Know which blood products totransfuse for a patient's bleeding
Know which blood products totransfuse for a patient's bleeding: Excerpt from Avoiding Common Pediatric Errors
Author:
Mindy Dickerman, MD
What to Do - Make a Decision
After the decision has been made to transfuse blood products, the most appropriate product must be chosen. Donated whole blood and other products
are modified in several ways that remove varying proportions of nonred cell
components. It is important to know the policies of the blood center you are
working with.
Packed red blood cells (PRBCs) are the blood product of choice for replacementduringsurgery,redcellloss,orfortransfusiontherapy.PRBCsare
stored with a preservative solution that enables them to be used 35 to 45 days
after collection. The process of removing white blood cells (WBCs) from
blood products is referred to as leukoreduction, and is done by highly efficient filters that reduce the number of WBCs by >99.9 %. There are several
adverse consequences of transfused WBCs that are reduced by leukoreduction. Febrile nonhemolytic transfusion reactions are mediated by leukocyte-
derived cytokines and direct donor cell leukocyte interactions.
In addition, human leukocyte antigen alloimmunization can be induced
by human leukocyte antigens expressed on donor leukocytes in recipients
whoreceivemultipletransfusions.Allosensitizationincreasestheriskofgraft
rejection in children who subsequently receive organ or hematopoietic cell
transplantation, and increases platelet refractoriness in patients requiring
multiple platelet reactions. WBCs can also transmit infectious agents that
are harbored in WBCs—most notably cytomegalovirus (CMV). Leukoreduction significantly reduces, but does not completely eliminate these reactions. Many blood centers in the United States have adopted a "universal
leukoreduction" policy in which all PRBCs are leukoreduced.
The few WBCs that remain after leukoreducing are capable of replicating and can cause transfusion-associated graft-versus-host disease (TAGVHD). Gamma irradiation of PRBCs stops proliferation of foreign lymphocytes, which entirely prevents TA-GVHD. The dose of irradiation used
for cellular blood products is not sufficient to kill viruses such as CMV and,
therefore, does not eliminate the need for leukoreduction or CMV-negative
blood products. TA-GVHD can occur from directed donor blood provided
by a relative, or if the recipient has decreased cellular immunity and is unable
to mount a response against donor lymphocytes. Directed donor blood from
family members as well as PRBCs destined for immunosuppressed children
should be irradiated. Irradiation can lead to reduced red cell viability and
a leakage of potassium, and there is potential for hyperkalemia to occur if a
patient is receiving massive transfusions of irradiated blood. To prevent this
potential complication, the supernatant solution containing excess potassium can be removed by washing the red blood cells prior to transfusion.
Freshfrozenplasma(FFP)ispreparedfromwholebloodorfromplasma
collected by apheresis techniques. FFP is frozen at -18°C to -30°C and is usable for 1 year from the date of collection. FFP contains all of the coagulation
factors but is not a concentrate of any of the circulating plasma proteins and
therefore should not be used to treat coagulation defects caused by known
deficiencies. It also does not contain any platelets. FFP should be used conservativelybecauseitservesasasourceforthefurthermanufactureofplasma
derivatives such as albumin, gamma globulin, and the coagulation factors.
FFP is indicated to treat a bleeding condition caused by a deficiency of
multiple coagulation factors such as is seen in warfarin overdose, vitamin K
deficiency, liver failure, or dilutional coagulopathy following massive transfusion. FFP may be needed for inherited factor XI deficiency or as a source
of factor V in severe cases of disseminated intravascular coagulation, when
platelet and cryoprecipitate transfusions do not correct factor V, factor VIII,
or fibrinogen consumption defects. There is little evidence to support the
use of FFP as prophylaxis for invasive procedure in patients with a mild
coagulopathy. FFP is screened for the presence of unexpected red blood
cell antibodies. FFP must be ABO compatible with the patient's red blood
cells. Anaphylactic reactions following transfusion of plasma may occur in
patients with immunoglobulin (Ig)A deficiency and antibodies to IgA. For
these patients, there is IgA-deficient plasma available. Cryoprecipitate is the
precipitate that is separated out by centrifugation when FFP is thawed at
4°C. It is a concentrated preparation that contains all of the factor VIII,
fibrinogen, fibronectin, factor XIII, and von Willebrand factor in FFP reduced from an initial volume of 250 mL to a final volume of 10 to 15 mL.
Cryoprecipitate contains approximately 200 mg of fibrinogen and 100 units
of factor VIII per bag. It is used in the treatment of congenital and acquired
deficiencies of fibrinogen, factor VIII, and factor XIII, as well as for the
treatment of von Willebrand disease when there is no other alternative.
Suggested Readings
DaraSI, Rana R, Afessa B, et al. Fresh frozenplasma transfusion in critically ill medicalpatients
with coagulopathy. Crit Care Med. 2005;33:2667–2671.
Roseff SD, Luban NL, Manno CS. Guidelines for assessing appropriateness of pediatric trans
fusion. Transfusion. 2002;42:1398–1413.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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