수혈요법의 실제
경희의대 종양혈액내과
조 경 삼
BLOOD
• Biologic agent
• Limited supply
Blood transfusion
• Donor : genetic differences • Blood banking
• Blood compatibility tests • Component therapy
• Apheresis therapy
헌 혈
• 자진 헌혈 (volunteer donation)
• 지정 헌혈 (directed donation)
Alternatives to Donor Blood
• Autologous blood transfusion– Preoperative autologous deposit – Preoperative dilution
– Intraoperative salvage – Postoperative salvage
• Directed donor program
– Legal, emotional, economic, GVH – Indication
지정 헌혈 (directed donation)
• 유사한 감염성질환 표지자 양성률 • 시간적 , 경제적 부담 • 이식편대숙주병 (GVHD) 발생 가능성 • 혈액 관리에 추가의 노력 • Contraindication – 임신가능 연령 : 남편 – 골수이식환자 : 친족 – 신생아용혈성질환 : 부혈액성분제제
• 농축적혈구 • 농축혈소판 • 신선동결혈장 • 동결침전제제 • 알부민 • 면역글로불린• 혈액응고인자 (VIII, IX-prothrombin complex) • Antithrombin III
혈액성분제제의 특성
• 전혈 : 456 mL (400 + 56) 365 mL (320 + 45) • 농축적혈구 : 250 mL (Hct 70%) • 혈소판풍부혈장 : 200 mL (5.5 X 1010) • 혈소판농축액 : 50 mL (5.0 X 1010) • 성분채집혈소판 : 200 – 250 mL (>3 X 1011) • 신선동결혈장 : 160 mL혈액의 보존
• 농축적혈구 1-6 oC 35 일 • 세척적혈구 1-6 oC 24 시간 • 신선액상혈장 1-6 oC 12 시간 • 신선동결혈장 <-18 oC 1 년 (3 시간 ) • 동결침전제제 <-20 oC 1 년 (1 시간 ) • 농축혈소판 20-24 oC 48 시간 (5 일 ) • 성분채집혈소판 20-24 oC24 시간 (5 일 ) • 동결해동적혈구 1-6 oC 12 시간Administration of Blood
• Identification of recipient and donor at bedside
• Appropriate set with filter:
– standard : 170 μm
– microaggregate blood filter : 20 - 40 μm
• Aseptic technique
• First 30 min. : close observation • Within 4 hr
Blood warming
• Adult : > 50 mL/kg/hr • 소아 : >15 mL/kg/hr • 영아의 교환수혈 • 한냉응집소를 가진 환자 • Central catheter 를 통한 빠른 수혈 • Blood wormer : 온도계 , 경보장치Red cell transfusion
• Whole blood
• Red blood cells (packed RBC)
• Leukocyte-depleted RBC (pre-filtered)
• Washed RBC
• Frozen-thawed-deglycerolized RBC
• Irradiated RBC
RBC Therapy Indications
• Whole blood massive bleeding,
exchange transfusion
• Packed RBC anemia
• Leukocyte-poor prior febrile reaction
prevention of alloimmunization CMV, HTLV-1 virus transmission
• Washed RBC prior urticarial reaction
IgA deficiency
• Frozen RBC rare blood type
autologous donation disaster
Transfusion guidelines in chronic anemia
• Stable patient with Hb > 6 - 7 g/dL :
no absolute indication for transfusion
• Unexplained lassitude, malaise, tachycardia,
dyspnea with Hb < 9-10 g/dL : consider transfusion
• Cardiopulmonary disease, fever, surgery :
maintain Hb level at 10 g/dL
• If management protracted (years) :
Sign and Symptom of Blood Loss
Volume lost
mL % Clinical sign
500 10 None; occasional vasovagal reaction
1000 20 Possibly a slight postural drop in BP Tachycardia with exercise
1500 30 Neck vein flat Postural hypotension
2000 40 Drop in CVP, cardiac output, BP Air hunger, rapid thready pulse, Cold clummy skin
Volume Replacement
• Crystaloid : saline, Ringer’s lactate
• Colloid : hydroxyethyl starch,
dextran (40, 70)
• Albumin
• FFP
Transfusion in Surgical Patients
• Optimal hemoglobin concentration • Duration of anemia
• Possibility of blood loss
• Maximal surgical blood order schedule
(MSBOS)
• Type and screen: ABO, RhD,
Platelet transfusion
• Platelet rich plasma
• Platelet concentrate: random donor
• Apheresis platelet: single donor
• HLA matched donor
• Refractoriness
Guidelines for platelet transfusion
• Platelet < 10,000 /mm3 :
spontaneous bleeding prophylactic
• Platelet < 50,000/mm3 with bleeding or
minor surgery : platelet transfusion
• Major surgery : platelet > 80,000/ mm3 • Refractoriness : HLA matched donor
Leukocyte transfusion
• Granulocyte transfusion
– Hematopoietic growth factor
• Lymphocyte transfusion
– LAK cell – DLI
Fresh Frozen Plasma (FFP)
• 160 mL (400 mL + 56 mL CPDA-1) • Fibrinogen : 230 - 240 mg/dL
• Factor V : 119 U/dL
• Factor VII : 89 - 94 U/dL • Factor VIII : 49 - 94 U/dL • Factor IX : 84 - 125 U/dL • Other factors : 100 U/dL
Indication for FFP
• Factor deficiency
• Rapid reversal of warfarin effect • Vitamin K deficiency
• DIC • TTP
• Antithrombin III, Protein S, C • C1 esterase inhibitor deficiency
• Massive transfusion, liver disease,
Cryoprecipitates
• 60 mL
• Factor VIII : 96 U
• Fibrinogen : 372 mg
• Factor XIII : 20 - 30 % of FFP
• vWF : 40 - 70 % of FFP
• Fibronectin
Plasma protein products
• Albumin
• Immune globulin, hyperimmune globulin • Factor VIII concentrates
• Factor IX concentrates (prothrombin complex) • Fibrin sealants
• Alpha A1 -proteinase inhibitor
• Antithrombin III
• C1-esterase inhibitor
Factor VIII concentrate
• Intermediate purity, high purity
• F VIII(U) = 40 x BW(kg) x {wanted F VIII
conc.(%) - patient F VIII conc.(%)}/100
• 250, 500, 1000 U/BT : 10, 20, 30 ml • 8 - 12 hr
Intravenous Immunoglobulin
• Hypogammaglobulinemia • CMV infection in BMT
• Autoimmune disease (ITP) • Adverse reaction
– First dose effect
– Flushing, chest tightness, chills, fever, nausea,
vomiting, diarrhea, dizziness, wheezing, diaphoresis, hypotension
Hyperimmune globulin
• RhoGam, WinRho : anti-D • Hepatitis B
• Varicella-zoster virus • CMV
Apheresis
• Plasma apheresis
• Leukapheresis
• Platelet apheresis
Transfusion reactions(1)
Immunologic transfusion reactions
– Major (acute) hemolytic reactions – Delayed transfusion reactions
– Febrile nonhemolytic reactions – Allergic reactions
– Transfusion-related acute lung injury (TRALI) – GVHD
– Posttransfusion purpura – Alloimmunization
Major Hemolytic Transfusion Reaction
• ABO incompatibility : clerical error • Jka, K, Fya, Rh system
• Chills and fever within first 30 min, low
back pain, chest pain, restlessness, dyspnea, pain at the site of transfusion
• Tachycardia, hypotension, tachypnea,
Management of MHR
• Stop transfusion immediately but do not remove the IV route
• Hydration and maintain BP and urine output greater than 100 mL/hr
• Sample for retyping and cross matching • Observe the plasma and urine color
• DIC study
Delayed hemolytic transfusion reaction
• 3 – 14 days post-transfusion
• Previously sensitized to RBC alloantigens with negative alloantibody screen
• Anamnestic response to transfused RBC • Usually no specific therapy required
• Febrile nonhemolytic transfusion reaction
– Most frequent
– Chills, rigors and more than 1oC BT rise
– Ab directed donor leucocyte and HLA Ag – Leucocyte-reduced RBC, acetaminophen
• Allergic reaction
– Urticarial reaction
– Plasma protein in transfused blood – Washed RBC, antihistamines
TRALI
(transfusion-related acute lung injury)
• High-titer anti-HLA Ab to recipientleucocyte --- aggregate in the pulmonary vasculature --- cytokines release
• Noncardiogenic pulmonary edema • Supportive Tx
Transfusion associated GVHD
• Immunocompromized patients : BMT, acute leukemia, malignant lymphoma etc.
• Blood donor is homozygous for one of the HLA haplotype of recipient
• Rash, diarrhea, liver failure, pancytopenia • 2,500 cGy irradiation to all blood products
Posttransfusion purpura
• Thrombocytopenia 7-10 days after transfusion
• Antibody to HPA-1a found on the platelet glycoprotein IIIa receptor
Alloimmunization
• Alloantibodies to RBC antigens : difficult cross-matching
hemolytic disease of newborn
• Alloimmunization to leukocyte and platelet : refractoriness to platelet transfusion
leukocyte reduced transfusion SDAP
Transfusion reactions(2)
Nonimmunologic transfusion reactions
– Volume overload
– Hypothermia : cardiac dysrhythmias – Hypocalcemia : citrate in blood
– Hyperkalemia : fresh of washed RBC for neonatals – Coagulation factor deficiency
– Iron overload : 200-250 mg/U
– Hypotensive reaction : ACE inhibitor 복용자
bradykinin ↑
Transfusion reactions(3)
Transfusion-transmitted infections
– Hepatitis A, B, C – HIV, HTLV-I
– CMV, EBV, Parvovirus B-19
– Parasitic: malaria, Chaga’s disease, toxoplasma,
babesiosis
– Bacterial: Yersinia, Pseudomonas, Serratia, E. coli,
coagulase negative Staphylococcus, Streptpcoccus, Salmonella,, brucellosis, syphilis, Lyme disease, variant Creutzfeld-Jacob disease