KAN TRANSFÜZYONLARI VE KOMPLİKASYONLARI DOÇ.DR SUAT BİÇER YEDİTEPE ÜNİVERSİTESİ TIP FAKÜLTESİ ÇOCUK SAĞLIĞI VE HASTALIKLARI AD

Transfüze edilen kan ürünleri Eritrosit (RBC) Trombosit (PLT) Granülosit (Nötrofil) Plazma

Eritrosit (RBC) Transfüzyonu Amaç: Kanın oksijen taşıma kapasitesini artırmak Doku oksijenasyonunu devam ettirmek Red blood cells (RBCs) are transfused to increase the oxygen-carrying capacity of the blood and, in turn, to maintain satisfactory tissue oxygenation. However, transfusions may be given more stringently to children, because normal hemoglobin levels are lower in healthy children than in adults and, often, children do not have the underlying multiorgan, cardiorespiratory, and vascular diseases that develop with aging in adults. Thus, children often compensate better for RBC loss and, as is true for patients of all ages, there is increasing enthusiasm for conservative practices (i.e., low pre-transfusion hematocrit values). Bibliography Bell EF, Strauss RG, Widness JA, et al: Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics  2005; 115:1685-1691. Centers for Disease Control and Prevention : HIV transmission through transfusion—Missouri and Colorado, 2008. MMWR  2010; 59(41):1335-1338. Eder AF, Hillyer CD, Dy BA, et al: Adverse reactions to allogeneic whole blood donation by 16- and 17-year olds. JAMA  2008; 299:2279-2286. Guay J, de Moerloose P, Lasne D: Minimizing perioperative blood loss and transfusions in children. Can J Anaesth  2006; 53:559-567. Hebert PC, McDonald BJ, Tinmouth A: Clinical consequences of anemia and red cell transfusion in the critically ill. Crit Care Clin  2004; 20:225-235. Kirpalani H, Whyte RK, Andersen C, et al: The premature infants in need of transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr  2006; 149:301-307. Kuehn BM: CDC launches surveillance system to improve blood transfusion safety. JAMA  2010; 303:1467. Lacroix J, Hébert PC, Hutchison JS, et al: Transfusion strategies for patients in pediatric intensive care units. N Engl J Med  2007; 356:1609-1619. The Lancet: Improving blood safety worldwide : Lancet  2007; 370:361. Lee JS, Gladwin MT: The risks of red cell storage. Nat Med  2010; 16:381-382. Morley SL: Red blood cell transfusions in acute paediatrics. Arch Dis Child Educ Pract Ed  2009; 94:65-73. Ross SD, Allen IE, Henry DH, et al: Clinical benefits and risks associated with epoetin and darbepoetin in patients with chemotherapy-induced anemia: a systematic review of the literature. Clin Ther  2006; 28:801-831. Stramer SL, Wend U, Candotti D, et al: Nucleic acid testing to detect HBV infection in blood donors. N Engl J Med  2011; 364(3):234-247. Strauss RG: Commentary: is it safe to limit allogeneic red blood cell transfusions to neonates?. Neonatology  2008; 93:217-222. Strauss RG: Controversies in the management of the anemia of prematurity using single-donor red blood cell transfusion and/or recombinant human erythropoietin. Transfus Med Rev  2006; 20:34-44. Strauss RG: How I transfuse red blood cells and platelets to infants. Transfusion  2008; 48:209-217. Vamvakas EC, Strauss RG: Meta-analysis of controlled clinical trials studying the efficacy of recombinant human erythropoietin in reducing blood transfusions in the anemia of prematurity. Transfusion  2001; 41:406.

ÇOCUK VE ADOLESAN (>1 YAŞ) Akut kan kaybı (>%25) Hb < 8 g/dL (Perioperatif dönemde) Hb < 13 g/dl ve ağır kardiyopulmoner yetersizlik varsa Hb < 8 g/dL ve semptomatik kronik anemi varsa Hb < 8 g/dL ve kemik iliği yetersizliği varsa BEBEK (≤ 4 AY) Hb < 13 g/dl ve ağır pulmoner hastalık varsa Hb < 13 g/dl ve ağır kardiyak hastalık varsa Hb < 10 g/dl ve orta derecede pulmoner hastalık varsa Hb < 10 g/dL ve major cerrahi geçirecekse Hb < 8 g/dL ve semptomatik anemi varsa GUIDELINES FOR PEDIATRIC RED BLOOD CELL TRANSFUSIONS*[†] CHILDREN AND ADOLESCENTS      Acute loss of > 25% of circulating blood volume Hemoglobin < 8.0 g/dL[†] in the perioperative period Hemoglobin < 13.0 g/dL and severe cardiopulmonary disease Hemoglobin < 8.0 g/dL and symptomatic chronic anemia Hemoglobin < 8.0 g/dL and marrow failure INFANTS ≤ 4 MO OLD Hemoglobin < 13.0 g/dL and severe pulmonary disease Hemoglobin < 10.0 g/dL and moderate pulmonary disease Hemoglobin < 13.0 g/dL and severe cardiac disease Hemoglobin < 10.0 g/dL and major surgery Hemoglobin < 8.0 g/dL and symptomatic anemia

Postoperatif dönem Akut hemoraji Devam eden kan kaybı + hemodinamik instabilite Transfüzyon Akut hemoraji Kanamanın durdurulması + Perfüzyonun sağlanması (kristalloid/kolloid) Kan kaybı > kan hacminin %25’i (>17 ml/kg) ve instabil hastaTransfüzyon In the perioperative period, it is unnecessary for most children to maintain hemoglobin levels of 8 g/dL or greater, a level frequently desired for adults. There should be a compelling reason to prescribe any postoperative RBC transfusion, such as continued bleeding with hemodynamic instability, because most children (without continued bleeding) can, over time, restore their RBC mass with iron therapy. The most important measures in the treatments of acute hemorrhage are to control the hemorrhage and to restore the circulating blood volume and tissue perfusion with crystalloid and/or colloid solutions. If the estimated blood loss is > 25% of the circulating blood volume (>17 mL/kg) and the patient's condition remains unstable, RBC transfusions may be indicated along with plasma transfusions at a 1 : 1 ratio of RBC : plasma volumes. In acutely ill children with severe pulmonary disease requiring assisted ventilation, it is common practice to maintain the hemoglobin level close to the normal range, although the efficacy of this practice has not been documented by controlled scientific studies.

Ağır pulmoner hastalık Ventilasyon desteği gerektiren ağır akciğer hastalığında Hb normal düzeylerde tutulmalıdır. The pre-transfusion blood hemoglobin level or hematocrit that should prompt a RBC transfusion is controversial (i.e., restricted or a low pre-transfusion level vs liberal or a high pre-transfusion level) despite a substantial amount of published information, including randomized clinical trials. Some physicians in critical care settings prefer to transfuse RBCs quite conservatively (i.e., restricted guidelines) and to permit modest anemia, because patients with levels close to the normal range (i.e., liberal guidelines) have poorer outcomes. Studies in critically ill adults demonstrated better outcomes when the hemoglobin level was maintained at 7-9 g/dL than at 10-12 g/dL. However, anemic adults with significant cardiac disease did better with hemoglobin levels maintained at 13 g/dL than at 10 g/dL. Similar studies in children admitted to intensive care units found no inferiority when RBC transfusions were given by restricted guidelines (transfusion threshold of 7 g/dL), although the patients were in stable clinical status and needed few transfusions. In contrast, unstable critically ill children may need more liberal RBC transfusions.

Anemi Demir eksikliği anemisi genelde iyi kompanse edilir ve oral demir tedavisine iyi yanıt alınır. (Hb>5 g/dL). Transfüzyon kararı: Çocuğun semptomları, bulguları, kompansasyon kapasitesine, Kardiyorespiratuar, vasküler ve merkezi sinir sistemi hastalığı olup olmamasına, Aneminin nedenine ve izlemine göre verilir. Alternatif tedaviler (Eritropoetin-KBY) Orak hücreli anemi ve talasemi major The pre-transfusion blood hemoglobin level or hematocrit that should prompt a RBC transfusion is controversial (i.e., restricted or a low pre-transfusion level vs liberal or a high pre-transfusion level) despite a substantial amount of published information, including randomized clinical trials. Some physicians in critical care settings prefer to transfuse RBCs quite conservatively (i.e., restricted guidelines) and to permit modest anemia, because patients with levels close to the normal range (i.e., liberal guidelines) have poorer outcomes. Studies in critically ill adults demonstrated better outcomes when the hemoglobin level was maintained at 7-9 g/dL than at 10-12 g/dL. However, anemic adults with significant cardiac disease did better with hemoglobin levels maintained at 13 g/dL than at 10 g/dL. Similar studies in children admitted to intensive care units found no inferiority when RBC transfusions were given by restricted guidelines (transfusion threshold of 7 g/dL), although the patients were in stable clinical status and needed few transfusions. In contrast, unstable critically ill children may need more liberal RBC transfusions. may need more liberal RBC transfusions. With chronic anemia, the decision to transfuse RBCs should not be based solely on blood hemoglobin levels, because children compensate well and may be asymptomatic despite low hemoglobin levels. Patients with iron deficiency anemia are often treated successfully with oral iron alone, even at hemoglobin levels < 5 g/dL. Factors other than hemoglobin concentration to be considered in the decision to transfuse RBCs include: (1) the patient's symptoms, signs, and compensatory capacities; (2) the presence of cardiorespiratory, vascular, and central nervous system disease; (3) the cause and anticipated course of the anemia; and (4) alternative therapies, such as recombinant human erythropoietin (EPO) therapy, which is known to reduce the need for RBC transfusions and to improve the overall condition of children with chronic renal insufficiency (Chapter 529.2). In anemias that are likely to be permanent, it is also important to balance the detrimental effects of anemia on growth and development against the potential toxicity associated with repeated transfusions.

Yenidoğan Fötal Hb var. Oksijen tutma kapasitesi yüksek. 2-3 difosfogliseratla ilişkisi zayıf. Kalp, akciğer ve damarların anemiyi kompanse etme yeteneği zayıf. Renal, hepatik ve nörolojik fonksiyonlar henüz tam gelişmemiş. Siyanotik konjenital kalp hastalıklı yenidoğanda Hb>13 g/dL (Hct>%40) düzeyde tutulmalıdır. Major cerrahi geçirecek olan yenidoğanda Hb>10 g/dL, Hct>%30 olmalıdır. Semptomatik anemide: Taşipne, dispne, taşikardi, apne, bradikardi, beslenmede güçlük, letarji Low plasma EPO levels provide a rationale for the use of recombinant EPO in the treatment of anemia of prematurity. Proper doses of EPO and iron effectively stimulate neonatal erythropoiesis. However, the efficacy of EPO therapy to substantially diminish the need for RBC transfusions has not been convincingly demonstrated, particularly for sick, extremely premature neonates, and recombinant EPO has not been widely accepted as a treatment for anemia of prematurity (Chapter 97.1). In rare cases, some preparations of EPO have been associated with the development of anti-EPO antibodies in adults that have produced severe anemia. Because of the controversies over recombinant EPO therapy, many low birthweight preterm infants need RBC transfusions (see Table 464-1). In neonatal patients with severe respiratory disease, defined as requiring relatively large quantities of oxygen and ventilator support, it has been customary to maintain blood hemoglobin at > 13 g/dL (hematocrit > 40%). Proponents believe that transfused RBCs containing adult hemoglobin, with their superior interaction with 2,3-diphosphoglycerate and leading to better oxygen offloading than that of fetal hemoglobin, are likely to provide optimal oxygen delivery throughout the period of diminished pulmonary function. Although this practice is widely recommended, little evidence is available to firmly establish its efficacy or to define its optimal use (the best hemoglobin level for each degree of pulmonary dysfunction), and as mentioned earlier, more restricted guidelines have been suggested. Infants with less severe cardiopulmonary disease may require less vigorous support; hence, a lower hemoglobin level is suggested for those with only moderate disease. Consistent with the rationale for oxygen delivery in neonates with severe respiratory disease, it seems appropriate to keep the hemoglobin value > 13 g/dL (hematocrit > 40%) in neonates with severe cardiac disease leading to either cyanosis or congestive heart failure. The optimal hemoglobin level for neonates facing major surgery has not been established by definitive studies. However, it seems reasonable to maintain the hemoglobin level at > 10 g/dL (hematocrit > 30%) because of the limited ability of a neonate's heart, lungs, and vasculature to compensate for anemia; the inferior off-loading of oxygen because of the diminished interaction between fetal hemoglobin and 2,3-diphosphoglycerate; and the developmental impairment of neonatal renal, hepatic, and neurologic function. This transfusion guideline must be applied with flexibility to individual infants facing different kinds of surgery. Stable neonates do not require RBC transfusion, regardless of their blood hemoglobin levels, unless they exhibit clinical problems attributable to anemia. Proponents of RBC transfusions for symptomatic anemia believe that the low RBC mass contributes to tachypnea, dyspnea, tachycardia, apnea and bradycardia, feeding difficulties, and lethargy, which can be alleviated by transfusion of RBCs. However, anemia is only one of several possible causes of these problems, and RBC transfusions should only be given when clinical problems are attributable to the anemia.

Eritrosit suspansiyonu Tam kandan sentifugasyonla ayrılır. Antikoagülan ve koruyucu eklenerek, %60 Hct (%70-90) düzeyiyle kan bankasında 42 güne dek saklanabilir. 10-15 ml/kg dozda, 2-4 saat sürede verilir. Hiperpotasemi !! (50 mEq/L) (Özellikle yüksek volümde (>25 ml/kg) transfüzyonda riskli) Taze eritrosit suspansiyonu The RBC product of choice for children and adolescents is the standard suspension of RBCs separated from whole blood by centrifugation and resuspended in an anticoagulant/preservative storage solution at a hematocrit value of approximately 60% for storage up to 42 days, per U.S. Food and Drug Administration (FDA) approval. The usual dose is 10-15 mL/kg, but transfusion volumes vary greatly, depending on clinical circumstances (continued vs arrested bleeding, hemolysis). For neonates, many centers transfuse the same RBC product as selected for older children, whereas others prefer a packed RBC concentrate (hematocrit 70-90%). Either is infused slowly (over 2-4 hr) at a dose of approximately 15 mL/kg. Because of the small quantity of extracellular fluid given at these relatively high hematocrit values and the slow rate of transfusion, the type of RBC anticoagulant/preservative solution used does not pose risks for premature infants. Packing RBCs by centrifugation at the time the aliquot is issued for transfusion ensures that a consistent RBC dose is infused with each transfusion but is not mandatory and is impractical for some blood banks. Depolama süresi <7 gün Hiperpotasemi riski düşük Yenidoğanlarda daha çok tercih edilir.

TROMBOSİT (PLT) TRANSFÜZYONU Trombositopeni (< 50 × 109/L) + kanama riski - Major cerrahi - Trombositopeni + kanama Guidelines for platelet (PLT) support of children and adolescents with quantitative and qualitative PLT disorders are similar to those for adults (see    Table 465-1 on the Nelson Textbook of Pediatrics website at www.expertconsult.com ), in whom the risk of life-threatening bleeding after injury or occurring spontaneously can be related to the severity of thrombocytopenia. PLT transfusions should be given to patients with PLT counts < 50 × 109/L when they are bleeding or are scheduled for an invasive procedure, and the PLT count should be maintained > 50 × 109/L until bleeding ceases or the patient is stable after the procedure.

PLT transfüzyonu endikasyonları Çocuk ve adolesan: PLT < 50 × 109/L ve kanama var, PLT < 50 × 109/L ve invazif prosedür uygulanacak, PLT < 20 × 109/L ve kemik iliği yetersizliği ve kanama riski var enfeksiyon, organ yetersizliği, pıhtılaşma bozukluğu, mukozal lezyonlar, ağır graft versus host hastalığı, anemi), PLT < 10 × 109/L ve kemik iliği yetersizliği var, Trombositler herhangi bir sayıda, trombosit disfonksiyonu var ve kanama var veya invazif prosedür geçirecek. CHILDREN AND ADOLESCENTS      PLT count < 50 × 109/L and bleeding PLT count < 50 × 109/L and an invasive procedure PLT count < 20 × 109/L and marrow failure with hemorrhagic risk factors PLT count < 10 × 109/L and marrow failure without hemorrhagic risk factors PLT count at any level, but with PLT dysfunction plus bleeding or an invasive procedure INFANTS ≤ 4 MO OLD PLT count < 100 × 109/L and bleeding or during extracorporeal membrane oxygenation PLT count < 20 × 109/L and clinically stable PLT count < 50 × 109/L and clinically unstable

PLT transfüzyonu endikasyonları < 4 ay: PLT < 100 × 109/L ve kanama var ya da ECMO uygulanıyor, PLT < 50 × 109/L ve invazif prosedür uygulanacak, PLT < 50 × 109/L ve klinik anstabil, PLT < 20 × 109/L ve klinik stabil, Trombositler herhangi bir sayıda, trombosit disfonksiyonu var ve kanama var veya invazif prosedür geçirecek. PLT count < 100 × 109/L and bleeding or during extracorporeal membrane oxygenation      PLT count < 50 × 109/L and an invasive procedure PLT count < 20 × 109/L and clinically stable PLT count < 50 × 109/L and clinically unstable PLT count at any level, but with PLT dysfunction plus bleeding or an invasive procedure

Trombositopeni ve risk faktörleri Ateş, Antimikrobiyal tedavi, Aktif kanama, İnvazif prosedür gereksinimi olması, Yaygın damar içi pıhtılaşma (DIC), Pıhtılaşma sorunu olan hastada karaciğer-böbrek bozukluğu olması. Hedef PLT > 50 × 109/L Studies of patients with thrombocytopenia resulting from bone marrow failure indicate that the risk of spontaneous bleeding increases markedly when PLT levels fall to < 20 × 109/L, and hemorrhagic risk factors (infection, organ failure, clotting abnormalities, mucosal lesions, severe graft versus host disease, or anemia) are present. In this high-risk setting, prophylactic PLT transfusions are given to maintain a PLT count > 20 × 109/L. This threshold has been challenged by studies of adult patients, who in many instances were selected to be in relatively good clinical condition without hemorrhagic risk factors. Consequently, a lower PLT transfusion trigger of 5-10 × 109/L is recommended for stable (i.e., low-risk) patients. In practice, however, severe thrombocytopenia is commonly associated with the development/occurrence of risk factors, including fever, antimicrobial therapy, active bleeding, need for an invasive procedure, disseminated intravascular coagulation, and liver or kidney dysfunction with clotting abnormalities. In these situations, PLT transfusions are given to maintain relatively high PLT counts. Despite the desire by some physicians to elevate the blood PLT count to 80 × 109/L or 100 × 109/L or even higher, there are no definitive data to justify a true benefit of PLT transfusions given at a PLT count > 50 × 109/L, unless bleeding is active with a PLT count between 50 and 100 × 109/L and thrombocytopenia seems to be the only cause.

Kalitatif trombosit fonksiyon bozuklukları Kalıtımsal ya da edinsel (karaciğer-böbrek fonksiyon bozukluğu ya da ECMO, kardiyak by-pass) Ömür boyu sürebilir (kalıtsal) Tekrarlanan PLT transfüzyonları alloimmunizasyon ve duyarsızlık oluşturur. Sadece kanama varsa ya da invazif prosedür gereksinimi varsa PLT transfüze edilmeli. Kanama zamanı>x2 Desmopressin asetat?? Antiplatelet etkili ilaçlar (ör: NSAID) verilmemeli! Qualitative PLT disorders may be inherited or acquired (in advanced hepatic or renal insufficiency or when blood flows through an extracorporeal circuit, such as during extracorporeal membrane oxygenation [ECMO] or cardiopulmonary bypass). In patients with such disorders, PLT transfusions are justified only if the risk of significant bleeding is quite high or actually occurs. Because inherited PLT dysfunction often is lifelong and repeated transfusions may lead to alloimmunization and refractoriness (i.e., poor response to PLT transfusions), prophylactic PLT transfusions are rarely justified, unless an invasive procedure is planned. In these cases, an abnormal result with the use of a modern PLT function device or, historically, a bleeding time more than twice the upper limit of laboratory normal may be taken as diagnostic evidence of PLT dysfunction. However, an abnormal bleeding time or any other abnormal laboratory test result is poorly predictive of hemorrhagic risk or the need to transfuse PLTs. Alternative therapies, particularly desmopressin acetate, should be considered to avoid PLT transfusions. Antiplatelet medications (nonsteroidal anti-inflammatory drugs) should be avoided in these patients.

Yenidoğan Kanama ve tromboz için risk faktörleri fazla Trombosit yıkımı yüksek Trombosit yapımı düşük Kemik iliğinde megakaryosit progenitörlerinin sayısı düşük - Trombopoetin yanıtı düşük Trombosit disfonksiyonu ve kanama ya da kanama riski yoksa >100 × 109/L

PLT transfüzyonu-Doz: Amaç: >50× 109/L (Çocuk) >100× 109/L (Yenidoğan) Doz: <30 kg: 5-10 ml/kg >30 kg: 1 ünite 2 saatte Özellikle tekrarlayan transfüzyonlarda lökositi azaltılmış kan ürünleri ve lökosit filtreleri kullanılmalıdır. Alloimmunizasyon, Yanıtsızlık CMV The goal of most PLT transfusions is to raise the PLT count above 50 × 109/L and to increase that for neonates to ≥ 100 × 109/L. These increases can be achieved consistently in children weighing up to 30 kg by infusion of 5 to 10 mL/kg of standard (unmodified) PLT concentrates, obtained either from processing whole blood units or by plateletpheresis. For larger children, the appropriate dose is 3-4 pooled whole blood–derived PLT units or 1 apheresis unit. Because PLT concentration varies in different PLT products made available for transfusion, each hospital should monitor post-transfusion PLT counts and determine the dose that works best locally. PLT concentrates should be transfused as rapidly as the patient's overall condition permits, certainly within 2 hr. Patients requiring repeated PLT transfusions should receive leukocyte-reduced blood products, including PLT concentrates, to diminish alloimmunization and PLT refractoriness and to reduce the risk of transfusion-transmitted cytomegalovirus infection. Routinely reducing the volume of PLT concentrates for infants and small children by additional centrifugation steps is both unnecessary and unwise. Transfusion of 10 mL/kg of an unmodified PLT concentrate is adequate because it adds 10 × 109 PLTs to 70 mL of blood (the blood volume of a 1-kg neonate), a number calculated (taking the usual hematocrit and post-transfusion PLT recovery values into account) to increase the PLT count by 100 × 109/L. This calculated increment has been validated because it is consistent with the actual increment reported. Moreover, 10 mL/kg is not an excessive transfusion volume, provided that the intake of other IV fluids, medications, and nutrients is monitored and adjusted. It is important to select PLT units for transfusion with the ABO group identical to that of the recipient and to avoid repeated transfusion of group O PLTs to group A or B recipients, because passive anti-A or anti-B in group O plasma can lead to hemolysis. Although proven methods exist to reduce the volume of PLT concentrates when truly warranted (e.g., many transfusions are anticipated, in which the quantity of passive anti-A or anti-B might lead to hemolysis, or failure of 10 mL/kg of unmodified PLT concentrate to increase the PLT count), additional processing should be performed with great care because of probable PLT loss, clumping, and dysfunction caused by the additional handling, all of which could diminish the efficacy and increase the toxicity of PLT transfusions. Bibliography Chakravorty S, Murray N, Roberts I: Neonatal thrombocytopenia. Early Hum Dev  2005; 81:35-41. Christensen RD, Paul DA, Sola-Visner MC, et al: Improving platelet transfusion practices in the neonatal intensive care unit. Transfusion  2008; 48:2281-2284. Josephson CD, Su LL, Christensen RD, et al: Platelet transfusion practices among neonatologists in the United States and Canada: results of a survey. Pediatrics  2009; 123:278-285. Murray NA: Evaluation and treatment of thrombocytopenia in the neonatal intensive care unit. Acta Paediatr Suppl  2002; 91:74-81. Strauss RG: Low-dose prophylactic platelet transfusions: time for further study, but too early for routine clinical practice. Transfusion  2004; 44:1680-1682. Copyright © 2011 Elsevier Inc. All rights reserved. Read our Terms and Conditions of Use and our Privacy Policy. For problems or suggestions concerning this service, please contact: online.help@elsevier.com  

GRANÜLOSİT (NÖTROFİL) TRANSFÜZYONU Nötropenik hastalar antibiyotiklerin ve granülosit koloni stimülan faktörlerin etkin kullanımına rağmen progressif bakteriyel ve fungal enfeksiyonlara karşı risk altındadırlar . Özellikle hematopoetik progenitör hücre tedavisi alanlarda risk büyüktür.

Granülosit transfüzyon endikasyonları: Çocuk ve adolesanda: Ağır nötropeni (kan nötrofil sayısı <0.5 × 109/L) ve antimikrobiyal tedaviye rağmen devam eden bakteriyel ya da fungal enfeksiyon, Kalitatif nötrofil defekti ve antimikrobiyal tedaviye rağmen devam eden bakteriyel ya da fungal enfeksiyon olması. ≤4 aylık bebeklerde: * İlk 1 haftalık yenidoğanda kan nötrofil sayısı <3.0 × 109/L ya da >1 haftada kan nötrofil sayısı <1.0 × 109/L olması ve fulminan bakteriyel enfeksiyon olması Table 466-1   -- GUIDELINES FOR PEDIATRIC GRANULOCYTE TRANSFUSIONS* CHILDREN AND ADOLESCENTS      Severe neutropenia (blood neutrophil count <0.5 × 109/L) and infection (bacterial, yeast, or fungal) unresponsive or progressive despite appropriate antimicrobial therapy. Qualitative neutrophil defect and infection (bacterial or fungal) unresponsive to appropriate antimicrobial therapy INFANTS ≤4 MO OLD Blood neutrophil count <3.0 × 109/L in 1st wk of life or <1.0 × 109/L thereafter and fulminant bacterial infection * Words in italics must be defined for local transfusion guidelines.

Doz < 10 kg: 1-2 × 109/kg nötrofil / granülosit solüsyonu Adolesan: 5-8 × 1010 nötrofil / granülosit solüsyonu İstenilen nötrofil düzeyi: Birkaç gün süreyle 1.0 × 109/L Once the decision to provide GTX has been made, an adequate dose of fresh leukapheresis cells must be transfused. Neonates and infants weighing < 10 kg should receive 1-2 × 109/kg neutrophils per GTX. Larger infants and children should receive a total dose of at least 1 × 1010 neutrophils per GTX; the preferred dose for adolescents is 5-8 × 1010 per GTX, a dose requiring donors to be stimulated with G-CSF plus dexamethasone. GTX should be given daily until either the infection resolves or the blood neutrophil count is sustained above 1.0 × 109/L for a few days. Bibliography Price TH: Granulocyte transfusion therapy. J Clin Apheresis  2006; 21:65-71. Strauss RG: Neutrophil collection and transfusion.   In: Simon TL, Snyder EL, Solheim BG, et al ed. Rossi's principles of transfusion medicine,  ed 4. Bethesda, MD: AABB & Blackwell Publishing Ltd; 2009:219-227.

PLAZMA TRANSFÜZYONU Plazma proteinlerinin (özellikle pıhtılaşma faktörlerinin) replasmanı amacıyla uygulanır. İki tip plazma ürünü vardır 1- Taze donmuş plazma (ilk 8 saatte hazırlanmış) 2- 24 saatlik plazma (Faktör V ve VIII düzeyleri daha düşük) Doz: 15 ml/kg Plasma is transfused to replace clinically significant deficiencies of plasma proteins (nearly always clotting proteins) for which more highly purified concentrates are not available. Two interchangeable plasma products are available for transfusion, plasma frozen within 8 hr of collection (fresh frozen plasma) and plasma frozen within 24 hr of collection. Although levels of factors V and VIII are lower in the latter plasma product, they are equally efficacious for literally all indications for plasma transfusions (see Table 467-1). Requirements for plasma vary with the specific protein being replaced, but a starting dose of 15 mL/kg is usually satisfactory.

Plazma endikasyonları (Bebek, çocuk ve adolesan) Pıhtılaşma faktörlerinde ağır düzeyde eksiklik ve kanama, Pıhtılaşma faktörlerinde ağır düzeyde eksiklik ve invazif prosedür uygulanacak olması, Warfarin etkisinin acil olarak giderilme gereksinimi, Dilüsyonal koagülopati ve kanama (ör, masif transfüzyon), Antikoagülan protein (antitrombin III, protein C ve S) replasmanı, Plazma değişiminde replasman sıvısı olarak (ör: trombotik trombositopenik purpura), kanama riski taşıyan pıhtılaşma faktörlerinde eksiklik(ler), karaciğer yetersizliği).   GUIDELINES FOR PEDIATRIC PLASMA TRANSFUSIONS* INFANTS, CHILDREN, AND ADOLESCENTS Severe clotting factor deficiency AND bleeding      Severe clotting factor deficiency and an invasive procedure Emergency reversal of warfarin effects Dilutional coagulopathy and bleeding (e.g., massive transfusion) Anticoagulant protein (antithrombin III, proteins C and S) replacement Plasma exchange replacement fluid for thrombotic thrombocytopenic purpura or for disorders in which there is risk of bleeding due to clotting protein abnormalities (e.g., liver failure)

Faktör II, V, X, XI eksikliğinde plazma tam tedavi sağlar. Faktör XIII ve fibrinojen eksikliği: Kriyopresipitat, Faktör VII, VIII (hemofili A), IX eksikliklerinde (hemofili B) ve von Willebrand hastalığında spesifik faktörler verilmelidir. Hafif-orta şiddette hemofili A ve von Willebrand hastalığında desmopressin yararlı olabilir. Aktif kanama ya da acil cerrahi operasyon öncesi gibi warfarin etkisinin acil olarak giderilmesi gereken durumlarda ve faktör II, VII, IX ve X eksikliklerinde K vitamini yeterli olmaz, TDP gerekir. Transfusion of plasma is efficacious for the treatment of deficiencies of clotting factors II, V, X, and XI. Deficiencies of factor XIII and fibrinogen are treated with cryoprecipitate. Transfusion of plasma is not recommended for the treatment of patients with severe hemophilia A or B, von Willebrand disease, or factor VII deficiency, because safer factor VII, VIII, and IX concentrates are available. Moreover, mild to moderate hemophilia A and certain types of von Willebrand disease can be treated with desmopressin (Chapter 471). An important use of plasma is for rapid reversal of the effects of warfarin in patients who are actively bleeding or who require emergency surgery (in whom functional deficiencies of factors II, VII, IX, and X cannot be rapidly reversed by vitamin K). Results of screening coagulation tests (prothrombin, activated partial thromboplastin, and thrombin times) should not be assumed by themselves to reflect the integrity of the coagulation system or regarded as indications for plasma transfusions. To justify plasma transfusion, coagulation test results must be related to the patient's clinical condition. Transfusion of plasma in patients with chronic liver disease and prolonged clotting times is not recommended unless bleeding is present or an invasive procedure is planned, because correction of the clotting factor deficiencies is brief.

Tromboz eğilimi Plazmada antikoagülan etkili antitrombin III, protein C ve protein S de var. TTP Plasma also contains several anticoagulant proteins (antithrombin III, protein C, and protein S) whose deficiencies have been associated with thrombosis. In selected situations, plasma may be appropriate as replacement therapy, along with anticoagulant treatment, in patients with these disorders. However, when available, purified concentrates are preferred. Other indications for plasma include replacement fluid during plasma exchange in patients with thrombotic thrombocytopenic purpura (i.e., thrombotic microangiopathies) or other disorders for which plasma is likely to be beneficial (plasma exchange in a patient with bleeding and severe coagulopathy). Plasma is not indicated for correction of hypovolemia or as immunoglobulin replacement therapy, because safer alternatives exist (albumin or crystalloid solutions and IV immunoglobulin, respectively).

Yenidoğanda plazma endikasyonları: Koagülasyon faktör düzeyleri düşük  Pıhtılaşma zamanları uzun Masif eritrosit transfüzyonlarında (kan değişimi, kardiyak cerrahi gibi) tam kan etkisi yaratmak amacıyla, K vitamini eksikliğine bağlı kanama, DIC ve kanama, Spesifik faktör replasmanının mümkün olmadığı koagülasyon faktör eksikliklerinde. In neonates, plasma transfusion merits special consideration. Clotting times are “physiologically” prolonged owing to developmental deficiency of clotting proteins, and plasma should be transfused only after reference to normal values adjusted for the birthweight and age of the infant (i.e., not to normal ranges for older children and adults). The indications for plasma in neonates include: (1) reconstitution of red blood cell (RBC) concentrates to simulate whole blood for use in massive transfusions (exchange transfusion or cardiovascular surgery); (2) hemorrhage secondary to vitamin K deficiency; (3) disseminated intravascular coagulation with bleeding; and (4) bleeding in congenital coagulation factor deficiency when more specific treatment is either unavailable or inappropriate. The use of prophylactic plasma transfusion to prevent intraventricular hemorrhage in premature infants is not recommended, as efficacy has not been proven. Plasma should not be used as a suspending agent to adjust the hematocrit values of RBC concentrates before small-volume RBC transfusions to neonates because it offers no apparent medical benefit over the use of sterile solutions such as crystalloid and albumin. Similarly, the use of plasma in partial exchange transfusion for the treatment of neonatal hyperviscosity syndrome is unnecessary, because safer crystalloid or colloid solutions (e.g., albumin) are available. In the treatment of bleeding infants, cryoprecipitate is often considered because of its small infusion volume. However, cryoprecipitate contains significant quantities of only fibrinogen, von Willebrand factor, and factors VIII and XIII. Thus, it is not effective for treating the usual clinical situation in bleeding infants with multiple clotting factor deficiencies, despite the appeal and convenience of a small infusion volume. In preliminary studies, infusions of very small volumes of recombinant activated factor VII have been lifesaving in patients with hemorrhage due to several mechanisms. Because the efficacy and toxicity of factor VIIa have not been fully defined in these “off-label” (not approved by the U.S. Food and Drug Administration) uses, it must be considered experimental therapy at this time. Bibliography Felderhoff-Mueser U, Buhrer C: Clinical measures to preserve cerebral integrity in preterm infants. Early Hum Dev  2005; 81:237-244. Goldenberg NA, Manco-Johnson MJ: Pediatric hemostasis and use of plasma components. Best Pract Res Clin Haematol  2006; 19:143-155. O'Shaughnessy DF, Atterbury C, Bolton Maggs P, et al: Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol  2004; 126:11-28. Stanworth SJ, Brunskill SJ, Hyde CJ, et al: Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol  2004; 126:139-152. Copyright © 2011 Elsevier Inc. All rights reserved. Read our Terms and Conditions of Use and our Privacy Policy. For problems or suggestions concerning this service, please contact: online.help@elsevier.com

TRANSFÜZYONLARDA KOMPLİKASYON VE RİSKLER HIV (1/2 000 000) Hepatit C (1/1 500 000 – 2 000 000)

Ürtiker ya da diğer deri reaksiyonları 1/50-100   TAHMİNİ RISK Febril reaksiyon 1/300 Ürtiker ya da diğer deri reaksiyonları 1/50-100 Eritrosit alloimmunizasyonu 1/100 Yanlış tranfüzyon 1/14,000-19,000 Hemolitik reaksiyon 1/6,000 Fatal hemoliz 1/1,000,000 Transfüzyonla ilişkili akciğer hasarı 1/5,000 HIV1 ve HIV2 1/2,000,000- 3,000,000 Hepatit B 1/100,000-200,000 Hepatit C 1/1,000,000- 2,000,000 Human T-cell lenfotropik virüs (HTLV) I ve II 1/641,000 Bakteriyel kontaminasyon 1/5,000,000 Malarya 1/4,000,000 Anaflaksi 1/20,000-50,000 Graft versus host hastalığı Sık değil İmmünmodulasyon ? ESTIMATED RISKS IN TRANSFUSION PER UNIT TRANSFUSED IN THE USA   ESTIMATED RISK Febrile reaction 1/300 Urticaria or other cutaneous reaction 1/50-100 Red blood cell alloimmunization 1/100 Mistranfusion 1/14,000-19,000 Hemolytic reaction 1/6,000 Fatal hemolysis 1/1,000,000 Transfusion-associated lung injury 1/5,000 HIV1 and HIV2 1/2,000,000-3,000,000 Hepatitis B 1/100,000-200,000 Hepatitis C 1/1,000,000-2,000,000 Human T-cell lymphotrophic virus (HTLV) I and II 1/641,000 Bacterial contamination 1/5,000,000 Malaria 1/4,000,000 Anaphylaxis 1/20,000-50,000 Graft versus host disease Uncommon Immunomodulation Unknown From Klein HG, Spahn DR, Carson JL: Red blood cell transfusion in clinical practice, Lancet 370:415–426, 2007.

Enfeksiyöz riskler: HIV, hepatit C, CMV Hepatitis (A, B, E) ve retrovirüsler (human T-cell lenfotropik virüs tip I ve II ve HIV-2), sifilis, parvovirüs B19, Epstein-Barr virus, human herpesvirüs 8, Batı Nil virüsü, sarı humma aşı virüsü, malarya, babesiyoz, Anaplasma phagocytophilum ve Chagas hastalığı. Varyant Creutzfeldt-Jacob hastalığı Transfusion-associated cytomegalovirus (CMV) can be nearly eliminated by transfusion of leukocyte reduced cellular blood products or by selection of blood from donors who are seronegative for antibody to cytomegalovirus. Although it is logical to hypothesize that first collecting blood components from CMV-seronegative donors and then removing the white blood cells (WBCs) might improve safety, no data are available to document the efficacy of this combined approach. Moreover, findings from one study suggest that this combined approach, surprisingly, may be incorrect. Large quantities of CMV are present “free” in the plasma of healthy-appearing donors during primary infection (while CMV antibodies are either still absent or are newly emerging), rather than being leukocyte associated as they are during latent infection, when substantial quantities of antibodies are present. Thus, virus will not be removed by leukocyte reduction, and donors will be misclassified as CMV seronegative because antibody is below the limits of detection in window-phase or early infection. Because nearly all plasma CMV disappears after donors are seropositive for CMV antibody for several months and the virus is almost exclusively leukocyte associated at this time, the best method to reduce CMV risk may be to effectively perform leukocyte reduction of blood from donors known to be CMV seropositive for at least 1 year. Additional infectious risks include other types of hepatitis (A, B, E) and retroviruses (human T-cell lymphotropic virus types I and II and HIV-2), syphilis, parvovirus B19, Epstein-Barr virus, human herpesvirus 8, West Nile virus, yellow fever vaccine virus, malaria, babesiosis, Anaplasma phagocytophilum, and Chagas disease. Variant Creutzfeldt-Jacob disease has also been transmitted by blood transfusions in humans.

Enfeksiyon dışı riskler: Hemolitik ve non-hemolitik reaksiyonlar, Sıvı yüklenmesi, GVH hastalığı, Elektrolit ve asit-baz denge bozuklukları, Demir yüklenmesi, Oksidan hasara karşı yatkınlık artışı, Hemoliz, Post-transfüzyon purpura, Akut akciğer hasarı, İmmunsupresyon, Alloimmunizasyon. Transfusion-associated risks of a noninfectious nature that may occur include hemolytic and nonhemolytic transfusion reactions, fluid overload, graft versus host disease, electrolyte and acid-base imbalances, iron overload if repeated transfusions are needed long term, increased susceptibility to oxidant damage, exposure to plasticizers, hemolysis with T-antigen activation of red blood cells, post-transfusion purpura, acute lung injury, immunosuppression, and alloimmunization (see Table 468-1). Immunomodulation may be reduced by leukocyte reduction. Transfusion reactions and alloimmunization to red blood cell and leukocyte antigens seem to be uncommon in infants. Adverse effects are seen primarily in massive transfusion settings, such as exchange transfusions and trauma or surgery, in which relatively large quantities of blood are needed, but are rare with the small-volume transfusions usually given.

GVH önlemi için irradyasyon Prematürebebeklerde immun olgunlaşma yetersizliği  Post-transfüzyon graft versus host hastalığı gelişim riskinde artış? Bebeğin postnatal yaşı, Transfüze edilen üründeki immunocompetan lenfosit sayısı, Donör ve alıcı arasındaki HLA uyumluluğu, Birçok yerde prematürelere kan ürünleri gama ışınlanmış (γ-irradiated) olarak verilmektedir. İntrauterin ve kan değişiminde kullanılan lökosit içeren kan ürünlerine, - Ağır kombine immun yetersizliği olanlara verilecek olan kan ürünlerine, Kalp cerrahisi uygulanacak olan Di George sendromlulara verilecek kan ürünlerine, Hematopoietic progenitor hücre transplantlarına gama ışınlama yapılmalıdır . Premature infants are known to have immune dysfunction, but their relative risk of post-transfusion graft versus host disease is controversial. The postnatal age of the infant, the number of immunocompetent lymphocytes in the transfusion product, the degree of human leukocyte antigen compatibility between donor and recipient, and other poorly described phenomena determine which infants are truly at risk for graft versus host disease. Regardless, many centers caring for preterm infants transfuse exclusively γ-irradiated cellular products. Directed donations with blood drawn from blood relatives must always be irradiated because of the risk of engraftment with transfused HLA-homozygous, haploidentical lymphocytes. Cellular blood products given as intrauterine and exchange transfusions should be γ-irradiated, as are transfusions for patients with severe congenital immunodeficiency disorders (severe combined immunodeficiency syndrome and DiGeorge syndrome requiring heart surgery) and transfusions for recipients of hematopoietic progenitor cell transplants. Other groups who are potentially at risk but for whom no conclusive data are available include patients given T-cell antibody therapy (antithymocyte globulin or OKT3), those with organ allografts, those receiving immunosuppressive drug regimens, and those infected with HIV.

γ-ışınlama ? T-hücre antikor tedavisi (antitimosit globulin ya da OKT3), Organ nakilleri, İmmunsupresif tedavi alanlar, HIV Other groups who are potentially at risk but for whom no conclusive data are available include patients given T-cell antibody therapy (antithymocyte globulin or OKT3), those with organ allografts, those receiving immunosuppressive drug regimens, and those infected with HIV.

Gama (γ) ışınlama: Sezyum, kobalt ya da lineer akselerasyonla 2500 - 5000 cGy dozda; minimum doz 2500 cGy. Hücresel komponenti olan tüm kan ürünleri ışınlanmalıdır. Plazma ve kriyopresipitat gibi dondurulmuş plazma ürünlerinin ışınlanmasına gerek yoktur. Lökositi azaltılmış kan ürünlerinin kullanılması durumunda da ışınlama yapılmalıdır. Current practice uses γ-irradiation from a cesium, cobalt, or linear acceleration source at doses ranging from 2,500 to 5,000 cGy; a minimum dose of 2,500 cGy is required. All cellular blood components should be irradiated, but frozen “acellular” products, such as plasma and cryoprecipitate, do not require it. Leukocyte reduction cannot be substituted for γ-irradiation to prevent graft versus host disease. Bibliography Alter HJ, Kein HG: The hazards of blood transfusion in historical perspective. Blood  2008; 112:2617-2626. Centers for Disease Control and Prevention : Anaplasma phagocytophilum transmitted through blood transfusion—Minnesota, 2007. MMWR Morbid Mortal Wkly Rep  2008; 57:1145-1148. Centers for Disease Control and Prevention : Transfusion-related transmission of yellow fever vaccine virus—California, 2009. MMWR Morbid Mortal Wkly Rep  2010; 59:34-36. Centers for Disease Control and Prevention : West Nile virus transmission via organ transplantation and blood transfusion—Louisiana, 2008. MMWR Morbid Mortal Wkly Rep  2009; 58:1263-1266. Centers for Disease Control and Prevention : Blood donor screening for Chagas disease—United States, 2006–2007. MMWR Morbid Mortal Wkly Rep  2007; 56:141-143. Hladik W, Dollard SC, Mermin J, et al: Transmission of human herpesvirus 8 by blood transfusion. N Engl J Med  2006; 355:1331-1338. Klein HG, Spahn DR, Carson JL: Red blood cell transfusion in clinical practice. Lancet  2007; 370:415-426. Strauss RG: Data-driven blood banking practices for neonatal RBC transfusions. Transfusion  2000; 40:1528-1540. Zieman M, Krueger S, Maier AB, et al: High prevalence of cytomegalovirus DNA in plasma samples of blood donors in connection with seroconversion. Transfusion  2007; 47:1972-1983.(plus Editorial, pages 1955–1958)