경희대학교 의과대학·의학전문대학원

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 : 부

혈액성분제제

• 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 mL

혈액의 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 시간

Administration 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 , 경보장치

Red 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 recipient

leucocyte --- 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