Blood Donation Flashcards
Allogeneic (homologous) whole blood donation
- Process tightly regulated by FDA and AABB
- Donor screening by history
a. Most facilities use FDA-approved template from
AABB called “uniform donor history questionnaire”
(UDHQ); printed at end of this handout
b. Necessary information
1) Full name (generally, formal ID required)
2) Home and/or work address
3) Date of birth/age
a) Minimum age 17 unless in a state where
donations approved at age 16.
4) Reasons for previous deferral
5) Date of last donation
a) > 8 weeks for whole blood
b) > 16 weeks for double red cell collections
c) > 4 weeks for infrequent plasmapheresis
d) > 2 days for platelet apheresis procedures
c. Not required, but often asked
1) Race
2) Social security number
a) Identity theft concerns
b) Alternative ID numbers (unique to donor)
d. HIV information
1) Information on signs/symptoms and risk factors for HIV
2) Donor told not to donate if they have any risk factors
3) Notification of alternate ways to get an HIV test if needed
e. Donor is formally notified of risks of the procedure
f. Donor questions
1) Version 1.1 of UDHQ (current version approved by FDA) has 48 questions
2) Donor centers may add additional questions, but only at end of questionnaire
a) Additional questions may only make rules more restrictive; never less restrictive
b) Commonly added questions are about medications or health issues not covered in UDHQ
g. Deferrals based on history
Permanent Deferral
Infectious Risks
- High-risk behavior for AIDS (including IVDA, male-male sex, exposure)
- Receiving money or drugs for sex
- Serologic positive for HIV, HBV, HCV, HTLV
- Viral hepatitis after 11th birthday
- Transfusion of clotting factor concentrates (in hemophilia)
- History of Babesiosis or Chagas’ disease
- Growth hormone from human sources (pre-1985)
- Insulin from bovine sources
- Dura mater graft
- *Malignancies (see below)**
- Leukemia or lymphoma
- *Teratogens**
- Tegison©
Three year deferrals
Infectious Risks
- Recovered from malaria
- Immigrants from malaria-endemic areas (after 5 consecutive years of living there)
- *Teratogens**
- Soriatane©
One year deferrals
- *Infectious Risks**
- Needle sticks or other contact with blood
- Sex contact with person with HIV or hepatitis
- Sex contact with person who used needles for drugs
- Rape victims
- Incarcerated > 72 consecutive hours
- Paying money/drugs for sex
- Blood transfusion (Allogeneic); including plasma/clotting factors in nonhemophiliacs
- Allogeneic transplant of organ/skin/bone
- Living with person with active hepatitis
- Receiving HBIG
- Tattoos/piercings (unless by regulated entity)
- Travel to malaria-endemic areas
- Syphilis or gonorrhea
- Non-prophylactic rabies vaccination
- “Travel” to Iraq
Special Situations
a) Malignancy deferrals
i) At discretion of medical director (FDA/AABB do not mandate)
ii) Studies do not show that malignancy can be transmitted via transfusion
iii) Most defer hematologic malignancies (leukemia/lymphoma) permanently, but some accept cured childhood leukemics
iv) For solid malignancies, many defer “indefinitely” and consider re-entry after 1-5 years disease-free
v) BCC and localized skin SCC do not require deferral.
b) Heart and lung disease
i) No specific mandated deferrals
ii) FDA says: Donor should be free of acute lung disease
ii) AABB says: Donor should be free of heart/lung disease unless determined suitable
by medical director
iii) Individual medical directors determine what is acceptable, most often based on time since diagnosis, presence of limitations on activities, and proper medical follow-up
c) Defer pregnant women through 6 weeks postpartum.
d) Defer people having non-routine dental work for 72 hours.
e) Questions 46 and 47 ask about being in Africa or being exposed to someone who was there.
i) This is primarily to prevent transmission of HIV group O (exceptionally rare in the US no reported cases since 1996).
ii) Being born in, living in, or having sexual contact with someone born or living in these
countries in central and western Africa since 1977 is a permanent deferral: Cameroon,
Benin, Central African Republic, Chad, Congo, Equatorial Guinea, Kenya, Gabon,
Niger, Nigeria, Senegal, Togo, or Zambia.
iii) If traveled to these countries since 1977 and got a blood transfusion: Permanent deferral
iv) HOWEVER, if an FDA-approved anti-HIV screening test that is sensitive for HIV group O is used, these questions may be omitted.
v) Note that the current AABB UDHQ does not include all of these countries (updated with FDA Guidance 8/09).
Permenent Deferral
Defer permanently for vCJD risk all donors who:
a) Spent more than 3 months cumulative in the UK, 1980 to 1996
b) Lived in France for over 5 years, 1980 to now
c) Received dura mater transplant, pituitary growth hormone injections, or bovine insulin injection
d) Were transfused in the UK, 1980 to now
e) Lived in Europe for over 5 years cumulative between 1980 and now
f) Have family history of CJD or vCJD
g) Were military members/dependents:
i) Stationed at Northern Europe bases (Germany, UK, Belgium, Netherlands) for 6
months from 1980 to 1990
ii) Stationed at other Europe bases (Greece, Turkey, Spain, Portugal, Italy) for 6 months from 1980 to 1996
Immunizations
Immunizations
a) General rule: no deferral for killed, toxoid, or recombinant/synthetic vaccines
b) Live attenuated vaccines (either viral or bacterial) give deferrals of varying lengths (see below).
Immunization Deferrals
- *Four Weeks**: Rubella, Varicella
- *Two Weeks**: Measles, Mumps, Oral polio, Yellow fever, Oral typhoid
- *No Deferral:** Anthrax, Cholera, DPT, Hepatitis A, Hepatitis B, Influenza, Lyme disease, Pneumococcus, Polio (injection), RMSF, Typhoid (injection)
12 Months: Unlicensed vaccines
c) Smallpox vaccination
i) Set of deferrals depending on presence/absence of vaccine scab and post-vaccination symptoms
ii) Without complications: defer until scab falls off or 21 days, whichever is longer
iii) With complications: defer until 14 days after symptoms resolve
Drugs
a) UDHQ only requires questioning about a limited number of medications
i) Some facilities add more questions to protect donor
b) UDHQ V 1.1 drug deferrals for teratogenicity:
i) Etretinate (Tegison©): Permanent deferral
ii) Acitretin (Soriatane©): Three year deferral
iii) Isotretinoin (Accutaine©): 30 day deferral
iv) Finasteride (Proscar©, Propecia©): 30 day deferral
v) Dutasteride (Avodart): 6 month deferral
c) UDHQ V 1.1 drug deferrals for infection risk:
i) Growth hormone (human pituitary source): Permanent deferral
ii) Bovine insulin: permanent deferral
iii) HBIG: 1 year deferral
iv) Unlicensed vaccine: 1 year deferral
d) Aspirin/aspirin like meds for platelets (48 hours)
Donor screening by physical criteria
a. General appearance
b. Arm check
1) Check both arms for evidence of IV drug use and for venous access
c. Physical requirements
Weight: > 110 lbs (50 Kg)
Temperature: < 99.5o F (37.5 C)
Pulse: 50-100 bpm (unless athlete)
Blood pressure: < 180/100
Hemoglobin or
Hematocrit: > 12.5 g/dl or 38%
Donation Specifics
a. Amount drawn
1) 450 +/- 45 ml still most common
a) 500 mL bag also being used; limit is 500 +/- 50
2) Maximum of 10.5 ml/Kg is allowed (to allow for double red cell collection via apheresis.)
b. Time limit
1) Within 15 minutes is best, but no upper limit in Standards or CFR.
Testing Donor Blood
- Testing donor blood
a. ABO grouping
b. Rh typing
1) Weak D required if D negative (see BB 1)
c. Antibody screen
1) Check for unexpected antibodies in donor serum.
2) May use pooled serum from several donors rather than testing each donor individually.
3) AABB Standards: if positive, may still use red cells, but only to make products with minimal plasma (ie, can’t use FFP, cryo, or platelets).
4) Label must reflect any positive results that are identified as clinically significant antibodies.
d. Infectious disease screening (as of 9/2009); see appendix on pg. 14 and further details in Blood Bank IV.
1) HbsAg
2) Anti-HBc
3) Anti-HCV
4) HCV nucleic acid testing (HCV NAT)
a) HCV window period decreased from ~ 70 days with anti-HCV alone to between 10 and 30 days with HCV NAT
5) Anti-HIV-1/2
6) HIV-1 NAT
a) HIV window period decreased from 16 days with combination of anti-HIV and p24 to about 10 days with HIV NAT.
7) Anti-HTLV-I/II
8) Serologic test for syphilis
9) West Nile virus
10) Trypanosoma cruzi (Chagas’ disease); approved by FDA; many centers using though not required yet.
Donor Reactions
- Vasovagal reactions
a. Most common reaction (2-5% of healthy donors)
b. Signs/symptoms
1) Bradycardia
2) Hypotension
3) Syncope
4) Nausea/vomiting
5) Incontinence
c. Treatment is supportive
1) Distinguish from hypotensive shock
2) Elevate feet, cold compresses on neck
2. Hypotensive shock
a. Extremely uncommon
b. Signs/symptoms
1) Tachycardia
2) Hypotension
3) Loss of consciousness
4) Shock parameters
c. Treatment
1) IV fluids
3. Hyperventilation
a. Especially common in first-time donors and children
b. Signs/symptoms
1) Shortness of breath
2) Facial twitching
3) Seizure activity (unusual)
c. Treat with rebreathing (the paper bag thing)
4. Local injuries
a. Hematomas: Less than 1% (bruises almost 25%)
b. Nerve injury: less common than bruises (less than 1%); usually resolve on their own
Apheresis procedures
- Separation of blood into components using several technologies
a. Centrifugation
1) Most common method
2) Separation based on varying density of blood components
3) Blood drawn into a spinning bowl or chamber, separated, desired component harvested (all else returned).
b. Adsorption
1) Blood passed over/through a column of material that attracts desired substance.
2) Staphylococcal protein A (SPA) and monoclonal antibodies are examples.
3) Used for ITP and removal of LDLs in hypercholesterolemia; has been tried in TTP
c. Membrane filtration
1) Used to separate plasma from cellular components (not to separate cellular components themselves)
2) Can use to remove abnormal plasma components
- Targets
a. Platelets
1) Volunteer donation
2) Essential thrombocythemia
b. Plasma
1) Volunteer donation
2) TTP/HUS
3) Waldenstrom’s macroglobulinemia/myeloma
4) Myasthenia gravis or Guillain-Barre
5) Goodpasture’s syndrome
6) Familial hypercholesterolemia
c. White blood cells
1) Donation (thankfully uncommon)
2) Blast crisis
d. Red blood cells
1) Volunteer donation
2) Sickle cell disease complications
3. Advanced technologies available
a. Equipment licensed to collect more than one product at
the same time:
- One RBC unit and one platelet unit
- One RBC unit and one plasma unit
- One RBC unit, one platelet unit, and one plasma unit
- Two RBC units
- Donor requirements
a. Platelet donors
1) Same hemoglobin/hematocrit requirements as regular donors
2) Donation interval at least 2 days
a) No more than 2 procedures per week
b) No more than 24 procedures per year
c) At least 8 weeks after whole blood donation or if procedure results in loss of greater than 100 mL blood
d) MD may waive above if for a particular patient need (requires written certification).
3) No aspirin/aspirin-effect products in last 48 hrs
4) Platelet count > 150,000/uL if less than 4 weeks from previous donation
5) Plasma volume loss less than 500 mL (600 mL if donor weight is greater than 175 lbs)
b. Plasma donors
1) “Occasional” (donating less often than every 4 weeks): same as whole blood
2) “Serial” (donating more often than every 4 weeks):
a) Total protein and SPEP check every 4 months
b) Donation interval at least 2 days; no more than 2
collections per 7 days
c) Red cell loss less than 25 mL/week
c. Double red cell donors
1) FDA Guidance 2/13/2001: no specific hemoglobin or height/weight guidelines, just “assure donor safety”
2) Double red cell donors are deferred for 16 weeks
- Apheresis donor reactions
a. “Citrate effect”
1) Citrate anticoagulant binds free calcium
2) Perioral tingling
3) Tetany and arrhythmias uncommon
4) Slow rate of infusion, give oral calcium
b. Hypersensitivity reactions
1) Classic: Hetastarch in WBC donors
a) Given to induce rouleaux (better separation)
Autologous Blood Collection - Preoperative autologous blood donation
- Less screening stringency than allogeneic collections
- AABB Standards: Don’t cross over units into regular inventory unless exceptional circumstances.
- More lenient physical criteria (see table below)
- Testing regulations
a. Infectious disease screening not required unless units are to be shipped to another facility
1) If not tested, units must be labeled “NOT TESTED”
b. Only first donation in a 30-day period MUST be tested.
1) All others after that are labeled “DONOR TESTED WITHIN THE LAST 30 DAYS” - Potential issues with autologous donations
a. Donor reactions
1) In general, more complex donors with more health problems, so more likelihood of donor complications.
2) Safety of donor during donation is responsibility of donor center medical director!
b. Clerical errors/transfusion errors
1) Risk of wrong unit going to wrong patient still present with autologous donations.
2) CAP survey (1992): about 1% of hospitals admitted making transfusion errors with autologous blood.
3) Systems must be in place to prevent allogeneic units from being transfused before autologous units.
c. Bacterial contamination
1) Currently a greater risk than HIV or HCV
2) Risk of undetected infection leading to contamination of unit is not changed by PAD.
d. Cost
1) More costly to patients if transfused and hospitals if not transfused (wastage).
e. Timing
1) Collections should be completed at least 72 hours before surgery (preferably sooner).
2) Surgery cancellations, etc, can lead to problems (freeze units? Let them expire?)
f. Positive infectious disease testing
1) If donor has a reactive test, both he and the requesting physician must be notified.
2) Autologous collections with reactive testing can lead to deferral from future allogeneic donations.
Allogeneic
Donation Interval 8 weeks
HB/HCT > 12.5 or 38%
Weight > 110 lbs (50 Kg)
Age > 16 or 17 (varies)
Infectious Disease Screening Required
History of Disease or Positive Test Not eligible
Autologous
Donation Interval 72 hours
HB/HCT > 11 or 33%
Weight None
Age None
Infectious Disease Screening Not required unless shipped
History of Disease or Positive Potentially eligible
Normovolemic (“isovolemic”) hemodilution
- Primary goal: reduce RBC volume during surgery.
- Removal of up to one liter of blood immediately before surgery
a. Collection is done into multiple standard blood bags and each bag should be monitored for overfill.
b. Standard formulae exist for collection amount; typically take patients down to HCT 28% or so.
c. Shelf life:
1) 8 hours at room temperature
2) 24 hours in monitored refrigerator
3. Volume replacement with saline or other crystalloid (3 ml per 1 ml of blood removed) or colloid (1 ml per ml of blood removed)
a. Replace the volume unit by unit; ie, when a unit is withdrawn, immediately give the appropriate volume (don’t remove a bunch of blood and THEN correct the volume).
4. Re-infuse blood near end of surgery.
a. Units usually re-infused in reverse order to how drawn (i.e., last drawn is first re-infused).
5. Indications (per AABB Technical Manual)
a. Greater than 10% likelihood of transfusion
b. Hemoglobin at least 12 g/dL
c. No serious medical disease
d. No infection or bacteremia
- Potential advantages
a. Better monitoring than in PAD; some use for higher risk patients.
b. Bleeding more dilute blood leads to less overall blood loss (maybe).
c. Decreased blood viscosity increases cardiac output and may improve oxygenation.
d. Coag factors and platelets survive well for short periods and help hemostasis.
e. May be used in future with blood supplements (“substitutes”): “augmented hemodilution”
- Potential disadvantages
a. Requires training of phlebotomist (most commonly done by anesthesiologist)
b. Units should be labeled with full name, date/time, medical record number, and “FOR AUTOLOGOUS USE ONLY.”
