Yvette Marie Miller, M.D. Executive Medical Officer American Red Cross October 20, th Annual Great Lakes Cancer Nursing Conference Troy, MI

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1 Yvette Marie Miller, M.D. Executive Medical Officer American Red Cross October 20, th Annual Great Lakes Cancer Nursing Conference Troy, MI

2 Overview of Hematology, ematology%20introduction.ppt Guidance for Industry: An Acceptable Circular of Information for the Use of Human Blood and Blood Components, revised December 2009 A Compendium of Transfusion Practice Guidelines, American Red Cross, First Edition 2012 reprint

5 Hematopoiesis RBCs WBCs Platelets Plasma Cryo Special Issues- TTD and reversing new class of anticoagulants Summary

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8 Normal Peripheral blood smear

9 RBC count: Male: 4.7 to 6.1 million cells/mcl Female: 4.2 to 5.4 million cells/mcl Hematocrit: Male: 40.7 to 50.3% Female: 36.1 to 44.3% Hemoglobin: Male: 13.8 to 17.2 gm/dl Female: 12.1 to 15.1 gm/dl Red blood cell indices: MCV: 80 to 95 femtoliter MCH: 27 to 31 pg/cell MCHC: 32 to 36 gm/dl WBC count: 4,500 to 10,000 cells/mcl Platelet count 150, ,000 platelets per microliter (mcl) Note: cells/mcl = cells per microliter gm/dl = grams per deciliter; pg/cell = picograms per cell lus/ency/article/ htm

1 gm/dl Red blood cell indices: MCV: 80 to 95 femtoliter MCH: 27 to 31 pg/cell MCHC: 32 to 36 gm/dl WBC count: 4,500 to 10,000 cells/mcl

11 Primary vehicle to transport oxygen to tissues Normal lifespan = 120 days Reticulocytes- Immature RBCs ; 1-2% RBC count Indications for Transfusion: Treatment of symptomatic or critical deficit of oxygen-carrying capacity Red cell exchange transfusion

Indications for Transfusion: Treatment of symptomatic or

12 Each unit of RBCs/Whole Blood increases hemoglobin by approximately 1 g/dl (increase hematocrit by 3%) For pediatric patients/small volume needs-use 10-15ml/kg

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15 Differential Neutrophils 45-65% Segs / Polys Lymphocytes 15-40% Monocytes 2-8% Eosinophils 0-5% Basophils 0-3%

16 Protect the body against infection; each cell type has a different disease-fighting activity Neutrophils fight acute, bacterial and viral infections Lymphocytes directed against viral, chronic infections

17 Eosinophils- for fighting off parasitic invasions and acute infections; elevated in allergic reactions Basophils contain histamine, heparin, biologically active proinflammatory substances, elevated in allergic reactions, parasitic infections Monocytes/macrophages-monocyte is blood cell; macrophages is a tissue cell; elevated in viral infections, involved with phagocytizing debris

elevated in allergic reactions, parasitic infections Monocytes/macrophages-monocyte is blood

18 Granulocyte transfusion therapy is controversial Collected by apheresis Broad-spectrum antimicrobials should be used before granulocyte transfusion therapy is considered Used in treatment of documented infections (gramnegative bacteria and fungi) unresponsive to antimicrobial therapy in the setting of neutropenia Neonatal sepsis If the intended recipient is CMV-seronegative and severely immunosuppressed; use CMV negative donor Patients with hereditary neutrophil function defects (such as chronic granulomatous disease) may be candidates for granulocyte therapy

therapy in the setting of neutropenia Neonatal sepsis If the intended recipient is CMV-seronegative and severely immunosuppressed; use CMV

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21 Platelets are essential for normal hemostasis; complex reactions occur between platelets, vwf, collagen and insoluble coagulation factors ultimately forming a primary hemostatic plug Platelets are cellular fragments; lifespan 10 days

22 Indications for transfusion: To treat bleeding due to critically low platelet count or dysfunctional platelets Prophylaxis to maintain platelet counts 10,000/uL in stable non-bleeding pt 20,000/uL in unstable non-bleeding pt 50,000/uL in actively bleeding or undergoing surgery Aplastic Anemia transfuse at 5000/uL

24 Liquid portion of blood; contains albumin, coagulation factors, fibrinolytic proteins, immunoglobulin, and other proteins FFP-prepared from whole blood or apheresis collection and frozen at 18 C or colder within 8 hours

25 FP-24 prepared from a whole blood; must be frozen at 18 C or below within 24 hours from collection Has reduced levels of factor V and VIII Thawed plasma derived from FFP or Plasma Frozen Within 24 Hours After Phlebotomy, thawed at 30 to 37 C, and maintained at 1 to 6 C for up to 4 days after the initial 24-hour postthaw period has elapsed Thawed Plasma contains stable coagulation factors such as Factor II and fibrinogen in concentrations similar to those of FFP, but variably reduced amounts of other factors

26 Plasma Cryoprecipitate Reduced-FFP thawed at 1 to 6 C, and the insoluble cryoprecipitate is removed

27 Transfusion indications: Dosed on pt size and clinical condition Used to correct multiple coagulation factor deficiencies Isolated factor deficiency for which there is no factor concentrate Plasma exchange for TTP DIC with active bleeding

29 Fresh Frozen Plasma (FFP) 1 to 6 C, and the insoluble fraction is cryoprecipitate Contains- 5 plasma proteins-fibrinogen, factor VIII, factor XIII, von Willebrand factor and fibronectin

30 Transfusion indications: Fibrinogen deficiency with bleeding DIC, cardiac surgery Fibrin sealant Massive transfusion

31 Effient-contains prasugrel inhibitor of platelet activation and aggregation; for overdose administer platelets Pradaxa-dabigatran-is a direct thrombin inhibitor; there is no reversal agent for dabigatran; initiate appropriate clinical support, discontinue treatment Dabigatran is excreted in the urine and can be dialyzed with the removal of about 60% of drug over 2 to 3 hours

32 Xarelto-rivaroxaban is a factor Xa inhibitor; an antidote is not available; discontinue XARELTO and initiate appropriate supportive therapy The use of activated charcoal to reduce absorption may be considered; due to the high plasma protein binding, rivaroxaban is not dialyzable

34 The risk of hepatitis B infection through blood transfusion is between 1 in 200,000 and 1 in 500,000 1,2 1 Stramer S. Current risks of transfusion-transmitted agents- A Review Arch Pathol Lab Med. 2007; 131: Zou S. et al Current Incidence and residual risk of hepatitis B infection among blood donors in the United States Transfusion 2009; 49:

35 ondonationfatalities

36 RBCs, Platelets and Plasma are the most commonly transfused blood products TRALI is the most common cause of transfusion related fatality

SARASOTA MEMORIAL HOSPITAL BLOOD COMPONENT CRITERIA AND INDICATIONS SCREENING GUIDELINES

SARASOTA MEMORIAL HOSPITAL BLOOD COMPONENT CRITERIA AND INDICATIONS SCREENING GUIDELINES TABLE OF CONTENTS SUBJECT PAGE ADULT CRITERIA Red Blood Cells/Autologous 2 Washed Red Blood Cells 2 Cryoprecipitate