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Febrile Nonhemolytic Transfusion Reactions

Febrile nonhemolytic transfusion reactions (FNHTRs) are common, occurring with 1–3% of transfusions. FNHTR manifests as fever and/or chills without hemolysis occurring in the patient during or within 4 hours of transfusion cessation. Diagnosis is made by excluding other causes of fever. Most common causes are passively transfused proinflammatory cytokines or recipient antibodies reacting with donor leukocytes. Most reactions are easily managed. FNHTRs are mitigated through prestorage…

Overview of Adverse Events and Outcomes After Transfusion

Transfusion of blood products can lead to number of adverse events and outcomes in recipients, ranging from subclinical infection with a virus that can remain undiagnosed for decades, to acute immune hemolysis or acute septic reaction resulting in rapid onset of hypotension, shock, and ultimately death. A number of classification schemes exist to categorize adverse events and outcomes, including groupings by pathogenesis (immune vs. nonimmune; infectious…

Patient Blood Management

Patient blood management (PBM) is the term given to the appropriate use of blood transfusion to optimize patient care. Patient-centric approach is its core principle ( Fig. 59.1 ). PBM is “transfusing the right product in the right dose to the right patient at the right time for the right reason.” PBM has five main tenets ( Fig. 59.2 ). In addition to improving patient safety,…

Massive Transfusion

Introduction Massive transfusion for an adult recipient is traditionally defined as the transfusion of ≥10 red blood cell (RBC) units < 24 hours (approximately, 1 total blood volume [TBV]). Some definitions that are more applicable in real time include the transfusion of ≥4 RBC units in 1 hour with anticipation of a continued need for blood product support, and replacement of 50% of the TBV within…

Platelet Transfusion Refractory Patients

Platelet refractoriness is defined as an inappropriately low platelet count increment after platelet transfusion. There are nonimmune and immune causes for platelet refractoriness ( Table 57.1 ), with nonimmune causes being responsible for the majority of cases. Evaluation of the potentially platelet refractory patient includes determining the etiology of the underlying thrombocytopenia, reviewing the patient’s underlying illness and current medications, determining sites and severity of active…

Management of Patients Who Refuse Blood Transfusion

A doctrine introduced in 1945 by Jehovah’s Witnesses teaches that the Bible prohibits the consumption, storage, and transfusion of human blood (Genesis 9:3, 4 and Acts 15:19, 20). The Watch Tower Bible and Tract Society of Pennsylvania have issued many doctrines since that time, citing that “blood is sacred to God,” and “even in the case of an emergency, it is not permissible to sustain life…

Blood Transfusion in Economically Restricted and Developing Countries

Over the past 10–20 years there have been major improvements in blood safety in low and lower middle-income countries (LIC, LMIC), largely driven by the human immunodeficiency virus (HIV) epidemic. Unfortunately, improvements in blood supply adequacy have not been as marked, and many challenges to the provision of an adequate supply of safe blood in these countries remain, particularly in countries that have relied or still…

Transfusion Management of Patients Receiving Antithrombotic Therapy

Hemostasis is the process by which blood components work in concert to halt bleeding as a consequence of injury. A blood clot forms in two general phases called primary and secondary hemostasis. Primary hemostasis involves the exposure of collagen in the subendothelium after a vascular injury. The collagen and blood flow shear forces stimulate von Willebrand factor to unfurl over the exposed collagen and provide a…

Transfusion Management of Patients Undergoing Hematopoietic Stem Cell and Solid Organ Transplantation

Transfusion in Patients Undergoing Hematopoietic Stem Cell Transplantation Human leukocyte antigen (HLA) compatibility is of greater importance than ABO compatibility in donor selection for HSC transplantation (HSCT). As such, ABO incompatibility may be present in up to 50% of donor/recipient HSCT pairs. Major ABO incompatibility occurs when the recipient expresses an antibody to A or B antigen present on the donor cells. Minor ABO incompatibility occurs…

Transfusion Management of Patients With Sickle Cell Disease and Thalassemia

Introduction Patients with hereditary hemoglobinopathies such as sickle cell disease (SCD) and thalassemia may require lifelong red blood cell (RBC) transfusion support, warranting special consideration by blood centers and transfusion services. Sickle Cell Disease SCD is usually caused not only by homozygosity for the hemoglobin (Hb) S mutation (sickle cell anemia) but is also caused by heterozygosity of HbS with a β-thalassemia or HbC. It affects…

Autoimmune Hemolytic Anemias

Autoimmune hemolytic anemia (AIHA) refers to a group of disorders where autoantibodies are directed against red blood cell (RBC) membrane antigens resulting in shortened RBC survival (normally 100–120 days) through activation of the complement system and/or RBC removal within the reticuloendothelial system (RES). Classification of AIHA includes warm autoimmune hemolytic anemia (WAIHA), cold agglutinin disease (CAD), mixed-type AIHA due to wide thermal amplitude of the autoantibodies,…

Perinatal Transfusion Medicine

Transfusion management of the pregnant woman and fetus requires special consideration. This chapter will address the following related issues: (1) routine prenatal and neonatal transfusion testing in relationship to maternal red blood cell (RBC) alloimmunization, (2) hemolytic disease of the fetus and newborn (HDFN), and (3) transfusion management of HDFN, including maternal, fetal, and neonatal testing and treatment. HDFN occurs when maternal plasma contains an RBC…

Neonatal and Pediatric Transfusion Medicine

Red Blood Cell Transfusions RBC Transfusion Considerations in Neonates Neonatal RBC transfusion thresholds are not clearly defined, with gestational age, postnatal age, and clinical condition being important considerations. Two randomized control trials (RCTs) (Bell et al. and Kirpalani et al.) comparing liberal to restricted hemoglobin (hb) transfusion thresholds in preterm neonates had conflicting results regarding neurocognitive outcomes, making general recommendations difficult. Two RCTs (one in the United States…

Pathogen Reduction Technologies

Blood safety is of major importance in transfusion medicine. To decrease safety risks, a combination of donor education, screening, and testing for selected agents has been implemented. Pathogen reduction (PR) technology (PRT, also known as pathogen inactivation) is a proactive approach to reduce contaminating pathogens. HIV in the blood supply resulted in many infected patients in the 1980’s. This spurred development of methods to better safeguard…

Volume-Reduced Blood Products

Volume reduction (also known as hyperpacking or hyperconcentrating), a process performed after a blood component has been manufactured, is the removal of a portion of supernatant of a cellular blood product, such as red blood cell (RBC) or platelet unit. The supernatant contains residual plasma and anticoagulant-preservative solution, and its removal results in a more concentrated cellular product. This procedure is performed more often in pediatric…

Washed Blood Products

Washing refers to a process that removes the noncellular fluid in red blood cell (RBC) and platelet products and replaces it, typically with saline. Usually, the process is performed in an open system where storage time is limited to 4–24 hours depending on the storage temperature. Washing removes >99% of plasma proteins (including antibodies) and original supernatant that may contain unwanted substances (e.g., anticoagulant-preservative solution, cytokines,…

Frozen Blood Products

Cryopreservation of blood products, which maintains their activity, is an effective way to increase their storage time. Plasma products are routinely stored frozen, but RBCs are sometimes cryopreserved (for cryopreserved hematopoietic progenitor cell products, see Chapter 84, Chapter 85 ). Rarely, platelet products are cryopreserved, but the recovery is low and the product is still under investigation and not FDA licensed. The primary indication for freezing…

CMV-Safe Blood Products

Description Although typically of little consequence in immunocompetent individuals, primary cytomegalovirus (CMV) infection is associated with considerable morbidity and mortality in at-risk populations. TT-CMV is a serious complication of cellular blood product transfusion. Indications Studies suggest that 13%–37% of immunocompromised patients will contract TT-CMV from transfusion of unfiltered cellular blood components that are not mitigated for CMV. Populations at greatest risk for TT-CMV include fetuses (intrauterine…

Leukoreduction of Blood Products

Leukocytes (white blood cells [WBCs]) remain in red blood cell (RBC) and platelet (PLT) components after simple component preparation. Residual leukocytes have the potential to cause harmful effects in the transfusion recipient including febrile nonhemolytic transfusion reactions (FNHTRs), HLA alloimmunization, and transmission of cytomegalovirus (CMV). Other possible effects include transmission of other leukocyte-associated herpesviruses and transfusion-related immunomodulation (TRIM). The likelihood of these effects depend on the…

Irradiation of Blood Products

Irradiation (or pathogen inactivation) of blood products is performed to abrogate the risk of transfusion-associated graft-versus-host disease (TA-GVHD), a rare and almost universally fatal complication of blood transfusion with no successful treatment options. Irradiation results in the generation of electrons that damage lymphocyte DNA, and therefore, renders the lymphocytes unable to proliferate. Pathogen inactivation (PI) also prevents lymphocyte replication ( Chapter 48 ). In this chapter,…