Transfusion Medicinereviews.berlinpharm.com/20180303/Transfusion_Med.pdfTherapeutic Platelet...
Transcript of Transfusion Medicinereviews.berlinpharm.com/20180303/Transfusion_Med.pdfTherapeutic Platelet...
Transfusion Medicine
Mar 3, 2018
Objective
• รจก blood product
• ใช blood product อยางเหมาะสม
• Management of complication
WB
PRC PRP
FFP PC
CRP Cryo
WB = Whole blood
PRC = Pack Red Cell
PRP = Platelet-rich plasma
FFP = Fresh frozen plasma
PC = Platelet concentrate
CRP = Cryo-removed plasma,
FFP with cryo.-removed
Cryo. = Cryoprecipitate
1-6oC
(Fibrinogen, FVIII, FXIII, vWF)
Donor
WB
PRC PRP
FFP PC
CRP Cryo
WBC filter
1-6oC
Prestorage-filtered
blood products
≠ LPB
Leukocyte
Poor
Blood
Donor
ระหวางรอทหอผปวยขอใดหามเกบในตเยนเดดขาด
1.Whole blood
2.Pack red cell
3.Fresh frozen plasma
4.Platelet concentrate
Blood ComponentVol (ml) Storage Shelf life
WB 500 1-6oc 35 d [CPDA-1]
PRC 180-200 1-6oc 21[ACD,CPD], 35, 42 d [AS-1,-3,-5]
FFP 200-280 <-18oc 1 yr
PLT conc 50 20-24oc 5 days
Cryo. 10-15 <-18oc 1 yr
PLT dysfunction,
Coagulation factor decay
Plasma derivatives: FFP, Cryo.
• No medications added
• Return to blood bank if not use within 30 min
• Most adverse transfusion reactions occur in the first 15 min.
• Time of transfusion – not exceed 4 hr
• Rate in adult (good cardiac condition) : 200 - 300 mL/hr
• NOT for: volume expansion, protein (alb, glob) nutrient
ช 60 ป ถายด าแดง 1 วน
• Cirrhosis Child C, DM, HT
• BP 80/60, P 115, R 18
• Pale, PR – marron stool, NG – frank blood continuously
• Hb 8.1 g/dl, Hct 24.3%
NSS was loaded,
Blood transfusion?
1. PRC
2. WB
3. PFB
4. No transfusion
Liberal strategy : Keep Hb >9 g/dL
Restrictive strategy : Keep Hb >7 g/dL
Exclude : massive exsanguinating bleeding,
acute coronary syndrome, symptomatic
peripheral vasculopathy, stroke, TIA, recent
trauma or surgery, lower GI bleed
Survival
Days
Keep Hb>7
Keep Hb>9
ช 55 ป sepsis/pneumonia at ICU
• โรคเดม : DM,HTN,DLP
•BP 130/70, P 90, R 18
•On ventilator, FiO2 0.4
•O2 sat 96%
•Euvolemia, No bleeding
•Hb 8, Hct 24%(3 mo ago: Hct 39%)
Rx anemia
1. PRC
2. LPB
3. Erythropoietin
4. No transfusion
Keep Hb 7-9
Keep Hb 10-12
ญ 70 ป Hip Fracture Surgery
• U/D: HTN, DLP, coronary
artery disease 2 years
• Postop Day 2
• BP 130/70, P 90, R 16
• No anemic symptom, No
bleeding
• Hb 8.5, Hct 26%
(Preop: Hct 34%)
Rx anemia
1. PRC
2. PFB
3. Erythropoietin
4. No transfusion
Patients with cardiovascular disease or CVS risk
>50 years
Compare : Hb >10 vs. >8 g/dL or anemic symptom
No difference:
60-day death rate, walk ability
CAD, CHF, stroke, DVT
RBC Transfusion in Hemodynamically Stable Patients: CPG from AABB, NICE
• In adult and pediatric ICU patients (pt), transfusion (Tf) should be considered at Hb <7g/dl [recommendation]
• In postop surgical pt, Tf should be considered at Hb <8 g/dl or for symptoms (chest pain, orthostatic hypotension or tachycardia unresponsive to fluid resuscitation, or CHF) [recommendation]
• Not address preop. Tf because of expected operative blood loss
Ann Intern Med 2012;157:49-58
NICE guideline. 18 Nov 2015
RBC Transfusion in Hemodynamically Stable Patients: CPG from AABB, NICE
• Hospitalized, stable patients (pt): Hb 7-8
g/dl (recommendation)
• Hospitalized pt with preexisting
cardiovascular dis. and considering
transfusion for pt with symptom or Hb <8
g/dl (suggestion)Ann Intern Med 2012;157:49-58Ann Intern Med 2012;157:49-58
NICE guideline. 18 Nov 2015
ญ 29 ป เหนอย 2 สปดาห เดนไมไหว 2 วน
• BP 100/60, P 125, R 20
• Pale, dyspnea, dry lip, mild
jaundice, systolic ejection
murmur at Lt.2nd parasternal area gr.II
• Hb 3 g/dL, Hct 10%, MCV
125, DCT 4+; spherocyte 2+
• Na 140, K 4, Cl 96, HCO3 18
• G/M PRC: no compatible blood
Steroid IV, O2
Other Rx?
1. PRC
2. EPO
3. Rituximab
4. Wait and see
RBC Transfusion
• Symptomatic & supportive Rx for anemia.
• Anemia ≠ RBC transfusion
• Use only if no definitive Rx or significant
symptomatic anemia not able to wait for
effects of definitive Rx
ช 25 ป หนาวสนมากหลงไดรบเลอด
•HbH with CS dis ไดรบเลอดเฉพาะชวง
มไขไมสบาย มอาการ
หนาวสนมากทกคร ง
บางคร งมแนนหนาอก
หายใจล าบาก ความ
ดนต า
Best choice of rbc
1. PRC
2. LPB
3. Irradiated rbc
4. Washed rbc
5. Prestorage filtered
rbc
Red Blood Cell Components
Component Character Indications
PRC Lower vol; higher Hct
Red cell deficit
Leukocyte-reduced rbc
Good flow in AS-1
↓febrile reaction, ↓CMV,
↓EBV, ↓alloimmunization (prestorage filter ดกวาแต แพงกวา LPB)
Washed rbc plasma
depleted, use within 24 hr
↓severe allergic reactions,
↓anaphylaxis in IgA def
ญ 60 ป CLL• Rx: RFC regimen
(rituximab, fludarabine,
cyclophosphamide) x 4
cycles last 3 weeks ago
• Hb 6 g/dL, Hct 18%, Wbc
2,500, PLT 55,000, DCT
negative
Proper choice of rbc
1. PRC
2. PFB
3. Irradiated rbc
4. Washed rbc
5. Frozen rbc
Red Blood Cell Components
Component Character Indications
Washed rbc plasma
depleted, use within 24 hr
↓severe allergic reactions,
↓anaphylaxis in IgA def
Frozen rbc
[glycerol]Long-term
storage [10+y]
; plasma & wbc depletion
Rare donor unit storage;
autologous storage for postponed surgery
Irradiated rbc
25-30 Gy,
expired 28 d
after irradiation
↓TA-GVHD : neonate,
cong. immunodef, ATG,
donor =1o relative, stem
cell transplant, fludarabine
RBC Antigen & Plasma Antibody
O A
B AB
A
B AB
Anti-A
Anti-BAnti-B
Anti-A
Blood group O
Blood group ABBlood group B
Blood group A
ญ 60 ป TTP, Blood gr.AB, Rh-ve
•Plasmaphereis is
planned.
•FFP choice is
limited.
Proper choice?
1. FFP gr AB, Rh+ve
2. FFP gr A, Rh-ve
3. FFP gr B, Rh-ve
4. Choice 1.+ Rh
immune globulin
5. FFP gr A, Rh-ve,
+irradiated
RBC Antigen & Plasma Antibody
Rh+ Rh-
D
No Anti-D No Anti-D
Blood group Rh+ve Blood group Rh-ve
Rh system: Only RBC-containing components
(WB, PRC, PC, SDPs) need to be matched for the D-antigen.
ญ ๒๒ ป จ าเขยวทขา ๑ สปดาห
• มจดเลอดออก และจ าเขยวทขาสองขาง ประจ าเดอนปกต ไมกนยาใด ไมมไข
• BP 100/60, P 70, R 14
• Not pale, petechiae & ecchymoses at legs, others unremarkable
• Hb 13, Hct 39%, wbc ปกต, Plt 2,000 [0-1/OF, giant plt]
• Coagulogram – normal
Initial Rx
1. PLT conc [PC]
2. PC + steroid
3. Steroid
4. Steroid + IVIg
5. Steroid + IVIg +
PLT conc
Platelet Products
• WB donations Platelet concentrates
• Apheresis Single donor platelets (SDPs)
Platelet Products
Platelet conc Single Donor PLT
Platelets 5.5x1010 3x1011
One adult dose 6 donors 1 donor
cost less more
Indications Prophylactic, therapeutic
PLT alloantibody
[crossmatched plt] ,
neonatal alloimmunethrombocytopenia
Therapeutic Platelet Transfusion
• Low platelet ≠ Platelet transfusion
• Symptomatic & supportive Rx
• NOT definitive Rx (อยาลมแกสาเหตเกลดเลอดต า และเหตเลอดออกอนๆ เชน varice, arterial bleed)
• Consider in actively bleeding with PLT. <50,000/uL
or PLT. dysfunction
• Contraindication: TTP, HIT (heparin-induced
thrombocytopenia)
PLT Transfusion: CPG from AABB
• Hospitalized adult patients with therapy-induced hypoproliferative thrombocytopenia PLT <10,000 (strong recommendation; moderate-quality evidence)
• Elective central venous catheter placement PLT <20,000 (weak; low-quality)
• Elective diagnostic lumbar puncture PLT<50,000 (weak; very-low-quality)
Ann Interrn Med 2015;162:205-13
PLT Transfusion: CPG from AABB
• Major elective nonneuraxial surgery PLT <50,000 (weak; very-low-quality)
• PLT transfusion for cardiopulmonary bypass who exhibit perioperative bleeding with thrombocytopenia and/or evidence of PLT dysfunction (weak; very-low-quality)
• ICH in patient receiving antiplatelet therapy : cannot recommend for or against PLT transfusion (uncertain; very-low-quality)
Ann Interrn Med 2015;162:205-13
ABO group selection for PLT transfusion
ABO of
Recipient
ABO of Donor (in order of preference)
O O, A, B, AB
A A, AB (O after plasma removal and
resuspension in additive solutions or
negative for high-titer anti-A/A,B)
B B, AB (O after plasma removal and
resuspension in additive solutions or
negative for high-titer anti-A/A,B)
AB AB (A, B, O after plasma removal and
resuspension in additive solutions or
negative for high-titer anti-A/A,B)
Blood Transfus 2009;7:132-50
PLT Refractoriness
Non-immune
• Fever
• Sepsis
• Drug eg,amphotericin
• Active bleeding
• Splenomegaly
• DIC
• Venoocclusive dis
Immune
• Anti-HLA antibodies
• Anti-HPA antibodies
• ABO mismatch
• Autoantibodies
• Drug eg, heparin
PLT alloantibody+ve
↓Cross-matched PLT
1-hr Corrected Count Increment
- PLT conc 1 bag ม PLT 5.5x1010
- SDP ม PLT 3x1011
BSA x PLT count increment x 1011
Number of PLT transfusedCCI =
ตวอยาง: BSA = 2
PLT count 10,000 40,000/microL
PLT conc 9 bags
CCI= 2 x 30,000 x 1011
9 x 5.5 x 1010
= 12,121 Plt x m2/microL
PLT Refractoriness
• Corrected Count Increment (CCI)
at 1 hr <7,500 (5,000-10,000) or
at 18-24 hr <4,500
• If 1-hr CCI is good, but plt count falls back
to baseline by 18-24 hr likely
nonimmune cause
• If 1-hr CCI is poor x 2 times likely
immune cause test for PLT Ab
ช 16 ป ปวดบวมขอเขาซาย มา 2 ชวโมง
• เปนโรค hemophilia A และม blood
group AB
• not pale, swelling+warm+
tenderness at Lt. knee joint
Best Rx
1. FFP gr AB
2. CRP gr AB
3. Cryoprecipitate
gr O
4. PCC
5. NovosevenR
Hemophilia A
• Factor VIII concentrates
• Cryoprecipitate
• FFP
• DDAVP
Hemophilia B
• Prothrombin complex
concentrate (PCC)
• FFP
• Cryo. Removed Plasma• F IX concentrates
vWD
• DDAVP• F VIII concentrates บางยหอ• Cryoprecipitate• FFP
ช 16 ป Hemophilia A ปวดทองมา 3 ชม.
• BW 50 kg
• Right lower quadrant pain and
tenderness, cannot extend
right hip due to pain,
numbness at right upper
thigh
• Hb 11 g/dL
• No factor VIII inhibitor
Proper Rx
1. Cryo 25 bags
2. Cryo 15 bags
3. Cryo 10 bags
4. NovosevenR
5. DDAVP
Rx of Bleeding episodes in Hemophilia
Site Initial Level (%) Rx Length
Joint 40 1-2 days
Muscle 40 2-3 days
Hematuria 50 3-5 days
Retroperitoneal 80-100 5 days
GI 80-100 7-14 d
Neck 80-100 7-14 d
Intracranial 80-100 14-21 d
Hemophilia A with hemarthrosis
• 60 kg.
• Raise F VIII to 40 %
• 1 u/kg raise 2%
• F VIII half life = 12 hr• Raise 40% -> 20 u/kg = 20x60 = 1200 u• Cryo. 12 bags ( cont. 6 bags q 12 hr)
Hemophilia B with hemarthrosis
• 60 kg.
• Raise F IX to 40 %
• 1 u/kg raise 1%
• F IX half life = 24 hr• Raise 40% -> 40 u/kg = 40x60 = 2400 u• FFP 2400 ml. ( cont. 1200 ml. q 24 hr)
FFP
•Contain all soluble coagulation
factors, albumin, hormones,
vitamins
•After thawing, the activities of
clotting factors decrease esp.
labile factors (V,VIII)
FFP: Indications
• Multiple acquired coagulation factor deficiency eg, Liver disease, Massive transfusion, DIC (Rx bleed, Before procedure)
• Rapid reversal of warfarin effect
• Plasma infusion or exchange for TTP
• Congenital coagulation defect
• C1-esterase inhibitor deficiency – acute episodes & prophylaxis of angioedema
FFP: Not Indicated
• Immunodeficiency
• Burns, Wound healing
• Reconstitution of packed rbc
• Volume expansion
• Source of nutrients
• Bleeding from Heparin/LMWH (consider protamine), fondaparinux
DIC
• Rx cause
• Bleeding• FFP , PLT concentrate
• Cryoprecipitate raise fibrinogen > 100 mg/dL: 1 bag/5 kg BW raise fibrinogen 100 mg/dL
• Thrombosis
• heparin : purpura fulminans, acral/dermal ischemia, retained dead fetus syndrome, giant hemangioma, aortic aneurysm without rupture
ช 66 ป STEMI ปวดหวอาเจยน หลงฉดยา Streptokinase
• เปนโรค STEMI & CHF ไดรบ streptokinase ตอมา 3 ชม. ปวดหวอาเจยนพง
• BP 170/90, P 90, R 15
• Alert, Rt.hemiparesis
• CBC ปกต
• CT Brain – left parietal hematoma
Best Rx
1. FFP
2. Cryoprecipitate
3. Vitamin K i.v.
4. Tranexamic
acid
5. 1+3+4
Cryoprecipitate: Indications
Fibrinogen
• Hypofibrinogenemia
(cong./acq. eg. DIC,
snake bite)
• Massive transfusion with
bleeding
• A component of fibrin
glue
• Reversal of thrombolytic
therapy with bleeding
Factor VIII
• Hemophilia A
vWF
• von Willebrand disease
• Uremic bleeding
F XIII
All ABO group acceptable
deficiency
Cryoprecipitate: Misuses
• Replacement therapy in patients with normal
fibrinogen level
• Reversal of warfarin therapy
• Rx of bleeding without evidence of
hypofibrinogenemia
• Rx of hepatic coagulopathy
• Underuse in massive transfusion with dilutional
coagulopathy and bleeding
General Management of Transfusion Reactions
• Stop transfusion
• Keep IV line open with NSS
• Supportive care: CVS, RS, Renal
• Symptomatic therapy
• Blood product labelling
• Patient identification
• Contact blood bank laboratory for additional testing
Lancet 2016;388:2825
Signs & Symptoms of Acute Transfusion Reactions
Sign/Symptom Possible Dx
Fever FNHTR
AHTR
TRALI
Microbial contamination
Itching, Rash,
Urticaria, Wheeze,
facial edema
Allergic reaction
SpO2 <90% TACO
TRALI
Dyspnea,
Respiratory
distress, Cyanosis
AHTR
Allergic reaction
Microbial contamination
TACO
TRALI
Sign/Symptom Possible Dx
Hypertension,
Tachycardia
TACO
Hypotension AHTR
Allergic reaction
Microbial
contamination
TRALI
Pain at IV
infusion site,
Abdominal/
chest/flank pain
AHTR
Allergic reaction
Cancer Control 2015;22:16
FNHTR, febrile nonhemolytic transfusion
reaction; AHTR, acute HTR;, TACO,
transfusion-associated circulatory
overload; TRALI, transfusion-related
acute lung injury
FNHTR AHTR Allergic
reaction
Microbial TACO TRALI
Fever +,chill +,chill + +
Itch, Rash,
Urticaria, Wheeze,
facial edema
+
SpO2 <90% + +
Dyspnea, Resp.
distress, Cyanosis+ + + + +
Hypertension,
Tachycardia
Tran-
sient+
Hypotension + + + +
Pain at IV infusion
site, Abdominal/
chest/flank pain
+ +
Other Dx by
exclusionDark urine,
DIC, ARF
FNHTR, febrile nonhemolytic transfusion reaction; AHTR, acute HTR; TACO, transfusion-
associated circulatory overload; TRALI, transfusion-related acute lung injury
Febrile Non-Hemolytic Transfusion Reaction (FNHTR)
• Dx by exclusion
• Rx: Antipyretic drug, pethidine
• Stop transfusion + antipyretic • not improve or Temp↑ >2oC or clinical signs of new
bacterial infection consider septic cause
• improve, no other symptom continue transfusion
• Prevention: leukocyte reduction
• Premed with antipyretics does not decrease rate of reactions in most patients
Lancet 2016;388:2825
Allergic & Anaphylactic Transfusion Reaction
• Occur within 4 h
• Most frequently assoc .with PLT transfusion
• Mild (cutaneous only) H1 antihistamine resolved restart transfusion if symptoms recur, stop transfusion
• Anaphylactic IM epinephrine; H1 / H2 antihistamine, bronchodilator, hydrocortisone IV
Lancet 2016;388:2825
Delayed Hemolytic Transfusion Reaction
• Risk: Hx of rbc alloAb (through pregnancy or transfusion exposure)
• Ab titre decreases to levels undetectable by routine Ab detection testing
• Second rbc exposure with relevant Ag anamnestic immune response 24 h to 28 days after transfusion hemolysis of donor rbc (Hbnot increase, ↑TB, DCT+ve)
• Dark urine or jaundice (45-50%), fever, chest/abd./back pain, dyspnea, chills, hypertension
Lancet 2016;388:2825
Acute Hypotensive Transfusion Reaction
• Abrupt BP drop >30 mmHg within 15 min of transfusion and resolving quickly (within 10 min) after stopping transfusion
• Activation of intrinsic contact coagulation pathway bradykinin (vasodilator, intestinal smooth muscle contraction) facial flushing, BP drop, abdominal pain
• Risk: ACEI, bedside leukocyte reduction filter, apheresis, PLT transfusion
• Rx: stop transfusion, not restart same unit
Lancet 2016;388:2825
TRALI TACO
Onset after
transfusion
Within 6 h Within 4-6 h
Body temp May increase No change
BP Hypotension Systolic BP↑
Pulse +/- Tachycardia
Clinical exam Rales Leg edema, JVP↑, S3
Fluid balance +/- Positive
Hypoxemia Always Common
LVEF ↓or normal ↓
CXR Bilateral infiltrates Bilateral infiltrates,
cardiomegaly
Response to
diuretic
Minimal Significant
TRALI TACO
Pulmonary edema
fluid/plasma
protein ratio
>0.75 (exudate) <0.65 (transudate)
BNP <250 pg/ml >1200 pg/ml or pre-
/post-transfusion
BNP ratio >1.5
CVP Normal/unchanged Increased
Pulmonary artery
occlusion pressure
<18 mmHg >18 mmHg
WBC count May show transient
leukopenia
Unchanged
WBC antibodies Cognate donor
WBC antibodies
support Dx
Donor WBC
antibodies may or
may not be present
Crit Care Med 2006;34:S109