Published on October 23, 2007
Transfusion : Transfusion Douglas M. Lublin, M.D., Ph.D. Medical Director, Transfusion Medicine Department of Pathology and Immunology Washington University School of Medicine Richard Lower: Richard Lower First documented animal to animal (dog) transfusion Oxford in 1665 Lower R: Philos Trans R Soc Lond 1:353, 1666 Successful Blood Transfusion : Successful Blood Transfusion Immunological compatibility: ABO - Landsteiner 1900 Pretransfusion type/crossmatch: Ottenberg 1907 Anticoagulation: citrate - 1914 Preservative: glucose - 1916 Blood bank: Leningrad 1932, Barcelona 1936, Chicago 1937 Blood component therapy Slide4: Blood Inventory Slide7: Blood Safety Potential Hazards of Transfusion: Potential Hazards of Transfusion Hemolytic transfusion reactions Febrile non-hemolytic transfusion reactions Allergic reactions Alloimmunization Graft versus host response Infections (especially viral) Bacteria (especially platelets) Volume overload Iron overload Potential Hazards of Transfusion: Potential Hazards of Transfusion Hemolytic transfusion reactions Febrile non-hemolytic transfusion reactions Allergic reactions Alloimmunization Graft versus host response Infections (especially viral) Bacteria (especially platelets) Volume overload Iron overload Slide11: Other Transfusion-transmissible Infectious Agents Malaria West Nile Virus Chagas Disease vCJD Slide12: Estimated Risk of Transmission of the West Nile Virus Through Blood Transfusion in the US, 2002 Biggerstaff, Transfusion 2003;43:1007 4156 Infections 21 Transmissions by blood 6 deaths from blood transfusion Slide14: ALI developing within 6 hours of transfusion Rapid onset tachypnea, cyanosis, dyspnea, fever Acute hypoxemia X-ray: diffuse infiltrates Treatment: aggressive respiratory support, including oxygen and mechanical ventilation Leading reported cause of fatal transfusion reactions in U.S. in 2003/4 TRALI Silliman et al. Blood 2005;105:2266 Pathogenesis of TRALI: Pathogenesis of TRALI Silliman et al. Blood 2005;105:2266 Slide16: Single Hospital Experience of TRALI 11 Cases of TRALI recognized over 12 years Observed incidence of TRALI caused by FFP was 1 in 7900 units transfused TRALI was the most common serious adverse effect of blood transfusion in their hospital Wallas et al. Transfusion 2003;43:1053 Serologic Findings in TRALI: Serologic Findings in TRALI Wallas et al. Transfusion 2003;43:1053 Slide18: Criteria For RBC Transfusion Slide20: ISBT Human Blood Group Systems Number Name Abbreviation 001 ABO ABO 002 MNS MNS 003 P P 004 Rh RH 005 Lutheran LU 006 Kell KEL 007 Lewis LE 008 Duffy FY 009 KiddJ K 010 Diego DI 011 Cartwright YT 012 XG XG 013 Scianna SC 014 Dombrock DO 015 Colton CO 016 Landsteiner-Wiener LW 017 Chido/Rodgers CH/RG 018 Hh H 019 Kx XK 020 Gerbich GE 021 Cromer CROM 022 Knops KN 023 Indian IN 024 Ok OK 025 Raph RAPH 026 JMH JMH Slide21: The Mayo Clinic Magic 10 Grams "When the concentration of hemoglobin is less than 8 to 10 g/dL, it is wise to give a blood transfusion before operation" Adams and Lundy. Surg Gyn Obstet 1941;71:1011 Blood Transfusion in Elderly Patientswith Acute Myocardial Infarction: Blood Transfusion in Elderly Patients with Acute Myocardial Infarction Retrospective study of 78,974 patients aged 65 or older with acute MI Lower hematocrit on admission associated with higher 30-day mortality Blood transfusion associated with lower 30-day mortality if admission hematocrit less than 30-33% For example, with admission hematocrit 24-27%, transfusion associated with adjusted odds ratio for 30-day mortality of 0.48 Wu W-C et al. N Engl J Med 345:1230-1236, 2001 Relationship of Blood Transfusion andClinical Outcomes in Patientswith Acute Coronary Syndromes: Relationship of Blood Transfusion and Clinical Outcomes in Patients with Acute Coronary Syndromes Retrospective study of 24,112 patients with acute coronary syndrome Transfusion associated with increased risk of 30-day mortality Adjusted odds ratio 3.94 with transfusion Transfusion not associated with improved survival when nadir hematocrit in 20% or 25% range Transfusion associated with worsened outcome when nadir hematocrit 30% or above Rao SV et al. JAMA 292:1555-1562, 2004 Slide32: Guidelines for Red Blood Cell Transfusion “In patients not at risk for coronary artery disease...transfusion is unlikely to be of benefit for Hgb > 80 g/L” “The presence of coronary artery disease likely constitutes an important factor in determining a patient’s tolerance to low Hgb” Can. Med. Assoc. J. 1997;156:S1-S23 Slide33: Demand for Platelet Products is Increasing Autologous stem cell transplantation Allogeneic stem cell transplantation Trauma surgery Complex cardiac surgery Slide37: THE THRESHOLD FOR PROPHYLACTIC PLATELET TRANSFUSIONS IN ADULTS WITH ACUTE MYELOID LEUKEMIA Rebulla P, et al. N Engl J Med 1997;337:1870-1875. Slide38: Bacterial Contamination of Platelet Products ~1:2,000 platelet products is culture positive ~1:50,000 platelet products causes fatal sepsis Bacterial screening of platelets started March 2004 Platelets stored for 24 h at RT before culture Culture held for 24 h before platelets released 7 d storage of platelets in Europe; recently FDA approved Slide39: Platelet Refractory Patients Non-immune causes: sepsis, fever, splenomegaly, DIC, allogeneic BMT, drugs, etc. Immune causes: ABO, HLA, HPA Slide40: TRANSFUSE FRESH FROZEN PLASMA (FFP) To increase the level of clotting factors in patients with a documented deficiency Slide45: CURRENT INDICATIONS FOR GRANULOCYTE TRANSFUSIONS 1. Daily transfusions (>1 x 1010 neutrophils) can benefit neutropenic (<500 neutrophils/ml) patients with a documented bacterial infection: a. not responding to antibiotics within 48 hrs. b. in whom neutropenia expected to persist more than one week. 2. Prophylactic WBC transfusions not justified. 3. Antibiotics are of primary importance.