TRANSFUSIONS WHY DO WE EVEN CARE?????

Transcription

1 TRANSFUSIONS WHY DO WE EVEN CARE?????

2 BECAUSE BLOOD CAN KILL 7 TRALI DEATHS SINCE 2002 WMC 5 women

3 Because in OB you are transfusing 2 instead of 1

4 BECAUSE BLOOD IS A LIQUID TRANSPLANT

5 JOINT COMMISSION SEVEN NEW BLOOD MANAGEMENT PERFORMANCE STANDARDS Transfusion consent RBC transfusion indications Plasma transfusion indications Platelet transfusion indications Blood administration documentation Preoperative anemia screening Preoperative blood type testing/antibody ID

6 RISKS versus BENEFITS versus ALTERNATIVES

7 RISKS

8 TRANSFUSION RISKS HUMAN ERROR INFECTIONS TRANSFUSION REACTIONS TERRIBLE T S

9 HUMAN ERROR Wrong Blood In Tube ABO Incompatibility DEATH

10 CURRENT TESTING ON DONOR BLOOD HIV 1 / 2 ANTIBODIES & TMA HCV ANTIBODIES & TMA HBV SURFACE ANTIGEN & TMA HBV CORE ANTIBODY HTLV I / II ANTIBODIES WEST NILE VIRUS TMA SYPHILIS SEROLOGY CHAGAS ANTIBODY Dengue Fever in PR

11 TRANSFUSION INFECTIONS HIV 1 / 2: 1 in 1-2,000,000 units HCV: 1 in 1-2,000,000 units HBV: 1 in 1-2,000,000 units Bacterial sepsis: 1 in 2,000-3,000 units HTLV I /II: 1 in 3,000,000 units West Nile Virus: 1 in 350,000 (pre-test) Syphilis: rare Chagas disease: rare Arch Patholo Lab Med,2007, 131,

12 TRANSFUSION INFECTIONS 68 Emerging Pathogens Babesiosis Malaria Lyme disease Chikungunya virus Parvoviruses vcjd Simian foamy virus Borrelia Parvoviruses Brucella Leishmania Rickettsia EBV TTV LCV Herpes viruses 6,7,8 Dengue 68 other emerging diseases from CDC

13 TRANSFUSION REACTIONS IMMEDIATE TYPE Allergic ---- range from hives to anaphylactoid Febrile non-hemolytic Acute hemolytic -- Mostly from non-abo antibodies!!! Anaphylactic Don t forget to ask about food allergies!!! Acute hypotensive Acute pain syndrome Transfusion associated dyspnea (TAD) Bacterial contamination --- Majority from platelets!!! Transfusion associated circulatory overload (TACO) Transfusion related acute lung injury (TRALI) Hypothermia Arch Pathol Lab Med. 2007;131:

14 DELAYED TRANSFUSION REACTIONS (DAYS TO MONTHS) Formation of red cell antibodies GET ANTIBODY SCREEN AT HOSPITAL Formation of leukocyte antibodies Formation of platelet antibodies Graft versus host disease (T-GVHD) Iron overload (TRIO) Arch Pathol Lab Med. 2007;131:

15 TRALI Transfusion Related Acute Lung Injury TRALI has been the #1 cause of transfusion related deaths to the FDA since 2004 Estimated incidence (1:1000 to 1:5000) 1 in 5000 Packed RBC 1 in 2000 units of plasma-containing components 1 in 400 units of whole blood derived platelets

16 TRALI Any blood product can cause it Noncardiogenic pulmonary edema within 6 hours of transfusion with hypoxia Dyspnea, hypoxia, hypotension, fever, crackles Anti-neutrophil or HLA antibodies/ cytokines Mortality 5% to 25% Supportive care Do NOT use diuretics

17 TACO Transfusion associated circulatory overload 1 to 11% in critically ill patients (1:350) Tachypnea, dyspnea, tachycardia, hypertension, increased pulmonary artery pressure, jugular venous distention (cardiogenic pulmonary edema) Mortality up to 20% Treatment with diuresis and ventilatory support

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19 TRANSFUSION RELATED IMMUNE MODULATION (TRIM) Immune Activation TA-GVHD TRALI Alloimmunization Red cell antibodies Platelet antibodies Leukocyte antibodies Immune Suppression Nosocomial Infections Postoperative Infections Cancer Recurrence Enhanced Allograft Survival Microchimerism Lymphoma (SLL) Leukemia (CLL) Chest 2005;127:

20 TRIO Transfusion related iron overload Can occur with greater than 10 units in children and 20 units in adults Serum ferritin greater than 1,000 Most common with sickle cell, thalassemia, myelodysplastic syndromes, aplastic anemia, and leukemia Chelation therapy

21 CLINICAL CONSEQUENCES OF RED CELL STORAGE Transfusion 2006;46:

22 RBCs ARE DAMAGED GOODS Decreased 2,3 DPG Decreased ATP Decreased nitric oxide Decreased deformability Increased adhesiveness and aggregation Increased free hemoglobin Formation of microparticles

23 RISK OF DEATH

24 2012 by American College of Physicians Carson J L et al. Ann Intern Med doi: /

25 BENEFITS and ALTERNATIVES

26 RBC TRANSFUSIONS Acute Hemorrhage Chronic Anemia only with significant symptoms (chest pain, CHF, marked orthostatic changes not responsive to saline)

27 APPROPRIATENESS OF TRANSFUSIONS REVIEW OF 555 STUDIES OVER PAST 13 YEARS SHOWS ONLY 11% OF TRANSFUSIONS IMPROVED OUTCOMES IN NON-HEMORRAGING PATIENTS

28 TRICC STUDY Transfusion Requirements In Critical Care Prospective, randomized, controlled trial Multiple ICUs (25 centers) 838 critically ill patients 418 pts restrictive strategy (<7g/dl) 420 pts liberal strategy (<10g/dl) 30 day mortality: 18.7% vs 23.3% Hospitalization mortality: 22.2% vs 28.1% Herbert PC et al. NEJM 1999; 340:

29 TRICC Results

30 RBC TRANSFUSIONS HBG LESS THAN 7 Resuscitated critically ill patients Critically ill with hemodynamically stable anemia Critically ill with mechanical ventilation Critically ill with stable cardiac disease

31 RBC TRANSFUSIONS Should be given as SINGLE units NEW RULE instead of 2 REMEMBER ---- less is more

32 Massive Hemorrhage NOTIFY BLOOD BANK x22850 Massive Blood Transfusion Protocol

33 Massive Blood Transfusion Protocol (MBT) Must have baseline labs (Hbg,INR,Plt,Fib) which is the acute bleed profile === === ===repeat 5 RBCs 4 FFP 1 Plateletpheresis 5 Cryo

34 MASSIVE TRANSFUSION Prevent hypothermia and acidosis TXA (tranexamic acid)(within 3 hours) Replace calcium, follow ionized levels Prothrombin Complex Concentrate (PCC) - Wait till used all blood components Variable outcomes (i.e. NOT a sure thing)

35 CHRONIC ANEMIA Don t transfuse unless having significant symptoms

36 CHRONIC ANEMIA FIRST --- Identify cause of the anemia Transfuse only with significant symptoms (chest pain, CHF, marked orthostatic changes not responsive to saline) ONLY ONE UNIT AT A TIME (NOT TWO) CONSIDER ALTERNATIVES

37 IV IRON THERAPY Iron Gluconate Order Set #233 Try oral iron first, if unsuccessful then use IV iron

38 IRON THERAPY ALWAYS consider oral or IV iron therapy as an ALTERNATIVE to RBC transfusions Usually have maximal reticulocytosis in 7 to 10 days Usually see 2 gram rise in hemoglobin 1 week Usually see normal hemoglobin values in one month

39 36 year old heavy menses hemoglobin 5.6 After 4 doses IV iron her hemoglobin was 10.4 in 3 and a half weeks

40 RED BLOOD CELL NO NOs Do NOT transfuse red blood cells for Anemia that can be treated medically Volume replacement Oncotic pressure Improve wound healing (only need 4-5 g/dl) Sense of well being

41 PRE-OP ANEMIA Diagnose it Treat it Do NOT transfuse it!!!

42 IRRADIATED BLOOD Cancer patients on chemotherapy Directed related donors Intra-uterine transfusions

43 YELLOW BLOOD PLATELETS FRESH FROZEN PLASMA (FFP) CRYOPRECIPITATE (CRYO)

44 HEMOSTATIC RANGE MUST DIFFERENTIATE HEMOSTATIC RANGE FROM REFERENCE RANGE Platelets: 50,000 (hemostatic) INR: less than 2 (hemostatic) Fibrinogen: 100 (hemostatic) Reference platelets: 150, ,000 Reference INR: Reference fibrinogen:

45 THE INR, PLATELET COUNT AND FIBRINOGEN DO NOT PREDICT WHO WILL BLEED BUT THEY CAN GUIDE REPLACEMENT THERAPY IF BLEEDING

46 PLATELETS Prophylaxis < 10,000 Bleeding < 50,000 Bleeding confined spaces (like brain) < 100,000 Platelet dysfunction (drugs) --- ANY count Massive blood transfusion

47 EPIDURAL / SPINAL 170 obstetrical patients with platelet counts between 50,000 to 100,000 No complications Recommendation of platelet count at least 75,000 for epidural anesthesia????? BEWARE of RAPIDLY FALLING platelet counts!!!!!!!!!!!

48 PLATELETS Therapeutic dose One plateletpheresis pack From only one donor Equivalent to 6 to 10 random platelets ABO/Rh compatibility preferred NEVER use microaggregate filter

49 PLATELETS Timing of transfusion If actively bleeding, then transfuse ASAP If pre-procedure, then give within 4 hours of procedure or surgery Should raise platelets 30 to 60K

50 PLATELET NO-NOs Do NOT transfuse platelets for Thrombotic thrombocytopenic purpura (TTP) Immune thrombocytopenia (ITP) Post-transfusion purpura Heparin induced thrombocytopenia (HIT) Drug-induced thrombocytopenia UNLESS life threatening bleeding

51 COAGULATION FACTOR HEMOSTATIC LEVELS Fibrinogen Prothrombin Factor V Factor VII Factor VIII Factor X Factor XIII 50mg/dl 20-30% 15-20% 15-20% 15-20% 15-20% 2-5% Mannuci, Blood, 2004;104:1243

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53 FRESH FROZEN PLASMA Bleeding with INR of 2 or greater Massive blood transfusion URGENT warfarin reversal (if no 4-PCC) Vitamin K (10mg IV) 4 Prothrombin Complex Concentrate (4-PCC) Factor deficiencies without concentrates Heparin resistance

54 FFP MUST BE ADEQUATE DOSE USUAL DOSE to 20 ml/kg Average volume of one FFP is 300 ml So minimum dose is usually at least 3 FFP in 70 kg patient (up to 5 FFP)

55 FFP MUST BE GIVEN AT RIGHT TIME Only give within 4 hours of a procedure or when actually bleeding Coagulation effect only lasts about 6 hours NEVER give the night before a procedure NEVER give to normalize INR

56 INR OF FFP INR of FFP was actually measured Only 20% had INR 0f % had INR of % had INR of 1.2 5% had INR of 1.3 THEREFORE 75% of FFP has an INR >1.0

57 FFP NO NOs Do NOT transfuse FFP to Normalize abnormal INR results Patients on heparin (unless heparin resistant) Increase blood volume Increase albumin level Elevated INR that can be corrected with Vitamin K or PCC

58 VITAMIN K Good stuff --- use oral or IV, but NOT SQ May work as quick as 12 hours (24 to 48) INR <5 without bleeding: hold warfarin INR 5-9 without bleeding: hold +/- Vit K INR >9 without bleeding: hold plus Vit K INR >20 : hold plus Vit K +/- FFP/PCC Chest 2008;133:160S

59 VITAMIN K IF you use ONLY 1.0 to 2.5 mg vitamin K THEN you will NOT make patient resistant to restarting coumadin

60 CRYOPRECIPITATE Bleeding with fibrinogen less than 100 UNLESS pregnant than less than 200 Massive blood transfusion Congenital fibrinogen deficiencies Factor XIII deficiency

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62 ANTIFIBRINOLYTICS Tranexamic acid (TXA) MBT --- given ASAP (best within one hour) Prophylactically C-sections (#197) Use in post-partum bleeding (TXA) WOMAN TRIAL in progress (15,000) Small study using 4 g TXA if > 800 ml bleed

63 TRANSEXAMIC ACID Efficacy of IV TXA in Reducing Blood Loss With Elective C-section: Prospective, Randomized, Double-blind, Placebo Controlled Study 660 women 330 in each arm 1 g TXA IV over 5 minutes at least 10 minutes prior to skin incision Oxytocin given after delivery

64 TXA Mean blood loss less in TXA group TXA group has less patients with >1000 ml bleeds No increase in thrombotic events

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69 CELL SAVER New and improved Better washing of red cells and use of microaggregate filter Very helpful with patient with multiple antibodies 800 procedures done safely in OB Amnionic fluid embolism risk negligible Can order as STAND-BY

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71 DIC AND TRANSFUSION

72 DIC DIAGNOSIS Need both clinical and laboratory data that is being continually monitored by repeating both lab tests and the clinical exam

73 DIC LABS DIC Profile (Wesley Lab) CBC (WBC, HBG, PLATELET COUNT) PTT PT/INR FIBRINOGEN D-DIMER NO MORE FSP.. As part of profile ORDER TESTS EVERY 30 MINUTES

74 DIC LAB RESULTS WITH ACUTE DIC Decreased platelet count Decreasing fibrinogen Increased PT/INR Increased PTT Increased D-DIMER (((((look at trends)))))

75 DIC D-DIMER Does NOT differentiate between SYSTEMIC fibrinolysis of DIC and the LOCALIZED fibrinolysis seen with surgery and trauma

76 DIC Activation of BOTH procoagulant and fibrinolytic pathways leading to thrombosis and bleeding Diverse etiologies

77 DIC ETIOLOGIES Sepsis (up to 50%) Obstetrical complications Malignancy (up to 20%) Trauma (especially brain and crush) Severe toxins (snakes) Immunologic reaction (incompatible blood) Organ destruction (acute pancreatitis) Vascular abnormalities

78 OB DIC Acute Hemorrhagic DIC Placental abruption (50%) Eclampsia (up to 7%) Amniotic fluid embolus (50%) HELLP (20 to 84%) Eclampsia Acute fatty liver of pregnancy Massive Hemorrhage/ Uterine rupture Septic abortion

79 TREATMENT DIC MOST IMPORTANT Control/correct the underlying triggering pathologic disease

80 TREATMENT DIC SUPPORTIVE CARE VOLUME EXPANSION WITH CRYSTALLOIDS TO CORRECT HYPOTENSION BLOOD PRODUCTS ONLY IF BLEEDING

81 DIC Major bleeding occurs in a minority (5-12%) of patients More common is organ failure secondary to intravascular thrombi

82 TREATMENT DIC BLOOD PRODUCT USAGE IF BLEEDING YELLOW blood can be life saving with severe hemorrhage If fibrinogen less than 200 transfuse cryo If platelets less than 50,000 transfuse platelets If INR greater than or equal to 2...transfuse FFP RED blood used to keep hemoglobin greater than 7 at least

83 TREATMENT DIC REMEMBER IF BLEEDING IS ONLY MILD, THEN DO NOT TRANSFUSE JUST BECAUSE THE LABS ARE ABNORMAL BLOOD PRODUCTS JUST BUY YOU TIME TO TREAT THE UNDERLYING PROBLEM ONLY TRANSFUSE IF SIGNIFICANT BLEEDING OR INVASIVE PROCEDURE WITH RISK OF SIGNIFICANT BLEEDING

84 TREATMENT DIC If bleeding is uncontrollable Then order MASSIVE BLOOD TRANSFUSION (MBT) PROTOCOL

85 BLEEDING DURING SURGERY Dilutional thrombocytopenia Dilutional coagulopathy DIC Fibrinolysis SO ORDER ACUTE BLEED PROFILE (order set)

86 BLEEDING DURING SURGERY FIBRINOLYSIS Overlooked as cause of bleeding Labs are normal, even fibrinogen Patient was clotting, then begins to ooze Use antifibrinolytics. DO NOT USE FFP

87 ALTERNATIVES Pharmacy is the NEW blood bank!!! IV Iron (iron gluconate, order #233) IV Vitamin K Antifibrinolytics (TXA, order #197) Coagulation Factor Concentrates Kcentra (4 factor PCC) Humate P Factor 8 and 9 concentrates Fibrinogen concentrate new, not at WMC yet

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90 PROPHYLATIC TRANSFUSIONS NOT for Central lines Thoracentesis Paracentesis Liver biopsies Kidney biopsies Endoscopies without biopsies Lumbar punctures for diagnoses