Dr Mere Kende, MBBS, MMED (Path),MAACB (AUS), MACTM (AUS),MACRRM (AUS) Department of Pathology Faculty of Health Sciences & Medicine UPNG

Transcription

1 Dr Mere Kende, MBBS, MMED (Path),MAACB (AUS), MACTM (AUS),MACRRM (AUS) Department of Pathology Faculty of Health Sciences & Medicine UPNG

2 Blood Group and Transfusion 1. ABO system 2. Rhesus system 3. Other Blood Groups 4. Blood Bank and X-Matching 5. Types of Blood Donation 6. Blood Bank Products 7. Blood Transfusion Procedure? 8. Transfusion Reaction 9. Management of Transfusion Reactions

3 Blood Groups Blood Group/Type is determined by the type of antigen (glycolipids, proteins, gylcoproteins) present on the red blood cells (RBCs) Of 100S of RBC antigens, only ~30 important clinially Naturally occurring antibodies allo-antibodies eg anti- A and anti- B

4 Blood Group systems 1. ABO system 2. Rhesus system 3. Other Blood Group system

5 Blood Type Inheritance

6 ABO system Most important Gene locus on chrom. 9 Natural Antigens (allo-antibodies) account for major blood group reactions in transfusion medicines Antigens are accompanied by allo-antibodies

7 Blood Type Phenotype A B AB O Genotype AA or AO BB or BO AB OO

8 Composition of ABO antigens Carbohydrate antigens (glycolipids) A and B

9 AB0 system Antigen & Antibody.

10 Frequency of ABO phenotypes Phenotypes A B AB O European Americans African Americans Germans South USA- Indians Australian Aborigines From Harrisons Text Book

11 Rhesus/Rh system Second in importance only to ABO system Gene locus in chrom 1 Rh antigens include C, D, E Rh D is the most antigenic and can cause compatibility problems 15% of Caucasians lack Rh D antigen

12 Rh system -Rh-positive (Rh+) Rh D is present on their RBCs (most people), -Rh-negative (Rh ) when Rh D is absent.

13 Anti-Blood Group ANTIBODIES Anti-ABO antibodies igm -do not cross placenta Naturally occurring Anti Rh D antibody IgG crosses placenta Acquired-Prior sensitisation required for formation 80% of patients receiving RhD positive blood will develop anti-d antibodies and subsequently will react to repeat transfusions

14 Importance of Rh system in pregnancy MUM (homozygous Rh -/Rh- Rhesus Negative Rhesus Positive Rhesus inheritance: RhD +ve/-ve Dad =100% babies RhD+ve RhD +ve/-ve Dad = 50% of babies Rh+ve b DAD (homozygous/heterozygous) Rh +/Rh + Rh+/Rh-

15 Rhesus sensitisation occurs In Pregnancy Abortion (spontaneous/induced) Amniocentesisi/chorionic venous sampling Placenta praevia/abruptio FDIU Caesarean section Following Transfusion RhD negative females receiving RhD positive blood

16 Effects of Isoimmunisation Hemolytic Disease of Newborn Severe jaundice/anaemia <24hrs Risk of Kenicturus/Brain damage Miscarriage/Abortion FDIU/stillbirth/blighted Ovum

17 Rhesus isoimmunisation Rhesus status of a population differs from country or ethnic group to another Caucasians have higher incidence of Rh negativity In PNG, majority are Rhesus positive

18 Rhesus D Isoimmunisation Essential to diagnosis Maternal Rh-negative Positive indirect coomb s test History of previous baby with Hemolytic disease Postnatal foetal blood Rh-positive and low Hb

19 Prevention of Rhesus isoimmunisation 1. Antenatal Screen 1 st Visit Rh /ABO group Indirect Coomb s Test 2. Avoid transfusing RhD +ve blood to RhD-ve mothers/females 3. Give Rhesus Immunoglobulin

20 Prevention of Rhesus isoimmunisation Give RhD ve mother Rh immunoglobulin unless the father is also Rh negative

21 Recommendations for prophylactic anti-d immunoglobulin in RHESUS D negative women After delivery/abortion/miscarriage etc if the infant is Rh positive Antenatally at 28 and 34 weeks - not yet universal RhD IgG prophylaxis reduces risk to 0.2%

22 ABO hemolytic Disease ABO incompatibility > RhD incompatibility i.e., 40-50% vs 1-2% Milder than that evoked by RhD or other blood group antigens Almost always in group A or B infant with Group O mothers. Serious fetal sequelae including anaemia is rare Phototherapy required in 10%, exchange transfusion in 1%, and Kernicterus (Brain damage) never occurs

23 Other Blood Group System Carbohydrate Blood Antigens Lewis system I system P system Protein Blood Antigens Kell Duffy Kidd systems Gerbich system

24 Other blood groups Lewis system common cause pre-transfusion incompatibility, not part of RBC but absorbed from plasma I system cause problems when cold blood is transfused or follows EBV, or mycoplasma pneumonia infections P system associated with syphilis/viral infections/pnh

25 Kell - 3 rd commonest outside ABO/Rh system Duffy - receptor for plasmodium vivax Kidd systems - delayed transfusion reactions Gerbich system -found northern coast of PNG

26 Importance of blood grouping Ensure Correct Blood Group is transfused Avoid Pregnancy related haemolytic Disease of Newborn

27 Cross matching (x-match) DONOR BLOOD + RECIPIENT BLOOD COMPATIBLE

28 A Blood (has anti-b) IS NOT COMPATIBLE with B blood (has anti-a) A Blood + B Blood Reaction (Hemolysis)

29 Donor Recipient Type O Universal Donor Type AB Universal Recipient

30 COMPATIBITY TESTING

31 compatibility

32

33 Whole Blood Plasma Packed Red Cells Platelets White cells Lymphocytes Clotting Factors Albumin Antibodies Blood Components

34 Blood Bank Products Whole Blood No elements removed 1 Unit=450ml (hct 40%) Contains all cell types Wbc & platelet may be non-functional Deficient V& VII INDICATION: Not for routine use Acute, massive loss Open heart surgery Neonatal total exchange

35 Blood Bank Products PACKED RED CELLS 1unit = mls Wbc & platelets removed 1 unit raises HCT by 3% or Hb 1g/dL INDICATION Most commonly used blood product Replacement in chronic and acute blood loss

36 Blood Bank Products UNVERSAL PEDI-PACKS mls divided into 3 bags Contains RBC and some WBC, PLT, and plasma INDICATIONS Transfusion of infants

37 Blood Bank Products LEUCOCYTE REDUCED or POOR RED CELLS Most wbc removed by filtration Minimal plasma Less antigenic 1unit = mls INDICATION Potential renal transplant pts Previous febrile transfusion reactions (common) Patients requiring multiple transfusion (eg AML)

38 BLOOD BANK PRODUCTS WASHED RBCS Wbc almost completely removed No plasma 1 unit= 300mls INDICATIONS As for leucocyte poor red cells Much more purified

39 BLOOD BANK PRODUCTS PLATELETS 1 packs= 50mls ( >5x10 power 10 PLTs) 1pck raises PLT by 5,000-8,000 Contains RBC & WBC INDICATION Low PLT 5,000-10,000 risk of spontaneous bleeding 10, if symptomatic < if surgery required

40 BLOOD BANK PRODUCTS CRYOPRECIPITATE ANTIHEMOPHILIC FACTOR ( cryo ) 1unit -10mls Contains factors VIII, XIII, vwf, fibrinogen INDICATION Hemophilia A (if [Factor VIII] not available) VWF disease Fibrinogen deficiency

41 Blood bank products Fresh Frozen Plasma (FFP) Contains factors II, VII, IX, X, XI, XII, XIII and heat labile factors V & VII 1unit=10mls About 1hr to thaw 1unit = mls INDICATIONS Emergency warfarin reversal (INR>10) Massive transfusion (>5L adults) Hypoglobulinaemia Coagulopathy/active bleeding (when concentrate not available)

42 Blood bank products SINGLE DONOR PLASMA Like FFP but no labile factors V, & VIII 1unit= mls 1hr to thaw INDICATION Stable factor replacement Warfarin reversal Hemophilia B /christmas disease

43 BLOOD BANK products Clotting Factor Concentrates VIII Prothrombin Complex (II, VII, IX, X) Increased risk of hepatitis (many donors) INDICATION Hemophilia A Hemophilia B/Christmas Disease

44 BLOOD BANK products Immune Serum Globulin Precipitate from plasma globulin INDICATION Immune globulin deficiency

45 BLOOD BANK products Rho Gam (Rho D IgG) Antibody against RhD factor Vol -1ml INDICATION Rh mother with Rh+ baby within 72hrs of birth to prevent Hemolysis (HDN)

46 BLOOD BANK products Albumin 5% or 25% Precipitate of Plasma INDICATION Volume expanders (acute blood loss) Hypoalbuminaemia Burns

47 Blood transfusion Blood Banking Procedure Determine/Types Blood Group (ABO, Rh) & screens for antibodies (combs antibody test) Cross matches if blood is immediately needed Cross Match involves testing recipients serum against donor blood cells (<1hr duration)

48 GROUPING & X-MaTCh process

49 Blood DONAtion 1. Voluntary (mainstay of Blood Donation) 2. Donor-Directed (Relative or friend) 3. Autologous (Patient s Own Blood)

50 Voluntary Donors Protocols available age>18 yrs Healthy Weight >50kg Limit 1unit/2moths Rejected: HRB (drugs/promiscuity); HBV, HIV, DM, major organ diseases) Screen: HBsAg, HCV, HIV, ABO antibodies, Rh Antibody, (HBc Antibody, malaria) Blood Donor Registry

51 Donor- directed donation A relative or a friend donates blood Not suitable for emergency Takes 48hrs to process blood Must be free of infections/risk behaviour Used as Packed cells

52 Autologous Donation Elective 3-7 days prior to surgery Donate 1unit every 3-7 days Give iron tab before and several months after surgery Units of WB can be held for 35 days

53 Emergency transfusion Massive hemorrhage Type specific (ABO/ Rh) blood preferred If not available - Type O blood, PRBC If possible support with colloid or crystalloid until x- matched blood is available

54 Red cell transfusion Acute blood loss Healthy person can tolerate blood loss of 30% (slight symptoms) Total Blood Volume (Litres) = 0.08 x weight (kg) Allowable blood loss (ABL) = Total volume x 0.3 (Assume Normal Hb) So estimate of ABL in 70kg person = 70 x 0.08 x 0.3 = 1680mls Manage with IVF if less than ABL Shock if blood loss if >ABL

55 Haemoglobin level and Transfusion Hb >10g/dL transfusion rarely indicated Hb 7-10g/dL transfuse if symptomatic (caution Heart Disease/COPD) Hb <7g/dL transfusion usually needed Chronic anaemia may not require transfusion but (iron/epo etc) unless symptomatic or very sick

56 RBC transfusion Formula 1unit raises Hb by 10g/L or 3% HCT Volume of PRBC/WB needed Total Blood Volume of Pt x (Desired HCT Actual HCT HCT of Transfusion Product Where TBV =70ml/kg for adults & 80ml/kg in children, HCT of Packed cell is 70% and Whole Blood is 40%

57 Transfusion procedures Follow Local Protocols Clotted blood necessary for Group +/-x-match Explanation & Consent form signed Select appropriate Blood Products and Quantity Ensure good access to VEINS/Proximal Veins

58 Transfusion procedures Choose large bore needle (size 14-18) Ensure correct blood product and patient ID by two nurses Transfuse within 3-4hrs Mix blood products with 0.9% NS only (D5W causes hemolysis in tubing) Avoid Transfusing at late night, during change over/end of shift

59 Transfusion procedures When transfusing large volumes of blood (>10units) Monitor PT, aptt, K+, Mg++, Ca+, lactate (hypocalcemia, hyperkalemia or acidosis risk) May need calcium, PLT & FFP replacements (Bleeding risk) Warm blood bags (hypothermia risk)

60 Monitoring blood transfusion Identify & Prevent risk of complications Heart failure/kidney disease/htn/severe anaemia/coad/acute RTI/cold blood /previous reactions Give lasix 20-40mg if required 30mins-60mins BP, HR, Pulse, temp & alertness

61 Features of reaction Symptoms Restlessness, vomiting, headache, dizzy SOB/chest pain Pain over IV site Itchiness Fever Chills & Rigor Abdominal pain Dark urine Signs Hypotension/hypertension High/Low Temp Hypoxaemia tachycardia Lung crackles Low Hb Hematuria/dark urine Hypocalcemia/hypoK+ Pink plasma Abnormal PT or APTT Low haptoglobulin

62 Nonhemolytic febrile reactions Mild allergic reactions Volume overload Acute intravascular hemolysis (very rare) Anaphylactic reaction (very rare) Acute lung injury (rare) Sepsis/Infections (rare) Alloimmunisation (rare) Transfusion Associated-Host versus Graft Disease (TA-GVHD)-

63 Other reactions/complications Electrolyte Abnormalities (Ca++, Mg+2 or K+) Coagulation Disorders/Thrombocytopenia Hypothermia

64 Managing tranfusion reaction 1. Give Stop transfusion 2. Notify Dr/Senior Nurse 3. Notify Blood Bank/Laboratory 4. Continue vitals Measurement 5. Give paracetamol/ibuprofen/diclofenac 6. Give phenergan mg or diphenhydramine 25-50mg IM/IV/PO

65 Managing tranfusion reaction If severe reaction: (restless/severe itch/hypotension) Methylprednisolone 125mg IV, 2mg/kg paediatrics Epinephrine/adrenaline 1:10,000; 0.1ml/kg ( mls adults) (Beware 1:1000 for IM/sc use ) Identify cause & Treat?infection/?Fluid overload/hemolysis?pulm Oedema etc

66 Treat cause Nonhemolytic febrile reactions Antipyretic and continue transfusion Use leucocyte-washed products in future Mild allergic Reaction Give phenergan/diphenhydramine 25-50mg IV/IM/PO resume transfusion if symptoms improve Anaphylactic Reaction Washing to remove donor plasma reduces risk of allergic reactions Terminate transfusion Give phenergan, methylpred, adrenaline Use premed in future, or use wbc-washed cells

67 Treat cause Acute Lung Injury Ventilation Support & oxygen Use WBC-washed cells in future Sepsis IV broad spectrum antibiotics Volume overload Slow infusion (3-4hours PRBC) Diuretics (lasix) Oxygen

68 Treat Cause Acute intravascular hemolysis Place IDC Monitor urine output Ensure diuresis (D5W, mannitol) Diuretics (lasic) +/- dopamine Monitor DIC Consult experienced Specialist /haematologist

69 Treat CAuse Hypothermia Monitor Temp Keep warm warm blood bags Avoid very cold IV fluids Electrolytes: Observe for cramps, arrhythmia Correct hypocalcemia/hyerkalemia Avoid aged blood transfusion Bleeding Disorder Check PT & aptt Give Platelet if bleeidng Identify cause & Treat

70 References: 1. LG Gomella. Clinician s Pocket Reference 11 th Edition 2. Harrisons Text Book 17 th Edition 3. Despopoulos. Colour Atlas of Physiology 5 th Edition