Treatment with

blood products

Mirosław Franków
Department of Hematology

Pomeranian Medical
University

BLOOD
COMPONEN
TS

Apheresis

Whole blood enters the centrifuge on
the left and separates into layers so that
selected components can be drawn off
on the right.

BLOOD COMPONENTS

Blood separated into
different parts:



Packed red cells

Packed red cells



Platelets

Platelets



Fresh frozen plasma

Fresh frozen plasma



Cryoprecipitate

Cryoprecipitate



Granulocytes

Granulocytes



Factor IX conc.

Factor IX conc.



Factor VIII conc

Factor VIII conc

.

.

Blood

Blood

component

component

Contents

Contents

Volume

Volume

Shelf life

Shelf life

Whole blood

Whole blood

Hct.35%,RBCs,

Hct.35%,RBCs,

WBCs.450ml

WBCs.450ml

blood,63ml

blood,63ml

CPDA1

CPDA1

520ml

520ml

35 days at

35 days at

4deg.C.

4deg.C.

Red cells

Red cells

Hct.60%,RBCs,25mlpla

Hct.60%,RBCs,25mlpla

sma,

sma,

100 ml Adsol.

100 ml Adsol.

340ml

340ml

42 days at

42 days at

4deg.C

4deg.C

Platelets

Platelets

Platelets,

Platelets,

few

few

WBCs,

WBCs,

RBCs,

RBCs,

50ml plasma

50ml plasma

50ml

50ml

5 days at

5 days at

22deg.C

22deg.C

FFP

FFP

Cryoppt.

Cryoppt.

Pl.

Pl.

proteins,

proteins,

clot.

clot.

Factors

Factors

Fibrinogen,factor

Fibrinogen,factor

VIII,IX.

VIII,IX.

225ml

225ml

15ml

15ml

1year at

1year at

-18deg.C

-18deg.C

Obtaining the Blood or
Component

•

Hospital employee obtaining blood/component

Hospital employee obtaining blood/component

from Transfusion Medicine must state the

from Transfusion Medicine must state the

patient’s name and hospital (unique) number.

patient’s name and hospital (unique) number.

•

An ‘issue report’ will be given to them along

An ‘issue report’ will be given to them along

with the blood/component.

with the blood/component.

•

Blood and components are to be infused

Blood and components are to be infused

immediately when received on the ward.

immediately when received on the ward.

•

If unable to do so, the product must be

If unable to do so, the product must be

returned to Transfusion Medicine.

returned to Transfusion Medicine.

•

Blood that is out of approved storage for

Blood that is out of approved storage for

longer than 30 minutes

longer than 30 minutes

MUST NOT

MUST NOT

be

be

transfused.

transfused.

Blood Component
Verification

P

P

hysician

hysician

must verify the blood component

must verify the blood component

with

with

issue report:

issue report:

•

The blood component

The blood component

•

The blood component unit number

The blood component unit number

•

Group and Rh of the blood

Group and Rh of the blood

component

component

A visual assessment of the blood unit should

A visual assessment of the blood unit should

be performed.

be performed.

Visual Assessment of
Blood

Is the seal secure and leak free?

Is there
hemolysis?
Is the
plasma
pink?

Are the red
cells red or are
they purple or
black?

Are there any
large clots
visible?

There should be no leakage, visible clots or hemolysis.

Red cells should be a normal color. If any abnormality

is noted, this should be reported to Transfusion

Medicine.

Patient Verification



Compare the patient’s name and

Compare the patient’s name and

hospital unique number on their ID

hospital unique number on their ID

armband with the blood/component

armband with the blood/component

label and the issue report.

label and the issue report.



The

The

P

P

hysician must sign the issue

hysician must sign the issue

report.

report.

In case of any discrepancy:

In case of any discrepancy:

blood/component must NOT be transfused

blood/component must NOT be transfused

Frequency of Transfusion
Adverse Events



Transfusion Associated Circulatory Overload

Transfusion Associated Circulatory Overload

1:200

1:200



TRALI

TRALI

1:5000

1:5000



ABO incompatible transfusion

ABO incompatible transfusion

1

1

:

:

30000-

30000-

60000

60000



Severe anaphylactoid reaction

Severe anaphylactoid reaction

1:20000

1:20000



GVHD/Post Transfusion Purpura

GVHD/Post Transfusion Purpura

1:750000 to

1:750000 to

1:1million

1:1million

Frequency of Transfusion
Adverse Events

Virus

Virus

Risk per Unit

Risk per Unit

Transfusion

Transfusion

Transmission

Transmission

Rate

Rate

Window

Window

Period

Period

HIV 1&2

HIV 1&2

1:2,135,000

1:2,135,000

90%

90%

11 days

11 days

HCV

HCV

1:1,935,000

1:1,935,000

90%

90%

10 days

10 days

HBV

HBV

1:205,000

1:205,000

70%

70%

59 days

59 days

HTLV

HTLV

1:3,000,000

1:3,000,000

30%

30%

51 days

51 days

WNV

WNV

1:10,000 to

1:10,000 to

1,000

1,000

(prior to NAT)

(prior to NAT)

Unknown

Unknown

-

-

Parvo B19

Parvo B19

1:40,000 to

1:40,000 to

3,000

3,000

Low

Low

-

-

Hepatitis

Hepatitis

A/E

A/E

1:1,000,000

1:1,000,000

Low

Low

-

-

Blood Testing



Syphilis

Syphilis



HIV 1

HIV 1



HIV 2

HIV 2



Human T-lymphotrophic virus 1 (HTLV-1)

Human T-lymphotrophic virus 1 (HTLV-1)



Hepatitis B surface antigen (HbsAg)

Hepatitis B surface antigen (HbsAg)



Hepatitis C virus (HCV)

Hepatitis C virus (HCV)



Alanine aminotrans

Alanine aminotrans

fer

fer

ase (ALT)

ase (ALT)



Hepatitis B core antibody (HbcAB)

Hepatitis B core antibody (HbcAB)



Surrogate marker for HIV infection

Surrogate marker for HIV infection



Surrogate marker for non-A, non-B hepatitis

Surrogate marker for non-A, non-B hepatitis

Cross-match – red cell

compatibility testing

Red Cell Products



Indication: Restore oxygen carrying capacity in

Indication: Restore oxygen carrying capacity in

symptomatic anemia

symptomatic anemia



Packed Red Blood Cells

Packed Red Blood Cells



Volume: 350 ml (250 ml CPDA units)

Volume: 350 ml (250 ml CPDA units)



Hct: 50 – 60% (70 – 80% CPDA units)

Hct: 50 – 60% (70 – 80% CPDA units)



Whole Blood

Whole Blood



Also replaces volume loss

Also replaces volume loss



Volume: 500 ml

Volume: 500 ml



Dose: 1 unit should raise the Hgb 1g/dl

Dose: 1 unit should raise the Hgb 1g/dl

(Hct 2-3%)

(Hct 2-3%)



Shelf-life: 35 – 42 days

Shelf-life: 35 – 42 days

Red Cell Products



Irradiated

Irradiated

(

( irradiation inactivates donor

lymphocytes, reduce risk for GVHD)



Washed

Washed

(

(Removes plasma proteins; Risk of

allergic reactions may be reduced)



Leukocytes Reduced

Leukocytes Reduced

(

(Risk of febrile

reactions, HLA alloimmunization, and
CMV infection reduced)

MODIFIED PRODUCTS

MODIFIED PRODUCTS

Rapid development of
anemia needing
transfusion



Massive hemorrhage

Massive hemorrhage



hemolytic/aplastic crises

hemolytic/aplastic crises



Autoimmune haemolysis - often

Autoimmune haemolysis - often

elderly but even young patients may

elderly but even young patients may

require transfusion in this setting

require transfusion in this setting



Delayed haemolytic transfusion

Delayed haemolytic transfusion

-SHOT -Delays in providing blood

-SHOT -Delays in providing blood

cause of death

cause of death

not

not

hemolysis

hemolysis

Iron overload and
chelation



Can occur in any patient requiring

Can occur in any patient requiring

chronic transfusion therapy or in

chronic transfusion therapy or in

hemochromatosis.

hemochromatosis.



Liver biopsy is the most accurate

Liver biopsy is the most accurate

test though MRI is being

test though MRI is being

investigated.

investigated.



Ferritin is a good starting test.

Ferritin is a good starting test.



Chelator, deferoxamine

Chelator, deferoxamine

Platelet Products



Indications:

Indications:



Correct bleeding due to thrombocytopenia or

Correct bleeding due to thrombocytopenia or

platelet dysfunction

platelet dysfunction



Prevent bleeding in critical thrombocytopenia

Prevent bleeding in critical thrombocytopenia



Platelet Concentrates (PCs)

Platelet Concentrates (PCs)



Volume:

Volume:

1 unit =

1 unit =

50 ml (majority is plasma)

50 ml (majority is plasma)



Dose: Approximately 1 unit/10kg (Adults, pool of

Dose: Approximately 1 unit/10kg (Adults, pool of

six units)

six units)



Shelf-life:

Shelf-life:



5 days (7 days with additional testing)

5 days (7 days with additional testing)



4 hrs if pooled

4 hrs if pooled

PLATELET PRODUCTS

Contain platelets,

Contain platelets,

plasma, and WBC from

plasma, and WBC from

4-8 donors

4-8 donors

Pooled

Pooled

Platelets

Platelets

Pooled

Pooled

Platelets

Platelets

Contain platelets,

Contain platelets,

plasma, and WBC from

plasma, and WBC from

one donor

one donor

Apheresis

Apheresis

Platelets

Platelets

Apheresis

Apheresis

Platelets

Platelets

PLATELET PRODUCTS



MODIFIED PRODUCTS

MODIFIED PRODUCTS

•

Irradiated

Irradiated

•

Washed

Washed

•

Leukocytes Reduced

Leukocytes Reduced

Platelet Therapy

Count

Count

Risk of Major

Risk of Major

Bleed

Bleed

>10,000/ul

>10,000/ul

Low

Low

5-10,000/ul

5-10,000/ul

Moderate

Moderate

<5,000/ul

<5,000/ul

High

High



One unit of PC can elevate the platelet count

One unit of PC can elevate the platelet count

by 5-10,000/ul in a stable, non-alloimmunized

by 5-10,000/ul in a stable, non-alloimmunized

70kg recipient

70kg recipient



A pre-operative platelet count of >50,000/ul

A pre-operative platelet count of >50,000/ul

is generally adequate for surgery

is generally adequate for surgery

Fresh Frozen Plasma



Indications: Correction of clotting factor deficiencies

Indications: Correction of clotting factor deficiencies

where clotting factor concentrates are not available or

where clotting factor concentrates are not available or

when multiple clotting deficiencies are present (e.g. liver

when multiple clotting deficiencies are present (e.g. liver

disease, Coumadin reversal, DIC)

disease, Coumadin reversal, DIC)

; u

; u

sed in TTP in

sed in TTP in

conjunction with

conjunction with

p

p

lasma

lasma

e

e

xchange

xchange



Volume: 200- 250 ml

Volume: 200- 250 ml



Dose: Approximately 10-15 ml/kg body weight

Dose: Approximately 10-15 ml/kg body weight

(Therapy is guided by coagulation studies (PT, aPTT)

(Therapy is guided by coagulation studies (PT, aPTT)



Storage: < -18C (requires thawing prior to

Storage: < -18C (requires thawing prior to

issuing –

issuing –

approx. 30 minutes to thaw)

approx. 30 minutes to thaw)



Shelf-life: 1 year; 24 hours if thawed

Shelf-life: 1 year; 24 hours if thawed



Contraindications

Contraindications



Available specific therapy: FVIII, FIX, Vit K

Available specific therapy: FVIII, FIX, Vit K



Volume expansion

Volume expansion



Patients with IgA antibodies or selective IgA

Patients with IgA antibodies or selective IgA

Deficiency

Deficiency

Cryoprecipitate



Preparation: Precipitates from FFP thawed

Preparation: Precipitates from FFP thawed

at 4C are refrozen

at 4C are refrozen



Contents:

Contents:



>80 IU Factor VIII

>80 IU Factor VIII



150 – 250 mg Fibrinogen

150 – 250 mg Fibrinogen



30 – 50 mg Fibronectin

30 – 50 mg Fibronectin



40 – 70% WB vWF

40 – 70% WB vWF



30% of WB Factor XIII

30% of WB Factor XIII



Volume: 5 – 15 ml

Volume: 5 – 15 ml



Storage: <-18C, must be thawed

Storage: <-18C, must be thawed

Cryoprecipitate



Indications:

Indications:



Correct bleeding due to fibrinogen, vWF, FVIII or

Correct bleeding due to fibrinogen, vWF, FVIII or

FXIII deficiency or dysfunction

FXIII deficiency or dysfunction



Bleeding due to uremia

Bleeding due to uremia



Dose:

Dose:



Depends on number of units of factor or

Depends on number of units of factor or

fibrinogen needed

fibrinogen needed



Usual adult dose (70 kg) = pool of 10 units (~ 2

Usual adult dose (70 kg) = pool of 10 units (~ 2

grams fibrinogen)

grams fibrinogen)



NOT concentrated plasma and should not be used

NOT concentrated plasma and should not be used

as a substitute for plasma

as a substitute for plasma

Factor VIII Concentrate



Intravenous infusion

Intravenous infusion



IV push

IV push



Continuous infusion

Continuous infusion



Dose varies depending on type of bleeding

Dose varies depending on type of bleeding



Ranges from 20-50+ units/kg. body

Ranges from 20-50+ units/kg. body

weight

weight



Half-life 8-12 hours

Half-life 8-12 hours



Each unit infused raises serum factor VIII

Each unit infused raises serum factor VIII

level by 2 %

level by 2 %

Factor IX Concentrate



Intravenous infusion

Intravenous infusion



IV push

IV push



Continuous infusion

Continuous infusion



Dose varies depending on type of bleeding

Dose varies depending on type of bleeding



Ranges from 20-100+ units/kg. body

Ranges from 20-100+ units/kg. body

weight

weight



Half-life 12-24 hours

Half-life 12-24 hours



Each unit infused raises serum factor IX

Each unit infused raises serum factor IX

level by 1%

level by 1%

Factor VII a



in the treatment of patients with

coagulation factor VIII or IX inhibitors or

in close collaboration with a physician

specialised in treatment of haemophilia



FVIIa is injected, which is the active form

FVIIa is injected, which is the active form

of Factor VII

of Factor VII



This probably associates with tissue factor

This probably associates with tissue factor

at the site of injury and activates IX and X

at the site of injury and activates IX and X



Inject 90 ug/kg and achieve 3 to 20 nM

Inject 90 ug/kg and achieve 3 to 20 nM

FVIIa; half life 2.7 hours

FVIIa; half life 2.7 hours

FEIBA



Factor Eight Inhibitor bypassing agent

Factor Eight Inhibitor bypassing agent



Purify the vitamin K dependent factors

Purify the vitamin K dependent factors

that undergo contact activation at some

that undergo contact activation at some

point

point



Contains FVIIa and Xa in addition to

Contains FVIIa and Xa in addition to

non-activated factors (amounts unclear)

non-activated factors (amounts unclear)



1 unit shortens the aPTT of an inhibitor

1 unit shortens the aPTT of an inhibitor

plasma by 50%

plasma by 50%



Give 50 to 100 U/kg up to twice a day

Give 50 to 100 U/kg up to twice a day

What is a transfusion
reaction?



Any untoward event that occurs as a result

Any untoward event that occurs as a result

of infusion of a blood component

of infusion of a blood component

(immediate or delayed)

(immediate or delayed)



When any unexpected or untoward sign or

When any unexpected or untoward sign or

symptom occurs during or shortly after the

symptom occurs during or shortly after the

transfusion of a blood component, a

transfusion of a blood component, a

transfusion reaction must be considered as

transfusion reaction must be considered as

the precipitating event until proven

the precipitating event until proven

otherwise

otherwise



Only a high index of suspicion will allow a

Only a high index of suspicion will allow a

transfusion reaction to be diagnosed

transfusion reaction to be diagnosed

Immediate Adverse Effects
Associated with Transfusion



Acute Hemolytic

Acute Hemolytic

Transfusion Reaction

Transfusion Reaction



Febrile Non-Hemolytic

Febrile Non-Hemolytic

Transfusion Reaction

Transfusion Reaction



Allergic Reactions

Allergic Reactions



Urticarial

Urticarial



Anaphylactic

Anaphylactic



Hypervolemia

Hypervolemia



Non-immune Red Cell

Non-immune Red Cell

Hemolysis

Hemolysis



Transfusion-Related

Transfusion-Related

Acute Lung Injury

Acute Lung Injury

(TRALI)

(TRALI)



Septic Transfusion

Septic Transfusion

Reaction (Bacterial

Reaction (Bacterial

Contamination)

Contamination)



Hypotensive Reactions

Hypotensive Reactions



ACE Inhibitors

ACE Inhibitors



Metabolic Disturbances

Metabolic Disturbances



Hypothermia

Hypothermia



Hyperkalemia

Hyperkalemia



Acidosis

Acidosis

Delayed Adverse Effects
Associated with Transfusion



Delayed Hemolytic Transfusion Reaction

Delayed Hemolytic Transfusion Reaction



Alloimmunization

Alloimmunization



Red Cell Antigens

Red Cell Antigens



HLA

HLA



Leukocytes

Leukocytes



Platelets

Platelets



Graft versus Host Disease (TA-GVHD)

Graft versus Host Disease (TA-GVHD)



Post-transfusion Purpura

Post-transfusion Purpura



Hemosiderosis

Hemosiderosis



Viral and Parasitic Infections

Viral and Parasitic Infections



Transfusion Related Immunomodulation

Transfusion Related Immunomodulation

(TRIM)

(TRIM)

Estimates of Non-Infectious Risks of
Transfusion

Type

Type

Incidence

Incidence

Type

Type

Incidence

Incidence

Acute

Acute

Hemolytic

Hemolytic

1:38,000 to

1:38,000 to

1:70,000

1:70,000

Delayed

Delayed

Hemolytic

Hemolytic

1:5000 to

1:5000 to

1:11,000

1:11,000

Anaphylactic

Anaphylactic

1:20,000 to

1:20,000 to

1:50,000

1:50,000

HLA

HLA

Alloimmunization

Alloimmunization

10 – 20%

10 – 20%

TRALI

TRALI

1:5,000

1:5,000

Red Cell

Red Cell

Alloimmunization

Alloimmunization

1 – 2%

1 – 2%

Circulatory

Circulatory

Overload

Overload

1:10,000

1:10,000

TA-GVHD

TA-GVHD

Rare

Rare

Febrile Non-

Febrile Non-

Hemolytic

Hemolytic

1:200 – 1:17

1:200 – 1:17

(RBC)

(RBC)

1:100 – 1:3

1:100 – 1:3

(Plts)

(Plts)

Post-Transfusion

Post-Transfusion

Purpura

Purpura

Rare

Rare

Urticaria

Urticaria

1:100 to 1:33

1:100 to 1:33

Hemosiderosis

Hemosiderosis

Dependent

Dependent

on # units

on # units

transfused

transfused

Acute Hemolytic
Transfusion Reaction



Etiology: Red cell incompatibility

Etiology: Red cell incompatibility



Most severe reactions are seen following ABO

Most severe reactions are seen following ABO

incompatible transfusions

incompatible transfusions



As little as 5 – 20 ml of red cells can precipitate

As little as 5 – 20 ml of red cells can precipitate

severe reactions

severe reactions



Occur within minutes to hours after transfusion

Occur within minutes to hours after transfusion



Signs & Symptoms

Signs & Symptoms



Chills

Chills



Fever

Fever



Hemoglobinuria

Hemoglobinuria



Hypotension

Hypotension



Renal failure with oliguria

Renal failure with oliguria



DIC (oozing from IV sites)

DIC (oozing from IV sites)



Back Pain

Back Pain



Pain at infusion site

Pain at infusion site



Anxiety

Anxiety



Clinical Approach/Assessment

Clinical Approach/Assessment



Stop transfusion

Stop transfusion



Initiate a transfusion reaction work-up

Initiate a transfusion reaction work-up



Notify the blood bank

Notify the blood bank



Return remaining product or empty bag and all attached tubing and

Return remaining product or empty bag and all attached tubing and

IV fluid bags to the blood bank

IV fluid bags to the blood bank



Send new patient sample to blood bank and send urine sample

Send new patient sample to blood bank and send urine sample



Management

Management



Maintain urine output at appropriate level with fluids and diuretics

Maintain urine output at appropriate level with fluids and diuretics



Analgesics

Analgesics



Pressors for hypotension (low dose Dopamine)

Pressors for hypotension (low dose Dopamine)



Hemostatic components (FFP, cryo, platelets) for bleeding/coagulopathy

Hemostatic components (FFP, cryo, platelets) for bleeding/coagulopathy



Follow-up labs (total/indirect bilirubin, creatinine, LDH, haptoglobin,

Follow-up labs (total/indirect bilirubin, creatinine, LDH, haptoglobin,

CBC, PT/PTT)

CBC, PT/PTT)



Prevention

Prevention



Adequate training

Adequate training



Follow specified procedures and policies

Follow specified procedures and policies



Reliable patient and sample identification

Reliable patient and sample identification

Acute Hemolytic
Transfusion Reaction

Delayed Hemolytic
Transfusion Reaction



Etiology: Anamnestic immune response to RBC antigens

Etiology: Anamnestic immune response to RBC antigens



Signs & Symptoms

Signs & Symptoms



Fever

Fever



Decreasing hemoglobin

Decreasing hemoglobin



New positive antibody screening test

New positive antibody screening test



Mild jaundice

Mild jaundice



Laboratory testing

Laboratory testing



Antibody screen + DAT

Antibody screen + DAT



Visual inspection (plasma-free Hb or methemalbumin)

Visual inspection (plasma-free Hb or methemalbumin)



Hemolysis labs: LDH, bili, urine hemosiderin,

Hemolysis labs: LDH, bili, urine hemosiderin,

haptoglobin, H/H

haptoglobin, H/H



Therapeutic/Prophylactic Approach

Therapeutic/Prophylactic Approach



Identify antibody & transfuse compatible blood as needed

Identify antibody & transfuse compatible blood as needed

Febrile Non-hemolytic
Transfusion Reaction



Etiology

Etiology



Antibody to donor WBCs

Antibody to donor WBCs



Accumulated cytokines in bag

Accumulated cytokines in bag



Signs & Symptoms

Signs & Symptoms



Chills/rigors

Chills/rigors



Fever (generally defined as a 1C (2F) increase)

Fever (generally defined as a 1C (2F) increase)



Headache

Headache



May be accompanied by changes in BP and HR,

May be accompanied by changes in BP and HR,

dyspnea, nausea or vomiting

dyspnea, nausea or vomiting



Laboratory testing

Laboratory testing



Rule out hemolysis

Rule out hemolysis



Therapeutic/Prophylactic Approach

Therapeutic/Prophylactic Approach



Antipyretic premedication

Antipyretic premedication



Leukocyte-reduced blood products

Leukocyte-reduced blood products

Allergic (Urticarial)
Transfusion Reactions



Etiology: Antibody (IgE) to donor plasma

Etiology: Antibody (IgE) to donor plasma

proteins (found in platelets, FFP, Cryo,

proteins (found in platelets, FFP, Cryo,

RBCs)

RBCs)



Signs & Symptoms

Signs & Symptoms



Urticaria

Urticaria



Pruritis

Pruritis



Flushing

Flushing



Therapeutic/Prophylactic Approach

Therapeutic/Prophylactic Approach



Antihistamine, treatment or

Antihistamine, treatment or

premedication

premedication



May restart unit slowly after

May restart unit slowly after

antihistamine if symptoms resolve

antihistamine if symptoms resolve

Anaphylactic
Transfusion Reaction



Etiology: Ab to donor plasma proteins (IgE, IgA, C4)

Etiology: Ab to donor plasma proteins (IgE, IgA, C4)



Pathophysiology: Immediate generalized reaction caused by release of

Pathophysiology: Immediate generalized reaction caused by release of

histamine and other mediators

histamine and other mediators



Signs & Symptoms

Signs & Symptoms



Hypotension

Hypotension



Urticaria

Urticaria



Bronchospasm (respiratory distress, wheezing)

Bronchospasm (respiratory distress, wheezing)



Local edema

Local edema



Anxiety

Anxiety



Laboratory testing

Laboratory testing



Rule out hemolysis (DAT, inspect for Hb)

Rule out hemolysis (DAT, inspect for Hb)



Anti-IgA

Anti-IgA



IgA quantitative

IgA quantitative



Therapeutic/Prophylactic Approach

Therapeutic/Prophylactic Approach



Trendelenberg position

Trendelenberg position



Fluids

Fluids



Epinephrine, antihistamine, corticosteroids,

Epinephrine, antihistamine, corticosteroids,

ß

ß

2 agonists

2 agonists



IgA-deficient blood components

IgA-deficient blood components

Transfusion-Related Acute
Lung Injury (TRALI)



Mechanism:

Mechanism:



Anti-WBC (neutrophil, HLA) antibodies in donor which bind to

Anti-WBC (neutrophil, HLA) antibodies in donor which bind to

granulocytes or monocytes leading to complement activation and

granulocytes or monocytes leading to complement activation and

neutrophil aggregation in the pulmonary vasculature

neutrophil aggregation in the pulmonary vasculature



Activated neutrophils release inflammatory enzymes and biologic

Activated neutrophils release inflammatory enzymes and biologic

response mediators that result in endothelial injury and leakage

response mediators that result in endothelial injury and leakage

of protein-rich fluid into the lungs

of protein-rich fluid into the lungs



Rarely due to patient antibodies

Rarely due to patient antibodies



Signs & Symptoms

Signs & Symptoms



Acute respiratory distress

Acute respiratory distress



Severe bilateral pulmonary edema

Severe bilateral pulmonary edema



Severe hypoxia

Severe hypoxia



Tachycardia

Tachycardia



Fever

Fever



Hypotension

Hypotension



Cyanosis

Cyanosis



Usually arises within 1-6 hours of transfusion of plasma-

Usually arises within 1-6 hours of transfusion of plasma-

containing blood component

containing blood component

s

s

Transfusion-Related Acute
Lung Injury (TRALI)



Laboratory testing

Laboratory testing



WBC antibody (HLA, granulocyte) screen in

WBC antibody (HLA, granulocyte) screen in

donor and recipient

donor and recipient



Consequences

Consequences



Mild to moderate cases

Mild to moderate cases



Lung injury and prolonged ventilator time

Lung injury and prolonged ventilator time



Predispose patient to pulmonary infection

Predispose patient to pulmonary infection



Severe cases

Severe cases



Fatal outcomes (3

Fatal outcomes (3

rd

rd

most common cause of

most common cause of

transfusion-related death)

transfusion-related death)



Therapeutic/Prophylactic Approach

Therapeutic/Prophylactic Approach



Supportive care until recovery

Supportive care until recovery



Defer implicated donors

Defer implicated donors

Transfusion-Associated
Graft versus Host Disease



Incidence: Rare

Incidence: Rare



Mechanism:

Mechanism:



Viable donor T-lymphocytes engraft in recipient

Viable donor T-lymphocytes engraft in recipient

and mount an immune response against recipient

and mount an immune response against recipient

tissues

tissues



Signs & Symptoms

Signs & Symptoms



Erythroderma

Erythroderma



Maculopapular rash

Maculopapular rash



Anorexia

Anorexia



Nausea & vomiting

Nausea & vomiting



Diarrhea

Diarrhea



Hepatitis

Hepatitis



Pancytopenia

Pancytopenia



Fever

Fever

Transfusion-Associated
Graft versus Host Disease



Laboratory testing

Laboratory testing



HLA typing

HLA typing



Skin biopsy

Skin biopsy



Treatment

Treatment



Approximately 90% of cases are fatal

Approximately 90% of cases are fatal

(complications of bone marrow failure)

(complications of bone marrow failure)



Irradiation of blood components for patients at risk

Irradiation of blood components for patients at risk

(including DDs and HLA-selected components)

(including DDs and HLA-selected components)



Dosage: 25 rad

Dosage: 25 rad



Detrimental effects on RBCs (K+ leakage)

Detrimental effects on RBCs (K+ leakage)



Shortened shelf-life: 28 days from time of

Shortened shelf-life: 28 days from time of

irradiation

irradiation

Who is at risk for TA-GVHD
and needs irradiated blood
products?



Significantly increased risk

Significantly increased risk



Congenital

Congenital

immunodeficiency

immunodeficiency

syndromes

syndromes



Bone marrow

Bone marrow

transplantation (allo & auto)

transplantation (allo & auto)



Transfusions from blood

Transfusions from blood

relatives

relatives



Intrauterine Transfusions

Intrauterine Transfusions



HLA-matched platelet

HLA-matched platelet

transfusions/blood

transfusions/blood

components

components



Hodgkin’s disease

Hodgkin’s disease



Patients treated with purine

Patients treated with purine

analogues

analogues



Minimally increased risk

Minimally increased risk



Acute leukemia

Acute leukemia



Non-Hodgkin’s lymphoma

Non-Hodgkin’s lymphoma



Solid tumors treated with

Solid tumors treated with

intensive

intensive

chemotherapy/radiation

chemotherapy/radiation



Exchange transfusion

Exchange transfusion



Premature neonates

Premature neonates



Neonates on ECMO

Neonates on ECMO



Solid organ transplant

Solid organ transplant

recipient

recipient



Perceived, but no reported risk

Perceived, but no reported risk



Healthy newborns

Healthy newborns



Patients with AIDS

Patients with AIDS

Post-Transfusion Purpura

Posttransfusion purpura (PTP) is

Posttransfusion purpura (PTP) is

characterized by severe

characterized by severe

thrombocytopenia following

thrombocytopenia following

blood transfusion (

blood transfusion (

5-12 days

5-12 days

)

)

that results from

that results from

alloimmunization to platelet-

alloimmunization to platelet-

specific alloantigens.

specific alloantigens.

Conclusion



Risks of transfusion are associated

Risks of transfusion are associated

with blood product safety and

with blood product safety and

administration

administration



Dramatic reduction of transfusion-

Dramatic reduction of transfusion-

transmitted infectious risk

transmitted infectious risk



Continued improvement needed to

Continued improvement needed to

reduce the non-infectious risks of

reduce the non-infectious risks of

transfusion

transfusion