Transfusion medicine

Transfusion Medicine

transfusion medicine part 1

What 2 blood products should be considered for packed red blood cells for massive transfusion protocol?

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Fresh frozen plasma and consider factor VII

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How can you reduce febrile reactions with packed red blood cells?

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Use washed red blood cells

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Which patients are at high-risk for developing febrile reactions to packed red blood cells?

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multiperous females and patients with high total lifetime number of transfusions

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What is a typical clinical presentation of a patient with a delayed hemolytic transfusion reaction?

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Jaundice, anemia, fever

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Which red blood cell surface antigens are targeted with delayed hemolytic reaction?

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Rh, Kidd, Duffy, Kell, MSN

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What is the time course for delayed hemolytic transfusion reactions ?

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7-10 days

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What is a microvascular acute hemolytic consequence following ABO mismatched PRBC transfusions ?

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DIC

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What is the immune mediated mechanism for acute hemolytic reactions following PRBC transfusions ?

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IgA and C3 / C4 cascade

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What are the 2 types of hemolysis seen with transfusions?

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Acute and delayed hemolytic reaction

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What is the pathophysiologic mechanism of anaphylaxis to packed red blood cells in IgA deficient patients ?

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Anti-IgA antibodies

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Which transfusion product is used for IgA deficient patients?

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Washed packed red blood cells

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Which donors would not be suitable for blood product donations ?

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Multiparous females given a high risk of anti- HLA antibodies

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What are the 4 criteria for TRALI ?

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Acute onset, partial pressure of oxygen less than 90%, no evidence of underlying cardiac cause, bilateral pulmonary infiltrates

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How is hepatitis C cleared from platelets during preparation ?

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Amotosolen and UVA

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Is there a higher risk of hepatitis B or hepatitis C contamination with red blood cell transfusions ?

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Hepatitis B-1 in 20,000 Hepatitis C 1 in 2 million

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Which bacteria is the most common cause of packed blood cell associated sepsis ?

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Yersinia

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What are some tropical parasites that can rarely be seen with packed red blood cells?

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T Cruzi , Babesiosis and Malaria

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How do you treat TACO?

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Diuretics

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What type of blood product preparation must be performed for allogeneic stem cell transplant and neonate recipients ?

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Gamma radiation, CMV negative matching, and leukocyte reduction

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What is a rare and serious complication of Parvovirus B19 from packed red blood cells in an immunocompetent host?

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None

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Which 2 viruses are the most concerning in packed red blood cell?

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HIV and HTLV-1

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What is the main challenge with donor packed red blood cell from relatives ?

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Transfusion related graft-versus-host disease

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Which patients would be appropriate for irradiated packed red blood cell transfusions ?

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bone marrow and solid organ transplant recipients

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Is autologous versus a related donor directed blood donation safer ?

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Both are discouraged

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What are the 2 ways to avoid allogeneic packed red blood cell transfusion in the operating room?

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Red blood cell salvage-recycle suctioned blood
Acute normovolemic hemodilution
Store 1-2 units of perioperative blood

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What type of packed red blood cell transfusion should allogeneic stem cell transplant recipients avoid ?

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Donor-related

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What is the time course for a delayed hemolytic transfusion reaction?

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7-10 days

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What is the prevalence of IgA deficiency in the general population ?

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1/300 – 1/1000

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What is removed with the process of PRBC washing ?

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plasma, WBC and platelets

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Which MPN patients are barred from donating blood ?

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PCV

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What PCWP can help distinguish TACO from TRALI ?

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TACO > 18 mmHg

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Would TRALI or TACO cause pleural effusions ?

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TACO

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What is the mechanism of amotolasen used in platelet preparation ?

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crosslinks DNA upon activation with UVA

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What is the risk of death with red blood cell transfusions ?

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1 per 2 million units

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What is the mortality rate with PRBC associated yersenia enterocolitis bacteremia ?

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60-70%

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What is the risk of sepsis with PRBC transfusion ?

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1/250,000

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transfusion medicine

Which biomarker could help distinguish TRALI from TACO ?

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BNP – would be elevated in TACO

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What is the prevalence of B19 seropositivity in adult blood donors ?

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more than 50%

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What is the risk of HIV transmission through packed red blood cell?

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less than 1/ 100,000

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Which relatives would potentially offer a lower risk of donor PRBC transfusion related complications ?

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All discouraged

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Which blood product would be appropriate for a patient with IgA deficiency ?

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washed PRBC

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transfusion medicine

Is autologous versus donor relative blood donation safer?

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Both are discouraged

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transfusion medicine

What 2 methods can be used to avoid allogeneic red blood cell transfusions in the operating room?

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Red blood cell salvage-, Acute normovolemic hemodilution, use preoperative stored patient blood

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transfusion medicine part 2

What is the procedure used to fractionate out IVIG from plasma?

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Cold ethanol and fractionation of fresh frozen plasma

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transfusion medicine

How is cryoprecipitate prepared?

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Fresh frozen plasma is kept at 4°C then removed with the supernatant thawed at 1-6°C

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What are the 5 factors that cryoprecipitate is enriched with?

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Factor VIII, factor XIII, fibrinogen, fibroNECTIN, von Willebrand factor

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If recombinant factor VIII replacement is not available, which blood products can be used for hemophilia A and hemophilia B?

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Hemophilia A–cryoprecipitate
Hemophilia B–fresh frozen plasma

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What product is recommended if recombinant factor VIII is not available?

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Cryoprecipitate

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Can thawed plasma be used for TTP?

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Yes because ADAMTS13 is stable

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Which 2 factors are not present in thawed plasma after 5 days?

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Factor V and factor VIII

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What are 6 common indications to use fresh frozen plasma?

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DIC, liver disease, Coumadin, vitamin K, plasma exchange, massive transfusion protocol

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What are the 3 available plasma products ?

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FFP – frozen within 8 hours and used within 24 hours of thaw
PF24-frozen within 24 hours and use within 24 hours of
Thawed plasma – 5 days refrigerated

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What can lead to an incompatible crossmatch?

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Warm autoimmune hemolytic anemia and Iso-Agglutinin

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What visible feature is being screened for on a type and screen test?

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Agglutination

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What is another name for the type and screen?

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Indirect Coombs

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Which hematologic autoimmune disease poses a challenge for type and screen?

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Autoimmune hemolytic anemia because of pan reactive antibodies

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What is a typical antibody screen?

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Patient’s serum on a standard red blood cell panel

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What are 3 explanations for mixed results with forward and reverse ABO typing?

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Recent blood transfusion, stem cell transplant recipient, newborn

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What is the difference between forward and reverse ABO typing?

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Forward-patient’s red blood cell and anti-IgA and anti-IgB with IgM.
Reverse: Patient’s serum with standard RBCA1 and RBCA2

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What is the difference between the replacement fluid for plasmapheresis in TTP versus other etiologies?

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TTP requires the use of fresh frozen plasma
while other indications require albumin

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What are the 5 indications for packed red blood cell exchange transfusion for sickle cell anemia?

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1–acute CVA management
2–acute chest syndrome
3 pre-orthopedic surgery
4–secondary CVA prophylaxis
5–high risk kids with a history of CVA

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For extracorporeal therapy, what are the white blood cells exposed to?

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Ex vivo white blood cells are exposed to 8- methoxy-psoralen then UVA then transfused back in the patient

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What are the 2 major risks of plasmapheresis?

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Thrombosis and central catheter associated problems

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What other agent is given with granulocyte colony stimulating factor for maximizing stem cell collection ?

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Prelixofor

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What is a very rare side effect of white blood cell growth factor mobilization?

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Spleen rupture

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What is the target number of stem cells to collect?

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20,000,000 cells/L

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Which chemotherapy is given along with white blood cell growth factors for stem cell mobilization?

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Cyclophosphamide

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What is the likely diagnosis in a post-allogeneic stem cell transplant patient with hyperbilirubinemia without evidence of venoocclusive disease ?

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Alloimmune Hemolysis

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What is a feared complication of ABO mismatch in allogeneic stem cell transplant patients ?

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Delayed immune mediated erythropoiesis ~ PRCA

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What is a severe complication of neutrophil transfusion?

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Pulmonary toxicity

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Which 2 types of infections are donor granulocyte infusions used in ?

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resistant fungal and bacterial infections

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transfusion medicine

With regards to auto and allogeneic stem cells, which are given fresh?

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Allogeneic

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What is the preservative used in stem cells collected for autologous stem cell transplantation ?

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DMSO

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Which type of packed red blood cell products should be used for aplastic anemia patients?

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Gamma radiated and white blood cell reduced

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transfusion medicine

What has proven to increase graft failure in aplastic anemia?

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High number of product transfusions prior to the transplant

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What type of packed red blood cell transfusions should be avoided in allogeneic stem cell transplant recipients ?

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Donor-related

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What type of packed red blood cell should be used for preterm neonates?

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White blood cell reduced and gamma radiated packed red blood cell, goal is to reduce CMV and passenger white blood cells

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What is a common CBC abnormality that is seen in preterm complication of neonates?

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Severe anemia

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How can you distinguish neonatal autoimmune thrombocytopenia and neonatal autoimmune neutropenia from maternal ITP and maternal autoimmune neutropenia?

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Check the mother’s complete blood count after delivery

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Which antigen causes neonatal autoimmune neutropenia?

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NA-1 and NA-2

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Which antigen causes neonatal autoimmune thrombocytopenia?

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HPA -1a

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How do you treat neonatal autoimmune thrombocytopenia and neutropenia?

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Mother derived IVIG or platelets, only for the mother not the child

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What are 2 scenarios of a hemolytic disease of the fetus and newborn?

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Rh negative mother and Rh positive fetus = hydrops fetalis
Tx = Rho-gham @ 28 weeks
ABO: O mom and A baby -with Anti-A Ab, Tx= phototherapy (AIHA in newborn)

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What is the treatment for Hydrops Fetalis prevention? At what point in pregnancy is it given?

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Anti-Rh antibody at 28 weeks

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How can you increase the lifespan of red blood cell in the presence of a cold reacting antibody?

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Keep both the patient and packed red blood cell warm

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Which antigen is commonly screened for auto antibodies?

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Rhe

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Which packed red blood cell surface antigen is seen with cold reacting antibody?

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I Antigen

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What lab technique can used in a patient with autoimmune hemolytic anemia who has been exposed to allogeneic packed red blood cells in the past?

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Auto adsorption

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Which 3 disease states with severe thrombocytopenia should very rarely receive platelet transfusion?

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ITP, TTP, HIT
These can worsen thrombosis

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How is the risk for alloimmunization in sickle cell anemia patients reduced ?

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Use extended matched packed red blood cells including minor antigens

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Which procedure can help determine post-bypass bleeding is secondary to a platelet versus coagulation defect?

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Thromboelastography

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What is the management of post-bypass surgery bleeding ?

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Platelet transfusion preferred because platelet dysfunction can occur secondary to bypass machine surface contact

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What are the 3 electrolyte abnormalities seen with a massive packed red blood cell transfusion protocol?

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Low calcium, high potassium, alkalosis

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transfusion medicine part 3

What type of red blood cell transfusion is required in patients being treated with Fludarabine or Cytarbine?

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Gamma irradiated PRBC should be used because iatrogenic lymphopenia increases the risk of treatment related GVHD

transfusion medicine part 3
transfusion medicine part 3

For blood groups A, B and O, are the anti-isoagglutinins IgG or IgM?

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A and B–IgM
O–IgG

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transfusion medicine

What is the primary difference between major and minor ABO compatibility between donors and recipients in the context of allogeneic stem cell transplant?

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Major–recipient has anti-A and anti-B antibodies
Minor–donor has anti-A and anti-B antibody

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What is the treatment for Alloimmune thrombocytopenia of the newborn?

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Washed maternal platelets

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Which platelet surface antigen causes post-transfusion purpura?

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HPA-1a

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Which blood group antigens are responsible for platelet refractoriness?

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HLA-A/B

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Which blood group antigen is most likely responsible for delayed hemolytic transfusion reaction?

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Kidd

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Which immunoglobulin molecule mediates an urticarial reaction during a platelet transfusion?

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IgE

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What is the urine pH target in a patient being treated for an an acute hemolytic reaction from ABO mismatched blood?

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Alkaline

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How is a directed blood product donation from a relative processed prior to an infusion?

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Gamma irradiation to minimize treatment-related GVHD

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What is the purpose for irradiating packed red blood cells?

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Lowers the risk of transfusion-related GVHD

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What are the 5 indications for leuko-reduced packed red blood cell use ?

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Allogeneic stem cell transplant – Packed red blood cell dependent
CMV negative donor and CMV negative recipient
AIDS patient with CMV negative recipient
Febrile nonhemolytic transfusion reaction
Pregnant female with CMV negative

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In which 2 scenarios would cryoprecipitate be preferred over fresh frozen plasma for acute bleeding?

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Cirrhosis and Coumadin-related bleeding because cryoprecipitate contains factor VIII, factor XIII, fibrinogen and von Willebrand factor

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Which patients should receive gamma irradiated packed red blood cells?

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Immunosuppressed patients to lower transfusion related GVHD

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What complication does leukocyte-reduction during the processing of packed red blood cells minimize ?

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CMV virus transmission

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What does leukocyte reduced packed red blood cell not protect against compared to gamma irradiated?

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Transfusion related GVHD

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What type of packed red blood cell can be offered to patients with increased alloimmunization?

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Cryopreserved-frozen

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What is a hemoglobin goal/target for acute bleeders?

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8 g/dL because of Rheology effects of increased hematocrit

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Which metabolite’s concentration decreases with increasing storage time of packed red blood cells?

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2,3-BPG

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What are the storage solutions used for collected red blood cells?

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AS-1, mannitol, adenosine, glucose

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What are the 2 methods of determining patient match for platelet refractory patients?

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HLA-A and HLA-B testing Platelet cross matching

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What are some methods of overcoming platelet refractoriness?

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IVIG, steroids, plasma exchange, aminocaproic acid

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Which HLA Ag is a bigger driver of platelet transfusion refractoriness?

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HLA-A/B

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What serum testing can assist in overcoming platelet transfusion refractoriness?

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HLA matching

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What minimum increase in the platelet concentration defines platelet refractoriness after transfusing 2 units?

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less than 10,000

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Should ABO compatibility be screened prior to platelet transfusions?

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Ideally, but ABO matched platelets are rarely used in practice

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What are single donor platelets superior to?

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They are not superior to anything

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How is the half-life of transfused platelets different in chemotherapy recipients ?

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Chemotherapy reduces the half-life to 3 days versus 7-9 days

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What is the shelf-life of platelets ?

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5 days

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What 2 conditions can antibodies against human platelet antigen cause?

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NAIT and post-transfusion purpura

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What are the 2 groups of platelet surface antigens that are clinically relevant ?

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HLA and human platelet antigen

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What is the feared complication of granulocyte transfusions in patients with + HNA antibodies ?

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Pulmonary toxicity

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Does ABO matching matter for neutrophil transfusion?

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Yes

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What is the shelf life of donor granulocytes?

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24 hours

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What surface protein on the neutrophil surface is a target of neutrophil antibody for autoimmune neutropenia?

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CD16 is the target of HNA-1a/1b

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Which conditions is HNA-1a/1b more concerning in ?

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NAIN, neutrophil transfusion, TRALI, delayed neutrophil recovery, secondary graft failure

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Which neutrophil antigens are the most antigenic?

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HNA -1a/1b

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transfusion medicine

What causes a false positive Coombs result in patients receiving IVIG?

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Positive DAT can occur given the pooled nature of IVIG resulting in anti-A and Anti0B antibodies

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What is the most common side effect with IVIG infusion?

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Fevers

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transfusion medicine

What are the 3 indications for cryoprecipitate use ?

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Congenital and acquired hypofibrinogenemia, VWF deciency , hemophilia A, recombinant factor unavailable

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What are some emergency situations where cryoprecipitate can be used?

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Uremic bleed and tPA bleed

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transfusion medicine

What is the infection risk with cryoprecipitate?

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10-fold increase because of 10 different donors

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