138 Blood Procurement and Red Cell Transfusion Flashcards
Used for anticoagulation of blood products
Citrate
Sodium citrate, citric acid, and dextrose
Blood donors are more likely than the general population to be:
- Male
- Ages 30 to 50 years old
- White
- Employed
- Have more education
- Higher income
The additive solutions enable storage of RBCs for up to ___ days at __ to __C.
In addition to citrate and dextrose, adenine, mannitol, and phosphate
42 days
1 to 6 C
The actual time for collection of 450 to 500 mL usually is approximately ___ minutes
7 minutes
Almost always is less than 10 minutes
TRUE OR FALSE
During blood donation, cardiac output falls slightly but heart rate changes little. A slight decrease in systolic blood pressure results with a rise in peripheral resistance and diastolic blood pressure.
TRUE
During blood donation, cardiac output falls slightly but heart rate changes little.
A slight decrease in systolic blood pressure results with a rise in peripheral resistance and diastolic blood pressure.
Collected blood is mixed with ______ mL of anticoagulant composed of citrate, phosphate, and dextrose.
63 to 70 mL
An untoward reaction after blood donation occurs in approximately 2% to 5% of donors, but, fortunately, most of the reactions are not serious.
Donors who have reactions are more likely to be:
Donors who have reactions are more likely to be:
* Younger
* Unmarried
* Have a higher predonation heart rate and lower diastolic blood pressure
* Have a lower weight
* Female
* First-time or infrequent donors
The most common reactions to blood donation
Weakness, cool skin, and diaphoresis
Bradycardia usually is considered a sign of a vasovagal reaction rather than hypotensive or cardiovascular shock, where tachycardia would be expected.
Packed red cells has a final hematocrit of about _____%
80%
A unit of packed red cells has a volume of around ______mL and will contain about _____ mL of red cells
300 mL
190 mL of red cells
About ____ mL of plasma remains from the original unit of whole blood.
20 mL of plasma
The red cell component can be stored at 1 to 6 °C for up to ____ days
42 days
Plasma that is frozen within _____ hours of collection it is referred to as fresh frozen plasma (FFP) and contains essentially all of the hemostatic capacity of fresh plasma.
Eight hours
Plasma that is not frozen until about 24 hours after collection
Has some value in hemostasis but lacks all of the levels of coagulation factors found in FFP
Frozen plasma (FP)-24
Plasma products are stored at –18 °C or below for up to ______.
One year
TRUE OR FALSE
When platelets are prepared from whole blood, four or five units from whole blood are pooled to obtain a therapeutic dose of platelets.
TRUE
When platelets are prepared from whole blood, four or five units from whole blood are pooled to obtain a therapeutic dose of platelets.
Whole blood–derived platelets are stored at 20 to 24 oC, similar to apheresis platelets.
Established or Potential Adverse Effects of Leukocytes in Blood Component
Immunologic effects
- Alloimmunization
- Febrile nonhemolytic transfusion reactions
- Refractoriness to platelet transfusions
- Rejection of transplanted organs
- Graft-versus-host disease
- TRALI
Established or Potential Adverse Effects of Leukocytes in Blood Component
Immunomodulation
- Increased bacterial infections
- Increased recurrence of malignancy
Established or Potential Adverse Effects of Leukocytes in Blood Component
Infectious disease transmission
- CMV
- HTLV1
- EBV
CHE!
Autologous blood for transfusion can be obtained by
- Preoperative donation
- Acute normovolemic hemodilution
- Intraoperative salvage
- Postoperative salvage
Most commonly this situation occurs with elective surgery.
TRUE OR FALSE
No age or weight restrictions exist for autologous donation.
TRUE
No age or weight restrictions exist for autologous donation.
TRUE OR FALSE
Pregnant women can’t donate their own blood if they require transfusion.
FALSE
Pregnant women can donate, but this practice is not recommended because these patients rarely require transfusion.
Usually only ______ units of blood can be obtained before the Hb falls below 110 g/L
Hb may be lower (110 g/L) than that required for routine donors (125 g/L)
2 to 4 units
If the autologous donor does not meet the FDA criteria for blood donation, the blood must be specially labeled, segregated during storage, and discarded if it is not used by that specific patient.
Autologous blood donors can be given ________________to increase the number of units of blood they can donate
Erythropoietin and iron
Are friends or relatives who wish to give blood for a specific patient because the patient hopes those donors will be safer than the regular blood supply
Directed donors
Appropriate transfusion therapy involves collecting blood from a particular donor for a particular patient
Patient-specific donation
Patient-specific donation: donor may donate as often as every _____ days as long as the Hb remains above the normal donor minimum of ______ g/L.
3 days
125 g/L
An exception is donation of maternal platelets for a neonate with neonatal alloimmune thrombocytopenic purpura.
Blood can be collected as part of the therapy of diseases (therapeutic bleeding) such as
Polycythemia vera or primary hemochromatosis
Such blood is not used for transfusion because the donors do not meet the FDA standards for donor health.
Plateletpheresis results in a platelet concentrate with a volume of approximatel____mL and containing approximately _______platelets and less than 0.5 mL red cells.
Plateletpheresis requires approximately 90 minutes
250 mL
3.5 × 1011
Contains less than 5 × 106 leukocytes and thus can be considered leukocyte reduced.
After plateletpheresis, the donor’s platelet count declines by approximately ______% but returns to pre-plateletpheresis levels in approximately ______days.
30%
4 days
In red cell apheresis, because two units of red cells are removed, donors may donate only every _____ months
Every 4 months
Leukapheresis: procedure involves processing 6500 to 8000 mL of donor blood for approximately ___ hours
Because the efficiency of granulocyte extraction from whole blood is less than for platelets
Has been used to produce a granulocyte concentrate for transfusion therapy of infections unresponsive to antibiotics
3 hours
TRUE OR FALSE
Plasmapheresis is used to obtain plasma for manufacture of derivatives and plasma for transfusion.
FALSE
Plasmapheresis is used to obtain plasma for manufacture of derivatives but not plasma for transfusion.
- Plasmapheresis usually can be performed in approximately 30 minutes and produces up to 750 mL of plasma.
- Because few red cells are removed, the procedure can be repeated up to two times per week
Must knows during apheresis
- No more than 15% of the donor’s blood should be extracorporeal during apheresis; thus, the donor’s size is considered when making decisions about specific apheresis procedures or instruments to be used.
- The donor must not have taken aspirin for at least 3 days.
- The amount of blood components removed from apheresis donors must be monitored. Not more than 200 mL of red cells per 2 months or approximately 1500 mL of plasma per week can be removed.
The major side effect of hydroxyethyl starch
Blood volume expansion manifested by headache and/or hypertension
Apheresis donors experience a higher incidence of:
Paresthesias
Probably because of the infusion of citrate (that may affect calcium levels)
Managed by slowing the blood flow rate through the instrument
When granulocyte colony-stimulating factor and glucocorticoids are used in leukapheresis to obtain a granulocyte concentrate, approximately 60% of donors experience side effects:
Myalgia, arthralgia, headache, or flulike symptoms
Tests for Transmissible Agents of
Donated Blood
- Syphillis
- Hepatitis B
- Hepatitis C
- HIV
- West Nile Virus
- T. Cruzi
- Zika Virus
- CMV
Tests for Transmissible Agents of Donated Blood
Only platelet concentrates tested
Bacterial culture
Tests for Transmissible Agents of Donated Blood
Only first-time donors are tested
Trypanosoma cruzi
Tests for Transmissible Agents of Donated Blood
Of use for immunodeficient recipients
CMV antibody
The most problematic infections transmitted currently are caused by
Bacteria from infected platelet concentrates that are stored at room temperature
Multicenter randomized controlled trials indicate that compared with a target Hb of 100 g/L, target hemoglobin values of _________ are associated with equivalent or better outcomes in most patient populations.
70 to 80 g/L
Major Randomized Controlled Trials for Safe Hemoglobin Thresholds in Adults
Population
TRICC:
FOCUS:
TRACS:
Upper GI Bleed:
Restrictive strategy no difference from liberal straegy
TRICC: ICU
FOCUS: History or risk factor for CV disease after hip fracture surgery/orthopedic patients
TRACS: Cardiac surgery with cardiopulmonary bypass
Upper GI Bleed: Severe acute upper GI bleed
MINT TRIAL: Myocardial Ischemia and Transfusion
Liberal transfusion strategy (<100 g/L) was associated with fewer major cardiac events and deaths
Major Randomized Controlled Trials for Safe Hemoglobin Thresholds in PEDIA
Population
TRIPICU:
Iowa Trial:
(PINT) study:
TRIPICU: PICU (age from 3 days old to 14 years of age)
Iowa Trial: Preterm infants with birth weights of 500 to 1300 g
PINT: Premature infants; extremely-low birth-weight infants
Indications for transfusion therapy in patients with sickle cell disease (SCD)
- Stroke
- Acute chest syndrome
- Acute exacerbations of anemia, and other complications
Transfusions are usually not necessary to correct baseline anemia or alleviate vasoocclusive crises.
In Thalassemia, transfusing to maintain a Hb of _______ g/L is considered sufficient to suppress extramedullary erythropoiesis
100 g/L
Remains an important predictor of success with HSCT
Human leukocyte antigen (HLA) matching
Blood preparation that reduces alloimmunization rates
Leukoreduction
Reduces risk for transfusion-associated graft-versus-host disease (TA-GVHD)
Irradiation
TRUE OR FALSE
Pretransplantation transfusions in immunocompetent patients (eg, aplastic anemia, hemoglobinopathies) should be avoided, because they are associated with increased graft failure rates
TRUE
Pretransplantation transfusions in immunocompetent patients (eg, aplastic anemia, hemoglobinopathies) should be avoided, because they are associated with increased graft failure rates
Extra care must also be taken if the stem cell donation comes from a blood relative. In this situation, family members should not give directed blood donations before transplantation, because this may lead to alloimmunization against major and/or minor HLA antigens that are present in the transplant organ.
In general, engraftment time is shortest when hematopoietic progenitor cells are obtained by apheresis (HPC-A), and greatest when hematopoietic progenitor cells obtained from umbilical cords (HPC-C) are used
When an ABO incompatible transplant is used, group ____ red cells are used to avoid incompatibility issues.
Group O red cells
Occurs when the transplant contains RBCs that are incompatible with the recipient’s plasma
When recipients have isohemagglutinins specific for the ABO type of the transplant, delayed erythrocyte engraftment and PRCA may ensue.
Major mismatch
intake ang RBC ng nagdonate
More commonly seen when the HSCT is derived from marrow, because more RBCs are present; however, RBC depletion techniques have effectively eliminated this complication
This is seen most frequently when group O patients receive a group A transplant, or with bidirectional mismatches.
Occurs when the donor plasma contains isohemagglutinins against the recipient’s RBCs
Minor mismatch
Umatake ang donor
Reported most frequently in transplants that use a group O donor with a group A recipient.
Condition wherein lymphocytes within the HSCT recognize the recipient RBCs as foreign, antibodies may be produced that are specific for ABO or minor RBC antigens
Passenger lymphocyte syndrome (PLS)
- Presents 7 to 14 days after the transplant with the abrupt onset of hemolysis
- Most frequently in transplants that use a group O donor with a group A recipient
- The hemolysis can persist as long as incompatible RBCs are present, but usually subsides within 5 to 10 days.
High risk for Passenger lymphocyte syndrome (PLS)
- Nonmyeloablative conditioning regimens
- Recipients of peripheral blood stem cells
- Graft-versus-host disease (GVHD) prophylaxis with only a T-cell inhibitor, such as cyclosporine, without an accompanying B-cell inhibitor
TRUE OR FALSE
Most CMV infections are likely the result of acquisition of a new strain rather than reactivation of virus from a previous infection.
FALSE
Most CMV infections are likely the result of reactivation of virus from a previous infection rather than acquisition of a new strain.
A more practical approach is to screen donated blood for CMV DNA or immunoglobulin (Ig) M antibodies, although we believe that the use of leukoreduced blood components is adequate
British Committee for Standards in Haematology (BCSH) recommendations for: Allogeneic transplant recipients
- Receive irradiated components for six months post transplantation, or until the patient’s lymphocyte count is greater than 1 × 109/L
- However, if chronic GVHD is present, then irradiated products should be given indefinitely.
All HSCT patients should receive irradiated components from the time of initiation of conditioning chemotherapy, and for at least one year after transplantation to prevent TA-GVHD.
British Committee for Standards in Haematology (BCSH) recommendations for: Autologous transplant patients
- Receive irradiated components from the time of initiation of conditioning chemotherapy, but can revert to nonirradiated components three months after transplantation
- If autologous transplant patients received total-body irradiation, extending the use of irradiated products for six months after transplantation.
All HSCT patients should receive irradiated components from the time of initiation of conditioning chemotherapy, and for at least one year after transplantation to prevent TA-GVHD.
TRUE OR FALSE
In general, immediate transfusion reactions are more dangerous than delayed reactions.
TRUE
In general, immediate transfusion reactions are more dangerous than delayed reactions.
Almost always caused by the immune-mediated destruction of ABO-incompatible transfused blood
Acute Hemolytic Transfusion Reactions (AHTRs)
Although rare, AHTRs can be caused by other blood group antibodies, particularly those in the ________ blood group system.
Kidd
The most common presenting symptom of AHTR
Fever with or without chills or rigors
Can be the first sign of intravascular hemolysis, particularly in anesthetized or unconscious patients.
Hematuria
The severity of AHTR is extremely variable and usually depends on
Rate and total volume of blood administered
The most common cause of AHTRs is
Clerical and human errors resulting from mistakes in identifying the patient, labeling the pretransfusions sample, or identifying the correct red cell unit for the patient
Defined, arbitrarily, as a temperature increase of 1oC (1.8 oF) or more during or up to 4 hours after transfusion
Febrile Nonhemolytic Transfusion Reactions (FNHTRs)
- More likely to occur after transfusion of platelets than RBC
- Leukocyte reduction decreases the incidence of FNHTRs
- Premedication with antipyretics (acetaminophen) is not helpful.
TRUE OR FALSE
In FNHTR, all associated blood components must be placed in quarantine until a septic transfusion reaction has been ruled-out.
TRUE
In FNHTR, all associated blood components must be placed in quarantine until a septic transfusion reaction has been ruled-out.
- Gram stain is not a highly-sensitive technique in this setting but may be used to rule-in bacterial contamination.
- Rapid qualitative immunoassay tests (eg, Verax or BacTx) are highly sensitive for most commonly encountered bacterial contaminants and may be used in lieu of Gram stain to screen implicated platelet units.
- In cases with a high index of suspicion, the unit should be cultured.
A common adverse reaction of transfusion therapy, ranging from a mild form characterized by localized pruritus and/or urticaria, to a severe anaphylactic or anaphylactoid reaction
Allergic Transfusion Reactions (ATRs)
The majority of ATRs are __________hypersensitivity reactions, mediated by preformed IgE antibodies binding to soluble proteins present within donor plasma.
Immediate (Type 1) hypersensitivity reaction
Prevention of Allergic Transfusion Reactions (ATRs)
Washing cellular components to remove residual plasma or using platelets stored in periodic acid-Schiff
TRUE OR FALSE
In cases limited to urticaria, the transfusion may be resumed immediately after symptoms resolve.
TRUE
In cases limited to urticaria, the transfusion may be resumed immediately after symptoms resolve.
Management of acute anaphylaxis
- Fluid resuscitation
- Subcutaneous epinephrine (0.3 mL of 1:1000 dilution)
- Airway management and intensive care
Management of shock
IV epinephrine (3–5 mL of a 1:10,000 dilution)
Glucocorticoids are usually not helpful in acute crises.
Occurs when patients are unable to effectively process the expansion in intravascular volume from a blood transfusion
Transfusion-Associated Circulatory Overload (TACO)
Risk factors for TACO
- Younger and advanced age patients
- Female sex
- History of congestive heart failure
- Hemodialysis
- Mechanical ventilation
- Recent use of vasopressors
- Positive fluid balance
Definition of TACO
During or up to 12 hours after transfusion when a patient has three of the following criteria, with at least one from the required criteria (1 and 2):
(1) acute or worsening respiratory compromise,
(2) evidence of pulmonary edema,
(3) evidence of cardiovascular system changes not explained by the patient’s underlying medical condition
(4) evidence of fluid overload, and
(5) supportive result of a relevant biomarker (eg, an increase of B-type natriuretic peptide level [BNP] or N terminal-propeptide BNP [NT-pro BNP])
Prevention of TACO
- Blood should be administered slowly (1–4 mL/kg/hour)
- Reduce the transfusion volume by splitting the blood product into smaller volumes if the transfusion is going to last longer than four hours
A syndrome of acute hypoxia caused by noncardiogenic pulmonary edema that occurs after a transfusion
Transfusion-Related Acute Lung Injury (TRALI)
TRALI Type I
Patients with no risk factors for ARDS must meet the following criteria:
- Acute onset;
- Hypoxemia (paO2/FiO2 ≤300 or SpO2 <90% on room air);
- Clear evidence of bilateral pulmonary edema on imaging; and
- No evidence of left atrial hypertension, or if left atrial hypertension is present, it is judged not to be the main contributor to the hypoxemia
- The onset must be during or within 6 hours of transfusion and there should be no temporal relationship to an alternative risk factor for ARDS
TRALI Type II
Patients who have risk factors for ARDS or have existing mild ARDS (paO2/FiO2 of 200–300) but whose respiratory status deteriorates secondary to a transfusion
- Acute onset
- Hypoxemia (paO2/FiO2 ≤300 or SpO2 <90% on room air)
The patient must have a stable respiratory status in the 12 hours before transfusion
Patient factors (first hits) that are associated with a greater risk of TRALI
- Patients on mechanical ventilation
- Sepsis
- Chronic alcohol abuse
- Severe liver disease
- Hematologic malignancy
TRUE OR FALSE
Transient leukopenia, which follows the reaction within few hours, can also distinguish TRALI from TACO.
TRUE
Transient leukopenia, which follows the reaction within few hours, can also distinguish TRALI from TACO.
TRALI can be ruled out as the sole cause of pulmonary failure by the presence of rales and jugular venous distension on physical examination and/or dilated pulmonary arteries on chest radiograph, which are evidence of congestive heart failure with or without TACO.
Prevention of TRALI
- Collect plasma from males, nulliparous females, and/or females tested and found to be negative for HLA antibodies
- Pooled plasma also may be used for TRALI mitigation because antibody titers drop as a result of dilution.
TRUE OR FALSE
Hemolysis from DHTR is typically intravascular, without dramatic clinical symptoms and signs, although some classes of IgG bind complement and will cause extravascular hemolysis.
FALSE
Hemolysis from DHTR is typically extravascular, without dramatic clinical symptoms and signs, although some classes of IgG bind complement and will cause intravascular hemolysis.
Hemolysis in DHTRs is usually mild and gradual; however, when antibodies are produced against antigens in the Kidd blood system, the hemolysis may be rapid, intravascular, and severe.
Posttransfusion purpura is a rare immune-mediated disorder directed against _________ alloantigens
Platelet alloantigens
Presentation of TA-GVHD
Maculopapular rash, fever, watery diarrhea, liver dysfunction, and bone marrow failure within 8 to 10 days of transfusion
Blood products that acellular and therefore pose no risk for GVHD
Plasma and cryoprecipitate
____________________ of components are effective prophylaxis for TA-GVHD.
Gamma and x-ray irradiation
A dose of at least 2500 sGy to the center of a cellular blood component and 1500 cGy throughout the unit leaves lymphocytes intact but unable to proliferate.
Leukoreduction is not sufficient because it reduces, but does not completely eliminate, white blood cells.
The level of extracellular potassium has been shown to increase with storage time in irradiated RBC.
As a result, RBCs may be stored for only ______ days after irradiation.
28 days
During storage, RBC units develop a progressive “storage lesion.”
Some of these changes include:
- An increase in free Hb, which acts as a nitric oxide scavenger
- A reduction in 2,3-diphosphoglycerate, which leads to increased oxygen affinity/ decreased oxygen delivery
- An increase in hydrogen ions in the supernatant, causing a drop in the pH
- An increase in microvesicles in the supernatant, creating a procoagulant effect
- A release in free iron, which could support the growth of some infectious organisms
- Reduced RBC membrane deformability.
An evidence-based, systematic, and multifaceted approach to optimizing the care of patients who might need transfusion
Patient blood management (PBM)
A comprehensive PBM program includes:
(a) hospital-wide guidelines for evidence-based use of blood components,
(b) early assessment and correction of preoperative anemia, and
(c) application of a variety of techniques to minimize perioperative blood loss
