Nobleza, Chelsea Mae N.

BSN 3- G Whole Blood Products By definition, whole Blood contains one unit of plasma and cells. Whole Blood can be stored, normally and conventionally, for 5 weeks. Factors V and VIII are labile and are significantly decreased after 7 days. Indication - If "fresh" (less than 24 hours since drawn,) whole Blood is still utilized in resuscitation of a patient who has been losing a lot of Blood. Whole Blood is not used for "routine" Blood transfusion when red cells (RBC) will suffice. Since one unit of donated Blood can be broken down into one unit RBC, one unit platelets, and one unit fresh frozen plasma (FFP), and more, the use of whole Blood is considered to be a waste of resources. Red Blood Cells (RBCs) A unit of RBC is prepared from a whole Blood collection using a closed sterile system. Blood is drawn into a bag containing the anticoagulant CPD. Most of the platelet rich plasma is separated with a centrifuge and separated into an attached container. 100 ml of an additive nutritive solution (Optisol) is added to RBC. Optisol is a crystalloid solution containing sodium, dextrose, adenine and mannitol. The Optisol supports red cell survival and extends the shelf life of the unit to 42 days. The added fluid volume of the Optisol also reduces the unit's hematocrit to ~57% (range 50 to 65%), thereby improving the flow characteristics of the component. Optisol is also known as AS-5. Indication - Red Blood cells are indicated for patients with symptomatic anemia that is not treatable with specific therapy such as iron, vitamin B12 or with folic acid. Washed Red Blood Cells Blood Products Description - Washed red Blood cells are red Blood cells washed with normal saline to remove most of the plasma. Washed red Blood cells should not be considered leukoreduced. Because the bag must be entered to introduce the saline, washed red cells must be given within 24 hours of their preparation. Indication - Washed red cells can be considered for patients who have had repeated hypersensitivity reactions to Blood or components despite prophylactic administration of antihistamines. It should be kept in mind, however, that the red cell washing procedure may not reduce the proteins enough to prevent hypersensitivity reactions (e.g. hypersensitivity to IgA). Therapeutic Effect - A unit of washed red Blood cells will raise the hematocrit less than will a unit of red Blood cells because of an approximate 20% loss of red cells from the unit during the washing process. Leukoreduced Red Blood Cells

Nobleza, Chelsea Mae N. BSN 3- G Description - Leukoreduced red Blood cell units contain leukocytes in a specifically reduced amount. In the United States, Blood processing centers use filtration to make leukoreduced red Blood cell units. Indication - The most common indication for leukoreduced red Blood cells is for patients who have experienced two or more non-hemolytic febrile transfusion reactions. Leukoreduced red cells are usually effective in preventing non-hemolytic febrile transfusion reactions for most patients. Leukoreduced red Blood cells are also effective in prevention of CMV transmission or HLA alloimmunization. Pediatric/Divided RBC Units Pediatric/Divided red Blood cell units are prepared by separating a CPD anticoagulated (containing no Optisol) packed red Blood cell unit into four bags. Each pedi-pack contains approximately 45 to 50 ml of red Blood cells and approximately 15 ml of plasma. Indication - Divided red Blood cell units are indicated for infants who require small amounts of red cells. Therapeutic Effect - A divided red Blood cell unit will increase the hematocrit/hemoglobin the same as a standard red Blood cell unit when corrected for the weight of the child and the volume infused. Platelets A Whole Blood Platelet Concentrate is prepared from whole Blood by an initial soft centrifugation to separate the red cells from the platelet rich plasma. Indications - Platelet transfusions are indicated for patients with bleeding due to either thrombocytopenia, platelet dysfunction or some combination of the two conditions. The point at which bleeding may occur varies depending on the patients condition. The majority of patients with normal platelet function will not experience bleeding until the platelet count drops below a certain point. In patients with abnormal platelet function, usually caused by drugs (e.g. aspirin or semi-synthetic penicillin), uremia or elevated split products of fibrinogen/fibrin, bleeding may occur with higher platelet counts. In patients undergoing surgery, bleeding may occur with relatively low platelet counts. Blood Products In addition to evaluating platelet count and patient condition, bleeding time may also be used in determining the need for platelet transfusions. A bleeding time twice the upper normal limit may be an indication for a platelet transfusion in a bleeding patient. HLA Matched platelets are indicated for patients who are refractory (demonstrate a poor post-transfusion platelets increment) to random donor platelets due to alloimmunization. Patients with auto-immune thrombocytopenic purpura (ITP) should not receive platelet transfusions unless bleeding is significant or life threatening. Platelet transfusions given to patients with ITP will be rapidly removed from circulation by

Nobleza, Chelsea Mae N. BSN 3- G the patients anti-platelet antibodies and thus will be, at most, only of transient benefit. Therapeutic Effect - Each unit of platelets prepared from donated whole Blood contains a certain number of platelets and can be expected to increase the platelet count of a 155-pound patient by a known approximate amount by one hour after transfusion. Since the usual dose for adults with platelet related bleeding is a pool of four to six units of platelet concentrates from whole Blood or one standard sized unit of apheresis platelets, an increase in the platelet count by one hour after transfusion is expected. . Granulocytes (Neutrophils) Description - Granulocytes (neutrophils) are obtained by an apheresis procedure from an ABO-Rh compatible donor. Since there are large numbers of red cells in granulocyte concentrates, compatibility testing must be performed between the donor unit and the recipient. Granulocyte concentrates from donors who have been stimulated by G-CSF, a practice currently under study, contain much larger numbers of leukocytes. Granulocyte concentrates are always irradiated to prevent graft versus host disease. Granulocytes should be administered as soon as possible after collection. If this is not possible, storage should be at room temperature for no longer than 24 hours after collection. A four hour expiration time is placed on the granulocytes once issued from the Blood center. Blood Products Indications - Granulocytes should be considered for patients with severe neutropenia (<200/l) and a documented life-threatening bacterial or fungal infection not responsive to appropriate antibiotic therapy. Additional indications include neonates with clinical sepsis and patients with infections who have neutrophil function defects. After granulocyte therapy is initiated, it is generally continued once daily until the infection clears or the neutrophil count begins to recover. Fresh Frozen Plasma (FFP) Description - Fresh frozen plasma (FFP) is the plasma removed from a unit of whole Blood and frozen at or below 55 Fahrenheit within eight hours of collection. FFP contains all coagulation factors in normal amounts and is free of red cells, leukocytes and platelets. It is not a concentrate of clotting factors. One unit is approximately 225 ml and must be ABO compatible with the recipients red cells, Rh need not be considered. Indications - FFP is indicated for patients with documented coagulation factor deficiencies who are actively bleeding or who are about to undergo an invasive procedure. Causes of such deficiencies include congenital deficiency, liver disease, anticoagulation with warfarin or massive transfusion with red cells and crystalloid/colloid solutions. Factor deficiencies severe enough to be clinically significant are usually associated with prolongation of the coagulation screening tests (prothrombin time, partial thromboplastin time) at least 1.5 times the control value or an INR of 1.6. FFP is also indicated in treatment of thrombotic

Nobleza, Chelsea Mae N. BSN 3- G thrombocytopenic purpura (TTP), usually in conjunction with plasma exchange. FFP should not be used for volume expansion or nutritional support. Immune globulin preparations are available for the provision of immune proteins instead of FFP. Reversal of warfarin anticoagulation should be accomplished with Vitamin K rather than FFP if two to three days can be allowed for clotting factors to return to hemostatic levels. Massively bleeding patients may be given FFP along with red Blood cells to prevent dilution of clotting proteins. Blood Products Therapeutic Effect - One ml of FFP per 2.2 pounds of patient weight will raise most clotting factors by approximately 1%. FFP should be used as soon as possible after it is thawed and always within 24 hours after thawing. The amount of FFP needed depends on the patients clotting factor levels, levels needed to achieve a therapeutic effect, whether or not the patient is bleeding and the patients Blood volume. Clotting factor activity should be estimated by specific coagulation factor assays, or in emergencies, at least by coagulation screening tests.

Cryoprecipitate (CRYO) Description - Cryoprecipitate (Cryo) is a low purity concentrate of three hemostatic proteins prepared from donated whole Blood. A single bag of Cryo contains an average of 100 units of factor VIII and von Willebrand factor and 150 to 250 mg of fibrinogen with some factor XIII and fibronectin. No compatibility testing is required and ABO-Rh type is not relevant. However, due to their small Blood volumes, children less than one year of age should be given ABO compatible Cryo in case trace amounts of anti-A or anti-B are present. When Cryo is ordered, units are thawed, suspended in sterile normal saline (20ml/bag) and pooled. Once pooled, Cryo should not be chilled or refrigerated as the protein will re-precipitate. The volume of a dose of Cryo depends upon the number of units pooled. For young children who cannot tolerate a large volume or to increase the fibrinogen concentration for fibrin glue preparation, Cryo can be suspended in 10 ml of saline per bag (reduced-volume Cryo). Cryoprecipitate is the only fibrinogen concentrate available for intravenous use. Indication - Cryoprecipitate is indicated for bleeding or imminent invasive procedures for patients with significant hypofibrinogenemia (<100 mg/dl). Commercial Clotting Factor Concentrates made with viral inactivation methods are preferred over Cryo for hemophilia A and von Willebrand treatment. Therapeutic Effect - When used for fibrinogen replacement, ten bags should provide enough fibrinogen to raise the fibrinogen 60 to 70 mg/dl in a 155 pound adult. Therapeutic effect can be monitored by fibrinogen levels and the patients clinical response. Factor VIII Concentrates Description - Factor VIII concentrates are a commercially prepared, lyophilized powder purified from human plasma to treat patients with hemophilia A or von Willebrands disease. Alternatively, recombinant (synthetic) protein is purified from

Nobleza, Chelsea Mae N. BSN 3- G genetically engineered non-human cells grown in tissue culture. The quantity of factor VIII coagulant activity is stated on the bottle. One factor VIII concentrate unit equals the clotting activity in 1 ml of fresh plasma. Factor VIII concentrate is cell free and is administered without regard to patient or donor ABO or Rh type. It is heat treated and/or solvent detergent treated to reduce the risk of virus transmission. Current processes appear to have eliminated the risk of HIV, HBV and HCV transmission. concentrates differ in the purification procedures. Highly purified factor VIII, e.g., preparations purified over a monoclonal antibody column or current recombinant factor VIII concentrates, are stabilized by adding 98% of pasteurized human albumin. Porcine factor VIII concentrate is available for patients with high titer anti-human factor VIII 'allo' or autoantibody inhibitors. Factor VIII concentrates are stored refrigerated at 35 to 45 Fahrenheit for up to two years from the date of manufacture (expiration date will be indicated on each vial). Some preparations may be kept at room temperature for extended periods. Once reconstituted, it should not be refrigerated. Factor VIII concentrate should be infused within four hours of preparation to reduce the risk of bacterial growth. Vials are usually shipped to a hospital pharmacy, Blood service or nursing unit and mixed there prior to use. Many patients or families receive them directly for home care. Blood Products Indication - Factor VIII concentrate is indicated for the treatment of bleeding or imminent invasive procedures in patients with hemophilia A, (congenital factor VIII deficiency) and for patients with low titer factor VIII inhibitors. Regular prophylactic doses are often used, as well as daily doses in some hemophilic inhibitor patients to try to induce immune tolerance. Patients with von Willebrands disease respond to one specific, pasteurized intermediate purity concentrate in which that factor activity is relatively preserved. Therapeutic Effect - Dosage is dependent on the nature of the injury, the degree of factor deficiency, the weight of the patient and the presence and level or absence of factor VIII inhibitors. The half life of circulating factor VIII is eight to twelve hours, therefore transfusions may need to be repeated every 12 to 24 hours to maintain hemostatic levels. Following surgery, it is necessary to maintain hemostatic levels for up to two weeks to prevent delayed bleeding and promote wound healing in the hemophilic patient. Factor IX Concentrates Description - Factor IX concentrates are a commercially prepared, lyophilized powder purified from human plasma to treat patients with hemophilia B. Crude preparations, previously referred to as prothrombin complex concentrates, contain coagulation factors II (prothrombin), IX, X and variable amounts of factor VII and carry a risk of thrombosis associated with administration. Purified factor IX concentrates, available since early 1991, essentially contain only factor IX and thus have eliminated the risk of thrombosis. Since both products are used primarily to treat factor IX deficiencies, the amount of Factor IX contained in each product is stated on the label. Factor IX concentrates are heat treated to reduce the risk of disease transmission, particularly HIV and hepatitis, and the purified forms currently manufactured are treated sufficiently to inactivate hepatitis viruses B and C. Prior to reconstituting, factor IX concentrates may be refrigerated at 35 to 45 Fahrenheit until the expiration date indicated on each vial, but should not be frozen.

Nobleza, Chelsea Mae N. BSN 3- G Indication - Factor IX concentrates are indicated for patients with hemophilia B (factor IX deficiency), also called Christmas Disease, who are requiring treatment of bleeding or about to undergo invasive procedures. Low purity factor IX concentrate may be used in treatment of hemophilia A patients with high titer inhibitors. It may be of value to patients with congenital factors X or II (prothrombin) deficiency. "Activated" concentrates are also used for some factor VIII inhibitor patients. Factor IX concentrates should not be used for patients with acquired combined deficiency of factor(s) II, VII, IX and/or X as plasma or whole Blood provides safer, more effective treatment in these patients. Purified factor IX concentrate is considerably more expensive than crude factor IX concentrates and is generally indicated only for hemophilia B patients who require repeated infusion and/or are at greater risk for thrombosis. A recombinant (synthetic) product was FDA approved in early 1997 and is recommended for hemophilia B patients with minimal or no prior exposure to plasma derived products or FFP. Low purity factor IX concentrates are contraindicated for patients with liver disease, as there has been an increased risk of thrombosis seen with the use of these products in this group of patients. Therapeutic Effect - Dosage will depend on the patient factor level and the circumstances making the transfusion necessary. Treatment for bleeding generally requires every 12-hour or daily infusions until symptoms resolve. For major surgery in hemophilia patients, purified concentrate is indicated for ten to fourteen days (until sufficient wound healing has taken place to prevent re-occurrence of the bleeding condition). In hemophilia A patients with inhibitors, undergoing surgery or experiencing major bleeding episodes, the treatment may consist of infusions of the crude concentrates every eight to twelve hours. Blood Products Antithrombin III Description - Antithrombin III concentrates are commercially purified from human plasma pools and lyophilized. They are provided as a powder in one vial and a diluent (e.g. sterile water) in a companion vial. Viracidal treatment appears to eliminate the risks of HIV or hepatitis B or C transmission. Prior to reconstituting, antithrombin III concentrates should be refrigerated (35 to 45 Fahrenheit) until they expire, but should not be frozen. Indication - Antithrombin III concentrates are approved for and indicated in reducing an acute increased risk of venous thrombo-embolic disorders in patients with symptomatic, congenital antithrombin III deficiency. This will usually be prophylactic therapy to correct levels from half-normal to around 100% during surgical procedures or periods of increased risk from immobility, etc. A potential role in acquired thrombic disorders or DIC is being investigated but has not been established. Therapeutic Effect - Due to a short life, long term prophylaxis with antithrombin III infusions is not feasible (versus use of oral anticoagulants). The dosage is as indicated in the paper included in the package. This Blood product is an 'order item' norrnally available, in most areas, within two working days. Blood Products

Nobleza, Chelsea Mae N. BSN 3- G CMV Negative Blood Components Description - CMV is a herpes virus that resides in the white Blood cells of persons who have been infected with the virus. There is a high prevalence of CMV positive persons worldwide. Most persons that are CMV positive have no history of illness. CMV transmission to susceptible patients is effectively prevented by use of either CMV seronegative, a donor determined to be negative for antibody to CMV, or Leukoreduced, containing less than a certain range of leukocytes. Cryoprecipitate and Fresh Frozen Plasma are cell free and have not been implicated in CMV transmission. Blood Products Indications - CMV negative Blood products are indicated for patients in the following categories, regardless of CMV status of the mother: P r e m a t u r e i n f a n t s ; Infants under four weeks of age; and, Patients requiring intrauterine transfusion.

CMV negative Blood products are indicated for CMV negative patients in the following categories: B o n e m

Nobleza, Chelsea Mae N. BSN 3- G a r r o w o r o r g a n t r a n s p l a n t r e c i p i e n t s (i f t h e m a r r o w o r t h e

Nobleza, Chelsea Mae N. BSN 3- G o r g a n d o n o r i s a l s o C M V n e g a ti v e ) ; Potential candidates for transplant; AIDS or HIV infected patients; Patients who have congenital immune deficiency; Patients undergoing splenectomy; and, Pregnant women.

If CMV status is pending in these patients, CMV negative components are indicated. CMV negative components are not considered necessary for patients receiving chemotherapy. Blood Products Therapeutic Effect - In patients with compromised immune systems, a CMV infection could result in a serious complication. CMV negative or leukoreduced Blood products reduce this hazard.

Nobleza, Chelsea Mae N. BSN 3- G Irradiated Blood Products Description - Irradiated Blood products are exposed to approximately 2500 rads of Gamma radiation to destroy the lymphocytes ability to divide. Transfusionassociated graft-versus-host disease (TA-GVHD) has not been reported from transfusion of cryoprecipitate or fresh frozen plasma (FFP), thus these components do not require irradiation. Fresh plasma (not frozen) for transfusion should be irradiated if the patient is at risk for TA-GVHD. Indications - The following indications for irradiation apply to patients with the listed diagnoses. Absolute Indication: B o n e m a r r o w t r a n s p l a n t ( B M T ) r e c i p i e n t

Nobleza, Chelsea Mae N. BSN 3- G s ( a ll o g e n e i c , a u t o l o g o u s ) ; BMT or stem cell donors if allogeneic transfusion must be given prior to completing the harvest; Cellular (T-cell) Immune Deficiency (congenital or acquired); Intrauterine transfusion; Transfusions from family members (any degree); Directed donors (when not identified as family members versus friends); HLA-matched platelet transfusions.

Appropriate Indication: H e m a t o l

Nobleza, Chelsea Mae N. BSN 3- G o g i c m a li g n a n c i e s (l e u k e m i a s ) ; Hodgkins Disease; Non-Hodgkins Lymphoma; Neonatal exchange transfusion; Premature infants; and, Certain solid tumors (neuroblastoma, glioblastoma).

Irradiation not considered as indicated: Blood Products A I D S ; Most solid tumors;

Nobleza, Chelsea Mae N. BSN 3- G Non-myeloablative chemotherapy recipients; Routine immunosuppressive drugs (such as prednisone); Solid organ transplant recipients; Aplastic anemia (except if BMT); and, Humoral immunodeficiency.

Therapeutic Effect - Irradiation destroys the ability of transfused lymphocytes to respond to host foreign antigens thereby preventing graft vs. host disease in susceptible recipients. Patients with functional immune systems will destroy foreign lymphocytes, making irradiation of Blood and Blood components unnecessary. Leukoreduced Blood Components Description - Cellular Blood components that contain less than a known and accepted range of leukocytes (white Blood cells) are considered leukocyte reduced. The leukocyte content of Blood components can be reduced by filtration. With platelet preparations, filtration results in the loss of 10 to 30% of the platelets. Single donor platelets prepared with the most modern apheresis machines will already contain a miniscule amount of leukocytes (LRS platelets), can be labeled as leukocyte reduced, and do not require filtration. Cryoprecipitate and fresh frozen plasma do not contain intact or viable leukocytes making leukoreduction unnecessary. Indications - Leukoreduced Blood and components are indicated: F o r p a ti e n t s w h o h a v e e

Nobleza, Chelsea Mae N. BSN 3- G x p e r i e n c e d t w o o r m o r e n o n h e m o l y ti c f e b r il e t r a n s f u s i o n r e

Nobleza, Chelsea Mae N. BSN 3- G a c ti o n s ; As a method of preventing transfusion transmitted CMV; and, As a method of preventing platelet alloimmunization in some cases