needed for storage 5 days storage

22 -24 C Continuous agitation

ไมควรนาไปเกบในต เยนทหอผ ปวย

ต เกบเกรดเลอด

เกบไดนาน 5 วน

Indications for Platelet Transfusions

Prevention and Treatment of hemorrhage patients

Thrombocytopenia or platelet function defects

Cause of thrombocytopenia should be established before a decision about platelet transfusion

Platelet transfusion: Indications

Bone marrow failure

Platelet function disorder

Massive blood transfusion

Cardiopulmonary bypass surgery

Disseminated intravascular coagulation

Ann Intern Med. 2015;162(3):205-213. doi:10.7326/M14-1589 Approximately 2.2 million platelet doses are transfused annually in the United States

2008 Apheresis 87%

The 2009 National Blood Collection and Utilization Survey Report

Platelet Transfusion: Indications

• Prophylactic: – Transfusing hospitalized adult patients with a

platelet count of 10 x 109 cells/L or less to reduce the risk for spontaneous bleeding

– patients having elective central venous catheter placement with a platelet count less than 20 x 109 cells/L.

– patients having elective diagnostic lumbar puncture with a platelet count less than 50 x 109 cells/L.

Ann Intern Med. 2015;162(3):205-213

Platelet Transfusion: Indications

• patients having major elective non-neuraxial surgery with a platelet count less than 50 x 109 cells/L.

• surgeries involving the central nervous system, platelets are conventionally transfused prophylactically for a pre-procedure platelet count less than 80 x 109 to 100 x 109 cells/L,

Ann Intern Med. 2015;162(3):205-213

ขอควรรเกยวกบเกรดเลอด

เปนทรพยากรทสาคญ และมจานวนไมเพยงพอ

เมอพรอมทจะให จงใหคนมารบทธนาคารเลอด เจาหนาทธนาคารเลอดจะรวม

หลายๆถง เปนถงเดยว

หลงจากรวมเปนถงเดยว ควรใหภายใน 30 – 60 นาท

ไมควรนาเขาไปเกบไวในตเยนทหอผปวย ขณะทรอเรม Transfusion

ควรใหหมดภายใน 30 – 60 นาท อาจจะใหไมตรง ABO ในกรณทไมม ตองใชชดใหเลอด (Transfusion set) ตามปรกต ไมควรใชรวมกบชดท

ให เมดเลอดแดง

Poor Response to Platelet Transfusion

• Platelet factors • Patient factors – nonimmune

– Majority of cases

• Patient factors – immune

Patient Factors – Immune

• HLA class I alloimmunization (most common) • Platelet-specific antigen alloimmunization • ABH alloimmunization • Autoantibodies • Drug-related antibodies

PAS

Primary ingredients

1. Citrate : To prevent activation of coagulation 2. Acetate : To serve as a substrate for oxidative

metabolism 3. Sodium chloride : For isotonicity and osmotic

strength 4. Phosphate : Stimulation of glycolysis and

maintainance of physiologic pH 5. Magnesium / Potassium : Decreases platelet

activation, improve morphology score and decrease lactate production

ADVANTAGES OF PAS

• Clinical advantages: – More Plasma for using in transfusion and

fractionation

– Standardize composition – Ability to control storage environment – Sterile, pathogen free – Decrease reactions by removal of plasma

• Less protein, fewer allergic reactions, • Lower ABO antibody titer • possibly TRALI ?

ALLERGIC REACTION

Fatal Shock after Transfusion of Platelets Contaminated

by Staphylococcus aureus

เมอเรองน เกดขนในโรงพยาบาลของคณ เกดขนกบผปวยทไดรบเลอดจากคณ

Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:

• ผชายอาย 60 ป ไดรบการวนจฉยเปน multiple myeloma รบไวในโรงพยาบาลดวยอาการ pancytopenia และ pneumonia.

• ผ ปวยไดรบยา melphalan และ prednisone นาน 3 สปดาห และ

มภาวะ severe global hypo-gammaglobulinemia.

• Empiric antibacterial chemotherapy with ciprofloxacin and tazobactam-piperacillin led to clinical improvement.

Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:

• At admission, the WBC count was 1100 cells/mm3 (lymphocyte count, 730 cells/mm3; monocyte count, 110 cells/mm3), and the platelet count was 26,000 platelets/mm3.

• Leukocyte-reduced platelets were transfused after the patient experienced a mild episode of hemoptysis. The unit of platelets was obtained by apheresis from a single donor 4.5 days before use.

Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:

• 20 minutes after the beginning of the transfusion, the patient developed chills, diarrhea, vomiting, tachycardia, and cardiovascular collapse.

• The transfusion was stopped immediately, after a total volume of 100 mL had been infused

• 4 hours later, the patient's temperature was 39.1°C, and severe hypotension, hypoxemia, and confusion occurred, necessitating intensive treatment.

Fatal Shock after Transfusion of Platelets Contaminated by Staphylococcus aureus:

• Gram staining of residual platelets from the transfusion bag revealed large numbers of gram-positive cocci in clusters. Cultures of samples of venous blood and residual platelets yielded S. aureus isolates

• The platelet donor was a healthy male volunteer who had undergone apheresis on several occasions. Nasal swabs showed S. aureus carriage. The result of a culture of an antecubital fossa swab specimen was negative.

คณจะอธบายใหญาตผ ปวยทราบอยางไรถงสาเหตการเสยชวต

Bacterial contamination of platelets UHCMC Cleveland 1991-2011 N=75

Transfusion Volume 54, Issue 3pt2, pages 857-862, 17 JUN 2013

PASSPORT Surveillance Cultures

• 4369 PC initially culture negative

– Re-tested after day 7 – 3 true positives: S. aureus , S. epidermidis,

S. veridans

• Residual risk: 686 per million PC (1 in ~1500) L. Dumont, BPAC, May 2008

TRALI HTR-non ABO

HTR-ABO Microbial infection

TACO Anaphylaxis Other

FY08 16 7 10 7 3 3 0

FY09 13 8 4 5 12 1 1

FY10 18 5 2 2 8 4 1

FY11 10 6 3 4 4 2 1

FY12 17 5 3 3 8 2 0

0

2

4

6

8

10

12

14

16

18

20

FY 08FY 09FY 10FY 11FY 12

สาเหตการตาย จากการไดรบเลอด ในสหรฐอเมรกา

Transfusion-related deaths 2010 to 2016 n=115

TACO = Transfusion associated circulatory Overload

Avoiding unnecessary transfusion

•Important strategy for reducing risks

•Supported in national patient blood management guidelines

•Three principles of patient blood management

– Optimise the patient’s blood levels before a surgical or medical intervention

– Lose less blood throughout the patient’s treatment

– Optimise recovery including tolerance of anaemia

THANK YOU!

V. CHONGKOLWATANA