11/17/2014 A little about me... Transfusion Medicine: When, What and How? Jillian DiFazio, DVM, DACVECC Emergency and Critical Care Outline Canine and feline blood groups Blood typing Cross-matching Blood donor screening Donor collection Transfusion administration Blood component therapy Risks of transfusions Controversies in transfusion medicine http://3.bp.blogspot.com/-gc68oytSkvY/UhfwmF5HyUI/AA AAAAAABJ8/HjIKf5UmOoI/s1600/dog-cat-transfusion.jpg • • • • • • • • • Transfusion history • First transfusion in 1665 in a dog http://home.netcom.com/~jskipper/victoria/transfusion.jpg http://www.kumc.edu/dc/pc/lower.jpgText Canine blood groups Universal blood donor? • 13 blood groups – DEA 1.1, 1.2, 3, 4, 5, 7 – No natural antibodies to DEA 1 system – Natural antibodies present 3, 5, 7 – Dal • DEA 1.1, 3, 5, 7 negative; 4 positive http://dogsdonateblood.files.wordpress.com/2012/10/037403-donor-dog-brisbane-veterinary-specialist-centre1.jpg 1 11/17/2014 DMS card http://www.agrolabo.it/html/home_diag_cane_agglutinazione/carte.jpg Canine blood typing • Laboratory testing – Tube agglutination • In-house typing DEA 1.1 – DMS card – Cartridge Quick Test, Alvedia – Gel column test Cartridge quick test Feline blood groups • A, B, AB – Differences in alloantibody strength http://www.dumpaday.com/wp-content/uploads/ 2013/03/grumpy-cat-blood-type.jpg • Mik antigen • No universal donor http://www.alvedia.com/images/dog-pos.jpg • Laboratory testing – Tube agglutination • In-house typing AB system – RapidVet-H feline card test – Cartridge Quick Test A+B, Alvedia • No in-house testing for Mik DMS card http://www.agrolabo.it/html/home_diag_gatto_agglutinazione/carte.jpg Feline blood typing 2 11/17/2014 Cartridge quick test Cross-matching • Major crossmatch • Minor crossmatch http://avmhk.com/ufiles/Alvedia1.jpg Canine cross-matching Feline cross-matching • Recommended if... • Should be considered first transfusion – Unknown transfusion history – Severe hemolytic transfusion prior – >3-7 days since first transfusion – Donor 7 blood type unknown http://www.alvedia.com/images/forme%20chats%20orange.jpg Cross-matching methodology Weltman 2014 RapidVet-H gel method • Manual method • RapidVet-H gel method http://www.rapidvet.com/xmatch.html 3 11/17/2014 Blood donor screening • CBC, chemistry, urinalysis, fecal • Bartonella • +/- Ehrlichia, Anaplasma, Neorickettsia, Cytauxzoon felis Anticoagulants and preservatives http://www.medvet.umontreal.ca/etudes/Enseignement Ligne/pathologie_clinique/images/CP_13_corr.jpg • Mycoplasma Heartworm Babesia Ehrlichia Neorickettsia Bartonella Mycoplasma haemocanis +/- Leishmania, Trypanosoma cruzi +/- Brucella canis Donor collection Feline blood donor screening • FeLV/FIV • • • • • • • • http://upload.wikimedia.org/wikipedia/commons /c/cd/Babesia-canis-dog.jpg • Physical exam http://smartyvet.com/site/wp-content/uploads/2014/03/ Dog-blood-donor-recipients.jpg • Healthy Canine blood donor screening • Dogs 15-20ml/kg • Cats 10-15ml/kg • Jugular vein http://www.catblooddonors.com Transfusion administration • Core principles • Monitoring http://img.tradeindia.com/fp/1/652/386.jpg • Gravity, pump, syringe administration – Dogs: Gravity + in-line filter – Cats: Syringe + HemoNate filter • Leukoreduction McDevitt 2011 Heikes 2014 4 11/17/2014 • • • • • Whole blood Packed red blood cells Fresh frozen plasma Frozen plasma Cryoprecipitate • • • • • Cryo-poor plasma Albumin Platelet concentrate Frozen platelets Lyophilized platelets Whole blood • Red blood cells, white blood cells, proand anti-coagulant factors, platelets • Anemia • Use within 4-6 hours http://bartramia.blogspot.com/2011_09_01_archive.html • Stable for ~ 1 month if refrigerated Packed red blood cells Formulas for transfusions • Red blood cells +/- white blood cells • VT (mL) = kg BW x blood volume (90ml) x [(desired PCV-recipient PCV)/ donor PCV] • VT (mL) = 1.5 x desired rise PCV x kg BW • Anemia • 20-37 days in refrigerator (additives) • Dosing http://www.interactive-biology.com/wp-content/uplo ads/2012/07/RedBloodCells3.jpg Blood component therapy • VT (mL) = 1ml x % PCV rise x kg BW overestimated • VT (mL) = 2ml x % PCV rise x kg BW underestimated Short 2012 Fresh frozen plasma Frozen plasma • All pro- and anti-coagulant factors, albumin • II, VII, IX, X, albumin • Coagulopathy • 1 year in freezer; frozen within 8 hrs • Dosing: 10-20ml/kg • Vitamin K1-dependent coagulopathy • 1-5 years in freezer; frozen >8hrs • 10-20ml/kg 5 11/17/2014 Refrigerated frozen plasma Cryoprecipitate • Time to thaw ~ 35 minutes • Refrigerated storage (14 days) resulted in significant decrease in activity of clotting factors • No values outside of RR • No contamination of units documented • VIII, vWF, fibrinogen, fibronectin, XIII • vWD, hemophilia A • 10 months in freezer • 1U/10kg Grochowsky 2014 Cryo-poor plasma Albumin • II, VII, IX, X, albumin • Concentrated albumin (human) • Vitamin K1-dependent coagulopathy • Hypoalbuminemia • 1 year in freezer • Stable for 3 years at room temp • 10-20ml/kg • Dosing 1.5 g/kg or albumin deficit Platelet-rich plasma and concentrate Frozen platelets • Platelets, plasma • Severe thrombocytopenia • Stable for 5 days, constant agitation • 1U/10kg http://complementaryoncology.com/wp-content/uploads/ 2012/04/dogrbcpl.jpg http://yuanda.en-cphi.cn/sell/id-5318.shtml • Platelets, 6% DMSO or 2% DMSO + Thrombosol • Severe thrombocytopenia • 6 months in freezer • 1U/10kg; humans 2.5U:1U fresh 6 11/17/2014 Lyophilized platelets Lyophilized platelets • Platelets • No difference between lyophilized vs. fresh platelets • Severe thrombocytopenia • 2 years in refrigerator • Dosing based on weight ranges – transfusion reaction rates – need for additional transfusions – 24 hour blood loss score (BLS) – hospitalization time – survival to discharge – 28 day survival Davidow 2012 Autologous transfusions Massive transfusions • Simple autotransfusion • Greater than blood volume in 24 hrs • Greater than 1/2 blood volume in 3 hrs – Crowe 2004 • Mortality 74% – Hirst 2012 (case series) http://www.wvc.vetsuite.com/Images/ViewImage. – Kellet-Gregory 2013 aspx?Id=442&height=305&width=485 • Complications • 1:1:1 ratio Transfusion reactions Transfusion reactions • Immunologic • Non-immunologic – Type I hypersensitivity reactions – Severe hemolytic reactions – Non-hemolytic febrile reactions – Acute lung injury (TRALI) – Immunomodulation (TRIM) – Decreased red cell survival – Sepsis – Electrolyte derangements – Volume overload (TACO) – Hypothermia – Storage lesions – Infectious diseases Thomovsky 2014 Jutkowitz 2002 http://www.vetmed.wsu.edu/resources/Techniques/images/cvp4.jpg • Cell salvage devices 7 11/17/2014 Transfusion reactions Controversies • What are the most common? • When to treat anemia? • How frequently do they occur? • Plasma for DIC? • What do we do when they occur? • Plasma for hypoalbuminemia? • When to give platelets? When to treat anemia? Plasma for DIC? • Goal to increase oxygen delivery • Human guidelines – DO2 = CO x CaO2 – CaO2 = [% Sat x 1.39 (ml/g) x [Hb] (g/dl) + (arterial PaO2 x 0.003)] • Target [Hb] Prittie 2010 TRICC trial 1999 CRIT trial 2004 ABC trial 2002 Plasma for hypoalbuminemia? – Cornerstone of DIC treatment is treatment of underlying condition – Blood component therapy (platelets or plasma) should not be given on basis of laboratory derangements alone • Active bleeding • Invasive procedures 2013 International Society on Thrombosis and Hemostasis Platelet transfusions? • Generally not indicated • 22.5ml/kg to raise albumin 0.5g/dl • Invasive procedures • No difference in albumin pre-/posttransfusion in canine retrospective thebark.com • Severe thrombocytopenia • Life-threatening hemorrhage Snow 2010 8 11/17/2014 References References Blais MC, Rozanski EA, Hale AS: Lack of evidence of pregnancy-induced alloantibodies in dogs. Journal of Veterinary Internal Medicine 2009; 23 (3): 462-465. Jutkowitz LA, Rozanski EA, Moreau JA: Massive transfusion in dogs: 15 cases (1997-2001). Journal of the American Veterinary Medical Association 2002; 220 (11): 1664-1669. Corwin HL, Gettinger A, Pearl RG, et al: The CRIT Study: Anemia and blood transfusion in the cirtically illcurrent clinical practice in the United States. Critical Care Medicine 2004; 32 (1):39-52 Davidow EB, Brainard B, Martin LG, et al: Use of fresh platelet concentrate or lyophilized platelets in thrombocytopenic dogs with clinical signs of hemorrhage: a preliminary trial in 37 dogs. Journal of Veterinary Emergency and Critical Care 2012; 22 (1): 116-125. Hebert PC, Wells G, Blajchman MA, et al: A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. New England Journal of Medicine 1999; 340 (6): 409-417. Kellett-Gregory LM, Seth M, Adamantos S, et al: Autologous canine red blood cell transfusion using cell salvage devices. Journal of Veterinary Emergency and Critical Care 2013; 23 (1): 82-86. Kessler RJ, Reese J, Chang D, et al: Dog erythrocyte antigens 1.1, 1.2, 3, 4, 7, and Dal blood typing and crossmatching by gel column technique. Veterinary Clinical Pathology 2010; 39 (3): 306-316. Kisielewicz C, Self I, Bell R: Assessment of clinical and laboratory variables as a guide to packed red blood cell transfusion of euvolemic anemic dogs. Journal of Veterinary Internal Medicine 2014; 28 (2): 576-582. McDevitt RI, Ruaux CG, Baltzer WI: Influence of transfusion technique on survival of autologous red blood cells in the dog. Journal of Veterinary Emergency and Critical Care 2011; 21 (3): 209-216. Heikes BW and Ruaux: Effect of syringe and aggregate filter administration on survival of transfused autologous fresh feline red blood cells. Journal of Veterinary Emergency and Critical Care 2014; 24 (2): 162-167. Prittie JE: Controversies related to red blood cell transfusion in critically ill patients. Journal of Veterinary Emergency and Critical Care 2010; 20 (2): 167-176. Hirst C, Adamantos S: Autologous blood transfusion following red blood cell salvage for the management of blood loss in 3 dogs with hemoperitoneum. Journal of Veterinary Emergency and Critical Care 2012; 22 (3): 355-360. McMichael MA, Smith SA, Galligan A, et al: Effect of leukoreduction on transfusion-induced inflammation in dogs. Journal of Veterinary Internal Medicine 2010; 24 (5): 1131-1137. Holowaychuk MK, Leader JL, et al: Risk factors for transfusion-associated complications and nonsurvival in dogs receiving packed red blood cell transfusions: 211 cases (2008-2011). Journal of the American Veterinary Medical Association 2014; 244 (4): 431-437. Jutkowitz LA, Rozanski EA, Moreau JA: Massive transfusion in dogs: 15 cases (1997-2001). Journal of the American Veterinary Medical Association 2002; 220 (11): 1664-1669. References Seth M, Jackson KV, Giger U, et al: Comparison of five blood-typing methods for the feline AB blood group system. American Journal of Veterinary Research 2011; 72 (2): 203-209. Seth M, Jackson KV, Winzelberg S, et al: Comparison of gel column, card, and cartridge techniques for dog erythrocyte antigen 1.1 blood typing. American Journal of Veterinary Research 2012; 73 (2): 213-219. Questions? Short JL, Diehl S, Seshadri R, et al: Accuracy of formulas used to predict post-transfusion packed cell volume rise in anemic dogs. Journal of Veterinary Emergency and Critical Care 2012; 22 (4): 428-434. Snow SJ, Jutkowitz A, Brown AJ: Trends in plasma transfusion at a veterinary teaching hospital: 308 patients (1996-1998 and 2006-2008). Journal of Veterinary Emergency and Critical Care 2010; 20 (4): 441-445. Thomovsky EJ, Bach J: Incidence of acute lung injury in dogs receiving transfusions. Journal of the American Veterinary Medical Association 2014; 244 (2): 170-174. Tocci LJ and Ewing PJ: Increasing patient safety in veterinary transfusion medicine: an overview of pretranfusion testing. Journal of Veterinary Emergency and Critical Care 2009; 19 (1): 66-73. Weltman JG, Fletcher DJ, Rogers C: Influence of cross-match on posttransfusion packed cell volume in feline packed red blood cell transfusion. Journal of Veterinary Emergency and Critical Care 2014; 24 (4): 429-436. 9
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