Immunohematology - 06 Transfusion Medicine

IMMUNOHEMATOLOGY DONOR SELECTION PROCESS TRANSFUSION MEDICINE: DONOR SELECTION PROCESS AND RBC PRESERVATION & STORAGE OUTLINE • Transfusion Medicine • RBC Preservation and o Governing Agencies Storage o Post Blood Transfusion • Donor Selection Process Complete Blood Count o Five Processes of Donor Selection o Storage of Blood o Recruitment Lesions of Storage o Screening & Physical Examination o Additive Solutions o Donor Deferral o RBC Rejuvenation o Hemapheresis Donor Selection o Red Cell Freezing o Additional Donor Guidelines o Deglycerolizaton o Autologous Donor Selection • Donor Selection & • Whole Blood Collection Collection o Step-By-Step Process in Blood Collection For Whole Blood Donation o AABB Protocol o Post-Donation Care o Adverse Donor Reactions and Management o Donor’s Blood Processing TRANSFUSION MEDICINE • • • The practice of blood transfusion and blood conservation, complementary activities that ensure the best balance between safety and convenience during emergency care or surgery. Blood is transfused to suffice deficiencies in blood/ circulation of the patient, single blood unit can save lives Blood donation can be beneficial by triggering bone marrow to produce new and more blood cells to replenish donated blood FIVE PROCESSES OF DONOR SELECTION 1. 2. 3. 4. 5. • RECRUITMENT • • • • US Food and Drug Administration (FDA) o Regulating agency o Blood - biological drug o Center for Biologics Evaluation and Research (CBER) - 1988 ▪ Responsible for regulating the colelction of blood and blood components used for transfusion ▪ Manufacture of pharmaceuticals derived from blood and blood components American Association of Blood Banks (AABB) o International association of blood centers, transfusion, and transplantation services, and individuals involved in transfusion medicine o Establish and provide highest standard of care for patients & donors in all aspects of transfusion medicine College of American Pathologists (CAP) o Provides a voluntary inspection and accreditation program for its member institutions o Since most transfusion services are part of the clinical laboratory departments in a hospital, they are included in a CAP inspection Often performed by telerecruiters and other medical professionals Act of donating blood must be voluntary TYPES OF ALLOGENEIC BLOOD DONOR • • • • Voluntary/ Non-renumerated o Walk-ins and does not accept cash of any forms o Usual type Family/ replacement/ directed donor o Directed donors are not usually directed to family members o First in, first out Professional/Paid/ Commercial Autologous o Donates blood for own personal use o Safest due to absence of untoward antibodies o Usually done by surgery patients o Applicable for patients w/ rare blood types (O-, AB-, Bombay) SCREENING AND PHYSICAL EXAMINATION • GOVERNING AGENCIES • Recruitment Screening Physical Examination Collection Post Donation Care One unit of blood = 450 mL Get the personal information of the potential donor o Donor’s name o Donor’s address, phone no. o Sex o Age (at least 17 y/o, with parent’s consent, elderly may donate at the discretion of blood bank physician) o Date of donation (previous donation) o Donor’s consent o Donor’s occupation o Race o Time of last meal PHYSICAL EXAMINATION • • General Appearance: o Observe if generally healthy looking o Pale, cyanotic, jaundiced patients are usually deferred o Patients under influence of alcohol are also deferred o Tattooed patients are directed for screening Weight: 110 lbs (50kg) o If donor is less than 110 lbs: ▪ Formula: ▪ Amount of Blood to be drawn: ▪ Allowable amount (mL): Donor’s wt. (lb) x 450 mL 110 lb ▪ Anticoagulant needed: Allowable amount x 14 100 ▪ Anticoagulant to remove: 63 mL - anticoagulation ▪ • • • • Example: If Whole Blood must be drawn from a donor who weighs 70 lbs, the calculations would be: Allowable amt = 70 lb x 450 mL = 286.36 mL 110 lb Anticoagulant needed = 286.36 x 14 = 40 mL 100 AC to remove = 63 - 40 = 23 mL Temperature: orally should not exceed 99.5C or 37.5C o Fevered individuals are not allowed to donate o Fertile patient - naturally warmer than usual o Patient from warm condition - higher temp o Patients taking diuretics - has higher temp o Patients should take rest before temp testing Pulse: 50-100 bpm o Active Px have higher than normal pulse o Px from extreme physical activity have high normal pulse Blood Pressure: systolic no greater than 180 mmHg, diastolic no greater than 100 mmHg o Anything higher should be deferred Hematocrit and Hemoglobin: 38% Hct (12.5 g/dL Hb) o Decreased Hct & Hgb - increased tendency for anemic, fainting of px during collectiom o Copper Sulfate Method ▪ (CuSO4) for Hemoglobin Determination ▪ Old & obsolete practice in checking Hg ▪ Principle: a drop of whole blood which dropped in a solution of copper sulfate, which has a given specific gravity, will maintain its density for approximately 15s. specific gravity for CuSO4 is 1.053, which equivalent to 12.5 g/dL ▪ Density of the drop is directly proportional with the amount of hemoglobin ▪ Blood denser than sp. gravity of soln, drop sinks to bottom an will not float SCREENING • • • Two goals or purposes for screening o Protects the health of the potential donor o Protects the health of the potential recipient Four outcomes o Accept - can donate blood, no issue in physical examination, screening o Temporary deferral - unable to donate blood for a limited period of time ▪ Px has colds, have high temp o Indefinite deferral ▪ Px with certain medications o Permanent deferral - will never be eligible to donate blood; any member of high-risk group Three components of screening o Registration o Health history interview o Limited physical examination ▪ General appearance, pulse, weight, temperature, blood pressure, Hct, Hgb DONOR DEFERRAL • Indefinitely or permanently o History of viral hepatitis ▪ (+) HBsAg (Hepatitis B surface antigen) ▪ Reactive for Anti-HBc (core part of virus) ▪ Past/present evidence of Hepatitis C infection • Can cause liver permanent damage ▪ Donor involved in post transfusion hepatitis o History of jaundice of unknown cause ▪ Will require additional testing for origin of jaundice o Past/present abuse of self-injected drugs (drug users) o Cancer ▪ Increased underdeveloped/nonfunctional cells ▪ Viscous blood o Abnormal bleeding tendencies ▪ Hemophilia - bleeding disorder; issue with coagulation factors o Cardiopulmonary diseases ▪ Affect heart/lungs o Leukemia, lymphoma o High risk sexual behavior ▪ Px with multiple sexual partners ▪ HIV/AIDS (low CD4 count) o High risk occupation (eg. prostitute) o Chaga’s disease ▪ Caused by Trypanosoma cruzi (hemoflagellate) ▪ Damages hollow organs o Babesiosis ▪ Caused by Babesia microti (sporozoite) o Px receiving growth hormone (Creutzfeldt-Jakob dse) ▪ Bovine meningoencephalopathy o o • • • • • • • • • Symptoms of AIDS-related Complex (ARC), HIV/AIDS Donors taking Tegison for psoriasis because its potentially teratogenic (induce cancer) ▪ Cause damage/mutation to genes o Active pulmonary TB ▪ Immunocompromised aptients Three Years Deferral o Those with infected with malaria o Visitors, immigrants or refugees from an area considered endemic for malaria/residents of area endemic for malaria (Palawan, Samar) 12-month deferral o Close contact to patient with hepatitis ▪ Partners, couples are also deferred o Donors who received blood or blood products, an organ or tissue transplant o Tattoo, ear, and skin piercing o Those who have received HBIg bec, it is given for exposure to possible infection and it may delay the onset of symptoms of disease o Donors who have had or been treated for syphilis or gonorrhea (STD) o (+) serologic test for syphilis o Donors who have traveled to areas considered endemic for malaria o Rabies vaccine ▪ One year after last shot of rabies vaccine o Sexual contact with any person who has high eisk of exposure to HIV Two months (8 weeks/ 56 days) o Whole blood donation 6 weeks o Pregnant: deferred during pregnancy and 6 weeks following a third trimester delivery o NOTE: 1st and 2nd trimester abortion or miscarriage need not to be a cause for deferral One Month (4-week deferral) o Donors taking Accutane (isotretinoin for acne therapy is also a potent teratogen) o Vaccination: ▪ Rubella (German measles) ▪ Varicella zoster (chicken pox/shingles) Two-week deferral o Vaccination: attenuated virus vaccines ▪ Mumps ▪ Oral polio (Sabin) ▪ Rubeola (measles) ▪ Smallpox ▪ Yellow fever ▪ Influenza (live virus) 3-days o Tooth extraction or dental work 48-hours o Donors participating in pheresis program o Until signs and symptoms are gone o Donors who have active cold or flu symptoms must be deferred until the symptoms are gone No deferral (accepted for blood donation) o Donors who had vaccinations of the following killed viral, bacterial, rickettsial vaccines or toxoids ▪ Diphtheria ▪ Tetanus ▪ Choleara ▪ Heap B vaccine o ▪ Pertussis ▪ Typhoid ▪ RMSF (Rocky Mountain Spotted Fever ▪ Influenza (killed) ▪ Injectable polio vaccine (Salk) Acceptable Drugs ▪ Allergy shots ▪ Birth control pills ▪ Analgesics (pain ▪ Corticosteroids medications such as ▪ Diuretics aspirin) ▪ Eye medication ▪ Anorexics (diet pills) ▪ Fertility agents (if not ▪ Antibiotics pregnant) (Completed ▪ Gout medication (must medication and is be symptom free) symptom free) ▪ Hormones ▪ Antidepressants ▪ Muscle relaxants ▪ Antacids ▪ Sedatives ▪ Antihistamines ▪ Thyroid ▪ Antihypertensive ▪ Tranquilizers agents ▪ Vitamins ▪ Antispasmodics ▪ HEMAPHERESIS DONOR SELECTION • Hemapheresis – ADDITIONAL DONOR GUIDELINES • • • • • • A donor must not exceed ?? in a year unless otherwise allowed by bloodbank physician. A donor must be tested to detect ?? If a donor donates whole blood, at least ?? must be elapsed before he can donate for pheresis. Extracorporeal blood ?? of the donor’s total blood volume. If platelet pheresis is to be performed a donor must have above ?? Possible adverse reactions to HES, steroids and/or heaparin must be determined. These substances are use in the apheresis procedures. AUTOLOGOUS DONOR SELECTION • • • • Autologous Donor – one who is donating blood for his or her own future use o Reservation for reservation for surgery o For people with rare blood type/phenotype Autologous blood – the safest blood possible for transfusion Advantages o No risk of disease transmission; alloimmunization to red cells, platelets, WBCs, or plasma proteins; transfusion reaction o Phlebotomy process stimulates the bone marrow to increase cell production o Decreases need for allogeneic blood and may actually increase supply for allogeneic blood supply Criteria o No age limit. o No strict weight requirements. o Hemoglobin/hematocrit – should not be less than 11 g/dL and 33% o Frequency - donations should not be more frequent than every 3 days and the final donation must be completed at least 3 days prior to the suggested surgical procedure • • Contraindications of Autologous Donations o Conditions of presenting risk of bacteremia o Unstable angina o Recent myocardial infarction and cerebrovascular accident o Significant disease with ongoing symptoms but who have not been evaluated by the physicians o Untreated aortic stenosis Type of Autologous Donations/Transfusions: o Pre-deposit donation – refers to the blood that is drawn some time before the anticipated transfusion and stored, usually liquid but occasionally frozen. o Intraoperative autologous transfusion – occurs when blood is collected during the surgical procedure and usually reinfused immediately. o Immediate preoperative hemodilution – takes place in the operating room when 1-3 units of WB are collected and the patient’s volume is replaced with colloid or crystalloid. The blood is reinfused during the surgical procedure. o Post-operative salvage – an autologous donation in which a drainage tube is placed in the surgical site and postoperative bleeding is salvaged, cleaned and reinfused • • • • • • AABB PROTOCOL • • WHOLE BLOOD COLLECTION • • • • Once donor is accepted, the next step is to collect blood. Blood collection is different than usual phlebotomy. 450 mL blood is collected. Requires at least 10 minutes to complete. Ensure safety of patient and sterility of collection area to avoid contamination. • STEP-BY-STEP PROCESS IN BLOOD COLLECTION FOR WHOLE BLOOD DONATION • • • • • • • Wear gloves and other PPE Identify patient. o Ensure comfort. o Confirm the identity of the patient. Palpate with both hands Search the vein (median cubital vein) o Median cubital vein is primarily recommended Clean with 70% alcohol Clean with scrub solution o Composed of ▪ PVP Iodine Complex and aka as povidone iodine complex, polymer of iodine solution, iodoform complex o Rinse with alcohol o Site of application ▪ At least 4 cm or1.5 inches at all directions ▪ Allow to dry and place sterile gauze ▪ If allergic to iodine (presence of red spots), alternative: • 70% isopropyl alcohol in chlorhexidine gluconate solution) ▪ If allergic to iodine and chlorhexidine, alternative: • 70% isopropyl solution ▪ Apply in up and down scrubbing for 30 minutes and repeat Allow to air dry the area and place sterile gauze to prevent any contamination Release the clip allowing the blood to flow freely Bevel up gauge 16 needle and blood bag is placed below the arm of donor Give stress ball (should be squeezed every 10-20 sec to promote blood flow and prevent numbness) When filled, remove tourniquet, reinsert the clip and remove the needle. Note: o Do not fill in completely to prevent spillage. o Shake/swirl the blood unit from time to time to allow the mixture of anticoagulant and the blood. Normal time of collection: o 450 mL blood withdrawal ▪ 8-12 mins (average of 10 mins) ▪ >15 mins. - presence of clot (remove needle from the tubing) If vein searching is performed, platelet component is not used for transfusion because primary hemostasis is activated. If blood clots are formed during colelction, the following are not allowed because primary hemostasis is activated; coagulation factors in the plasma and platelets are already consumed o Plasma component (FFP) o Platelet component o Cryoprecipitate o *Only packed RBC is component allowed Labels in the Primary Bag o Donor Accession Number (hospital number) ▪ Name of the donor must not be written ▪ Written in alphanumeric o Date and Time of Collection ▪ Basis for first-in and first-out rule o Initials of Phlebotomists POST DONATION CARE • • • • • • It is recommended that donors remain in an area where they can be observed by the donation center staff and be given instruction to follow for the next 24 hours. Advise donors to remain in the area to prevent few side effects (fainting, etc.) Donors are suggested to consume fluids (water) Donors will also be asked to contact blood center in cases of issues. Advise donors to have plenty of rest within 24 hours Don’ts o Do not drink alcohol for 24 hours o Do not take of bandages immediately o Do not perform strenuous exercise nor lift heavy objects in the next 24 hours ADVERSE DONOR REACTIONS AND MANAGEMENT • Mild o Syncope or fainting, nausea or vomiting, hyperventilation, twitching, and muscle spasm. Syncope may be idiopathic or may be brought about by the sight of blood. o The donor may show signs of sweating, dizziness, pallor, or convulsions o • • Fainting and vasovagal reactions ▪ Characterized by general weakness, dizziness, palor, and loss of consciousness. ▪ Low BP and pulse rate ▪ Management • Remove the tourniquet and withdraw needle • Place cold compresses on the donor’s forehead • Raise the donor’s legs above the level of the head • Loosen tight clothing and secure airway • Administer aromatic spirit of ammonia (inhalation) - donor should respond by coughing • Monitor vital signs o Hyperventilation ▪ Twitching/muscle spasms - initial signs ▪ May induce tonic-clonic movement similar to convulsion ▪ Management: Talk to patient to disrupt breathing pattern and breathe into paper bag o Citrate toxicity ▪ SS: perioral paresthesias, acral paresthesis, shivering, lightheadedness, twitching, and tremors ▪ As ionized Calcium falls farther, symptoms may progress to muscle spasms, tetany, and seizures o Nausea and vomiting ▪ Instruct px to breathe slowly and deeply ▪ Provide emesis basin and clean towels o Cardiogenic/hypovolemic shock ▪ Increase in pulse rate o Hematoma ▪ Phlebotomy-induced reactions ▪ Bluish discoloration of skin → needle going through vein with subsequent leakage of blood ▪ Mgt: Apply pressure with sterile gauze pad for 710 mins and apply ice to the area for 5 minutes Moderate o A moderate reaction can include any of the reactions listed above in addition to loss of consciousness. o The donor may have a decreased pulse rate, may hyperventilate, and may exhibit a fall in systolic pressure to 60 mm Hg. Severe o Convulsions can be caused by cerebral ischemia, marked hyperventilation, or epilepsy. o The former is associated with vasovagal syncope or reduced blood flow to the brain owing to the shock symptoms, and hyperventilation is caused by marked depletion of carbon dioxide. DONOR’S BLOOD PROCESSING • • • • • • • • ABO/Rh Antibody screen HBSAg and Anti-HBC Anti-HCV (Hepatits C) Anti-HIV 1/2 Plasmodium (Malaria) Serologic test for syphilis Anti-HTLV I/II (T lymphotropic virus) RBC PRESERVATION AND STORAGE • • • RBC is the most transfused donor unit or component in transfusion practice Successful transfusion happens when 70-75% or more of the donor RBC are able to survive in the recipient’s circulation. How to determine? o Post-blood Transfusion Complete Blood Count POST BLOOD TRANSFUSION COMPLETE BLOOD COUNT • • Carried after 6 hrs after blood transfusion. Results must be Increased hemoglobin, hematocrit, and RBC concentration Low results = failed transfusion STORAGE OF BLOOD – LESIONS OF STORAGE • • • • • • Decrease in pH o Acidic pH = decreased 2,3-DPG o Decreased 2,3-DPG - shift to the left phenomenon Buildup of Lactic Acid o Increased lactic acid affects pH levels Decrease in Glucose o Once glucose is consumed by ATP, there would be lactic acid buildup due to anaerobic glycolysis o Increased glucose metabolism decreases glucose concentration Decrease in ATP Loss of RBC function o Cause for hemolysis o Reduced glucose weakens RBC integrity which increases susceptibility to hemolysis Increase in hemolysis o Decreases sodium & increased potassium in plasma o Causes hyponatremia and hyperkalemia ADDITIVE SOLUTIONS • • • • • Additional source of nutrients for extended RBC storage Prevents lesions of storage Components: o Saline - provides the physiologic isotonic suspending medium for additive solution components o Dextrose - maintains RBC viability by preserving cell membrane integrity to prevent lysis o Adenine - major source of ATP for cell utilization o Mannitol - to retard in vitro storagelysis Approved Preservative solution o Acid Citrate Dextrose - 21 days o Citrate Phosphate Dextrose (CPD) - 21 days o CP2D - 21 days (double dose of dextrose) o CPDA1 (w/ adenine) - 35 days Additive Solution Used in US o ADSOL (AS-1) if primary anticoagulant is CPD o Nutricel (AS-3) if additive solution of choice is CP2D o Optisol (AS-5) if CPD is used RBC REJUVENATION • • • Carried out 3 days after expiration to regenerate 2,3-DPG and ATP levels o For cell utilization and vitality Done for 1-4 hours at 37C Good for rare phenotypes like AB- and Bombay phenotype • Rejuvesol o Only FDA approved rejuvenation solutions o Consists of PIPA (Before it was PIGPA) o PIGPA: Phosphate, Inosine, Glucose, Pyruvate, Adenine (No without glucose) RED CELL FREEZING/ GLYCEROLIZATION/CRYOPROTECTION • • • • Protects RBCs from extremely cold temperatures Cryoprotective agent is used o ex. Glycerol (most commonly used) RBCs can be stored at -65C for colder for 10 years o Longest expiration date o Uses: Done for autologous units o Note: RBCs should be less than 6 days old (prime requirement) Two Types Of Glycerol Used: o High Concentration Glycerol (HCG) ▪ 40% glycerol concentration ▪ Mechanical freezer ▪ Temperature: -65C ▪ Commonly used o Low Concentration Glycerol (LCG) ▪ 20% ▪ Liquid nitrogen freezer ▪ Temperature: -120C ▪ High maintenance High Low Glycerol Glycerol Initial freezing temperature -80C -196C Need to control freezing rate No Yes Type of freezing Mechanical Liquid Nitrogen Maximum storage temp. -60C -120C Shipping Requirements Dry Ice Liquid Nitrogen Effects of changes in storage Can be Critical (can temperature thawed/frozen cause damage to RBCs) DEGLYCEROLIZATION • • • • Is a 3 cell washing procedure that utilizes the wash solution (hypertonic salt solution) in decreasing concentration until highly isotonic solution is reached 1st washing - 12% salt (hypertonic) solution is used. o Promotes removal of glycerol from RBC but will not affect the cell morphology 2nd washing - 1.6% salt solution is used. o Promotes complete removal of glycerol from RBC but will not affect cell morphology 3rd washing - 0.2% dextrose in NSS (0.85-0.99% isotonic salt solution) o To maintain RBC morphology prior to blood transfusion METHODS OF CENTRIFUGATION • • Intermittent Flow Centrifugation (IFC) o Single needle/1 arm procedure o Processed in batches or cycles o 1 cycle completed after another cycle Continuous Flow Centrifugation (CFC) o Double needle/2 arm procedure o Performed simultaneously o 2 arms are used for withdrawing and returning of blood unit