Blood Bank UpdateBrian Platz, MDAP/CP, BB/TM

Department of PathologyKaiser West Los Angeles

June 17, 2010

Ordering in HealthConnectTesting/Crossmatching TATsSpecial Needs

CMV negLeukoreductionIrradiation

Transfusion Reactionsincluding TACO and TRALI

Infectious Risks of Transfusion

Ordering in HealthConnect

Ordering a transfusion involves the following:

1.Order for Initial Blood Work2.Order requesting the Blood Product from the BB3.Order permitting the nurse to transfuse the unit

NOTE: A CHANGE IN WHAT I’VE SAID BEFORE

We no longer can pre-crossmatch units if the antibody screen is positive….We need to have the crossmatch order in HC to process units in Cerner.

ANTIBODY SCREEN NEGATIVE ANTIBODY SCREEN POSITIVE

Can Use “Immediate-spin crossmatch” (5 minutes)

First, must perform a “Panel” to identify which antibody is

being made (45 minutes)

Must use units that lack the identified antibody (takes 5-30

minutes to type the unit)

Must use “Coombs Phase Crossmatch” 30 minutes)

Total time: 35 minutes. Total time: 2 hours +

As long as the sample is valid (72 hours), additional units will take about 5 minutes.

Additional units will take 30 minutes to an hour to get

ready.

TYPE AND SCREEN

TYPE—ABO and Rh (5minutes).SCREEN—For “unexpected” antibodies, (30 minutes).

Special NeedsCMV Negative—Historically, based on Serology of donor, but Prestorage Leukocyte reduction is equivalent, for most situations. Used for pregnant women, intrauterine transfusion, low birth weight or premature infants, BM/solid organ transplant patients, and severely immunocompromised patients (including HIV infection). Not indicated if patient is CMV positive, (50-80% of population is positive).

Leukocyte-Reduction (LR)—Prestorage LR reduces the number of white cells to <5 x 10^6/unit (>3-log reduction). Helps prevent febrile reactions and HLA alloimmunization.

Irradiation—Treating a unit with 2500 cGy of gamma radiation destroys the lymphocytes ability to divide. The ONLY purpose is to prevent GVHD. Used for Directed donations to family members, HLA-matched platelet tx, intrauterine tx, organ transplant patients

CMV NegativeSerologic test not 100% reliable—

A “negative” unit can actually be positive either because of the window period, or because the antibody titer becomes undetectable.

Leukoreduction— Appears to be as effective.Some Suppliers (ARC)— No longer supply them.

THUS,

When “CMV-negative” is requested, we will supply Leukocyte-reduced. If you really, really want CMV-seronegative units, you must call the blood bank.

Leukocyte Reduction

“Pre-storage” Performed under controlled conditions, over a specified period of time, at a cooled temperature. Greater than 3-log reduction in lymphocytes.

“Before-issue” Run through a LR filter in the lab, before being picked up. (We don’t do this here. I’ve never worked somewhere that did this)

“At the Bedside” Run through a LR filter while being transfused to the patient.

NOTE: a Leukocyte-reduction filter is different from the “microaggregate” filter that is used for all cellular products.

NOTE: A CHANGE IN WHAT I’VE SAID BEFORE

When you order “Fresh Frozen Plasma,”

you may not actually get it.

FFP Separated and frozen within 6 hours of donation. Prevents degradation of the “labile” factors (V, VIII). Must be used within 24 hours after being thawed.

Plasma, thawed Can be stored and used for up to 5 days.

After 24 hours, must be destroyed or relabeled as

Degradation of Coagulation Factors in FFP

Transfusion ReactionsTYPE CAUSE FREQ NOTES

Febrile Transfused WBCs/cytokines 1:100 Cellular productsF>MGive Tylenol

Allergic Patient allergic to something transfused plasma (nuts, PCN).

1:333 Give antihistamines

Anaphylactic/Anaphylactoid

Severe allergic reaction orIgA deficient patients making anti-IgA. Circulatory collapse, laryngeal edema. Hypotension without fever.

1:20,000 to1:47,000

~1 death per yearSelf-limited, but may require intubation/ICU

Septic Platelets: StaphRBCs: Yersinia enterocolitica. Hypotension with high fever.

1:5000 Plt1:250,000 RBCs

Fatal in 1:50,000 platelet tx

Transfusion Reactions (Cont)TYPE CAUSE FREQ NOTES

Transfusion-AssociatedCirculatoryOverload(TACO)

Too much volume given. Cardiogenic edema.NL to high BP

Varies with the underlying dz. Up to 10% in elderly and ICU.

(less frequent since advent of pRBCs)BNP elevated5-15% mortality

Transfusion-RelatedAcuteLung Injury(TRALI)

Anti-HLA antibodies + patient’s PMNs. Get caught up in pulmonary bed and cause non-cardiogenic edema. NL to low BP, +/- fever. Usually within 6 hours of transfusion.

1:5000 UK uses only male donors for plasma.BNP < 2505-10% mortality

Acute Hemolytic

Error in patient identification.Incompatible red cells given.

1:250,000 to1:600,000 fatal

Est 1:6,000 to1:33,000 non-fatal

TRALI TACODYSPNEA YES YES

ABG Hypoxemia Hypoxemia

BP Low to Normal Normal to High

TEMP Normal to Elevated Normal

CXR White out. Normal heart size. No vascularcongestion.

White out. Normal to increased heart size. Vascular congestion.Pleural effusions.

BNP Low (<250 pg/mL) High

Pulmonary artery occlusion pressure

Low to Normal High

Echocardiogram Normal heart function Abnormal heart function

Response to Diuretics Worsens Improves

Response to Fluids Improves Worsens

TRALI v TACO

Infectious Disease RisksAgent Risk Comments

HIV 1:2,135,000 About 1:200 in early 80s (cities)About 1:500,000 with HIV Ab testNow we do NAT testing

HCV 1:2,000,000 About 1:200 in early 80s (cities)About 1:180,000 with HCV testNow we do NAT testing

HBV 1:205,000HTLV I-II 1:641,000WNV, T. Cruzi (Chagas’), Babesiosis, malaria, B. burgdorferi (Lyme), leischmania, CJD

rare Screening questions are still used to screen out donors with recent travel to endemic areas.

Keeping It in Context…Agent Risk

HIV 1:2,135,000

HCV 1:2,000,000

HBV 1:205,000

HTLV I-II 1:641,000

Struck by lightning in any given year 1:500,000

Struck by lightning in a lifetime (80 yrs) 1:6250

Winning Mega-Millions Jackpot 1 :175,711,536

Donor TestingDonor tested for (antibodies):

anti-HIV 1/2, anti-HCV, anti-HTLV I/II, anti-HBc

Donor also tested for:HBsAg, Serologic Test for Syphilis

Donor also tested for (Nucleic Acid Testing, NAT):HCV RNA, HIV-1 RNA, WNV RNA

Donor also tested for anti-CMV, unless they are known to be anti-CMV positive.

Anybody New to Kaiser WLA?

“Double-Check” system for ABO typing

brianplatz.com