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Compendium July 2004 (Vol 26, No 7)

Transfusion Medicine

by Sarah Haldane, BVSc, MACVSc, Jennifer Roberts, DVM, Steven L. Marks, BVSc, MS, MRCVS, DACVIM (Small Animal Internal Medicine), Marc R. Raffe, DVM, MS, DACVA, DACVECC

    Abstract

    Transfusion therapy is indicated in patients with many different diseases and conditions, including anemia, hemorrhage, coagulopathy, and hypoproteinemia. After whole blood is collected from a donor animal, it may be administered immediately or fractionated into its component parts (e.g., packed red blood cells, fresh-frozen plasma, cryoprecipitate, platelet products). Transfusion reactions may manifest as complications of blood product administration. However, selecting the appropriate blood product and carefully collecting, storing, and handling blood, in combination with blood-typing and crossmatching, can decrease the risk of transfusion reactions.

    There are many indications for transfusion therapy in veterinary practice, and with the increased availability of blood products, it is becoming more widespread. Fractionating whole blood into its component products has made it easier to treat a broad range of conditions when donors are not available. Blood components accessible to veterinarians include fresh and stored whole blood, packed red blood cells (pRBCs), fresh-frozen plasma (FFP), cryoprecipitate, and platelet products. However, administering blood products is not a benign procedure. Red blood cells (RBCs) are very antigenic and can promote a significant immune response.1 Administering foreign proteins, leukocytes, or platelets may also stimulate the immune system.2 The appropriate blood product should be selected based on maximum benefit with minimum risk to the patient.

    Selecting Blood Donors

    Blood donors should be healthy adult (i.e., 2 to 8 years of age) dogs and cats. Dogs should weigh more than 66 lb (30 kg); have a packed cell volume (PCV) of 40% or more; be fully vaccinated; and be free of heartworm infection, brucellosis, and tick-borne diseases (e.g., Ehrlichia canis, Babesia canis, Rickettsia rickettsi, Borrelia burgdorferi infections).3 It is also recommended that canine donors test negative for dog erythrocyte antigen (DEA) 1.1 (universal donors would also need to test negative for DEA 1.2 and 7).4,5 Purebred and crossbred Akitas have high levels of intracellular potassium in their RBCs and should not be used as blood donors.6

    Cats should weigh more than 11 lb (5 kg), be lean, and preferably be shorthaired. Feline donors should have a PCV greater than 35%; be fully vaccinated; and be free from FeLV, FIV, Toxoplasma gondii, and Hemobartonella felis (now called Mycoplasma hemofelis) infections. Cats should be blood typed before blood collection.5,7

    Withdrawal of 10% to 20% of the blood volume from a blood donor should not result in clinically significant anemia. An 11-lb (5-kg) cat may have 50 to 60 ml of blood collected in one donation, whereas a 66-lb (30-kg) dog may have 450 ml of blood collected. Hypovolemia can result if 20% or more of the blood volume is withdrawn; if this occurs, administering IV fluids is indicated. Blood should not be collected more than once every 4 to 6 weeks.8

    Canine Blood Groups

    Nine blood groups (i.e., DEA 1.1, 1.2, 1.3, 3, 4, 5, 6, 7, 8) have been identified in dogs.9 The most clinically significant are DEA 1.1 and 1.2.10 Spontaneously occurring antibodies (i.e., alloantibodies) to these antigens have not been identified; thus immunologic reactions are rare for the first transfusion administered to dogs. However, if a transfusion of blood positive for DEA 1.1 is administered to a recipient with blood negative for DEA 1.1, antibody induction will occur. If a second transfusion of blood positive for DEA 1.1 is administered, an immune-mediated transfusion reaction may destroy all transfused cells in less than 12 hours.9,10 Pregnancy can also induce alloantibodies to DEA 1.1 in up to 25% of dogs.10

    Alloantibodies against DEA 7 are present in up to 15% of dogs. These antibodies cause a delayed-type immune response against RBCs positive for DEA 7, resulting in hemolysis 1 to 3 days after transfusion.8,11 Delayed-type hemolytic reactions may also occur if the donor animal has alloantibodies to DEA 3 or 5; however, these occur rarely in the general population.12

    Feline Blood Groups

    There are three feline blood types: A, B, and AB. There is no universal donor group because cats with type A blood have anti-type B antibodies and cats with type B blood have anti-type A antibodies.13 Type B blood transfused into a cat with type A results in hemolysis of transfused cells within 2 to 3 days. However, even a small amount of type A blood transfused into a cat with type B blood results in acute hemolysis and may be fatal.14 Therefore, crossmatching (see box) is essential for all feline blood transfusions. Cats with type AB blood have been considered universal recipients because they have no RBC alloantibodies in their blood. However, if type B blood is transfused into a recipient with type AB blood, the anti-A alloantibodies present in the donor blood can cause a significant transfusion reaction. Cats with type AB blood should be transfused with type-specific blood, if available, or type A blood if it is not.15

    Blood-typing cards (Rapid Vet-H Feline blood-typing cards, DMS Laboratories, Inc., Flemington, NJ) are available for feline donors to discriminate among types A, B, and AB (Figure 1). There are also canine blood-typing cards (Rapid Vet-H Canine blood-typing cards, DMS Laboratories, Inc.) that identify the presence or absence of DEA 1.1 on donor RBCs. These cards can be quickly and easily used and may be helpful in emergencies.16 However, blood-typing cards should not be considered a substitute for crossmatching.

    Preparing Blood Components

    Whole blood can be collected (usually into commercially prepared blood bags) from donors via aseptic venipuncture. Anticoagulants used for blood products are citrate-phosphate-dextrose-adenine (CPDA-1) and acid-citrate-dextrose (ACD). CPDA-1 has a shelf life of 35 days, and ACD has a shelf life of 21 days. Additive solutions can be used to preserve RBC function for up to 42 days.17-19 Heparin has no preservative action, and heparinized blood should be administered within 8 hours of collection.5

    Units of fresh whole blood may be centrifuged and fractionated into their component parts. RBCs precipitate after centrifugation at 5000g for 5 minutes at 42.8°F (6°C). The RBCs can then be separated from the plasma fraction and stored at 33.8°F to 42.8°F (1°C to 6°C).20 Plasma can be rapidly frozen (within 6 hours of blood collection) at -4°F to -94°F (-20°C to -70°C) for later use as FFP.5 FFP contains albumin, globulins, and all the coagulation factors, including the labile factors V and VIII. The coagulation factors in FFP remain relatively stable for up to 1 year, after which FFP is no longer considered fresh but can be used as a source of albumin and vitamin K-dependent clotting factors II, VII, IX, and X.3,5

    Cryoprecipitate is formed when FFP is briefly thawed and recentrifuged at 39.2°F (4°C) and 5000g for 5 minutes. After separation, the precipitate should be rapidly refrozen at -4°F to -94°F (-20°C to -70°C). Cryoprecipitate contains concentrated von Willebrand factor (vWF), clotting factors VIII and XIII, and fibrinogen.

    To prepare platelet-rich plasma, whole blood should be centrifuged at room temperature and 2000g for 3 minutes. Additional centrifugation at 4000g for 6 minutes can be used to separate platelets from plasma to produce a platelet-concentrated unit.5 Platelet products prepared in this way should be administered as soon as possible (ideally, within 8 to 12 hours of collection).5,21,22 Plateletpheresis involves removing whole blood from a donor, separating the platelet fraction, and transfusing the remaining blood components into the animal.5 This technique is used in large blood-banking institutions to prepare platelet concentrates, which can then be suspended and frozen in dimethyl sulfoxide (DMSO) and stored for 6 months.23,24

    Using Blood Components

    Whole Blood

    Fresh whole blood contains RBCs, serum proteins, clotting factors, and platelets. When whole blood is stored, the labile clotting factors V and VIII are destroyed within 24 hours and platelets within 2 to 4 hours. Concentrations of 2,3-diphosphoglycerate (2,3-DPG) progressively decline with storage,20 adversely affecting the ability to unload oxygen into peripheral tissues. However, human studies have shown that 2,3-DPG in transfused blood regenerates to 50% of normal levels within 7 hours of administration and reaches normal levels in 24 to 72 hours.25

    Transfusing fresh or stored whole blood may be indicated during acute hemorrhage or when multiple blood components are required.26 Animals with hemolytic anemia or decreased production of RBCs often have increased intravascular volume as a compensatory response to decreased oxygen delivery to tissues.27 Volume overload may be a concern with whole blood transfusions in these patients. Ammonia levels increase while blood products are stored. It has been suggested that animals with liver disease should be transfused with products that have been stored for less than 2 weeks, although posttransfusion hyperammonemia in veterinary patients has not been documented.28

    Packed Red Blood Cells

    pRBCs have the advantage of containing the same amount of RBCs, and therefore oxygen-carrying capacity, as a unit of whole blood, but in a significantly smaller volume. The PCV of a unit of pRBCs may vary from 55% to 80% in dogs or 45% to 65% in cats, depending on the PCV of the donor, diluting effects of added preservatives, and amount of residual plasma volume in the bag. Some residual plasma is required to provide a healthy environment for RBCs.29

    pRBC transfusion is indicated in patients with anemia caused by decreased erythropoiesis, hemolysis, or blood loss. The smaller volume is also an advantage when transfusing animals with concurrent cardiac or renal compromise.30

    Leukocytes

    Leukocyte transfusion has not been shown to be beneficial in critically ill veterinary patients.29 Leukocyte transfusions are expensive and difficult because they must be harvested from the buffy coat layer of multiple units of blood. Transfusing foreign leukocytes is unlikely to provide an immune benefit to a recipient animal and may more likely cause an immune reaction against the transfused cells.29

    Plasma Products

    The indications for using plasma products include treating inherited and acquired factor deficiencies, treating coagulopathy, enhancing protective enzyme levels (i.e., α1-antitrypsins, α2-macroglobulins), and augmenting intravascular colloid concentration.31

    Coagulopathy

    Liver failure or vitamin K deficiency (from either cholestatic disease or vitamin K-antagonist ingestion) may result in clinical coagulopathy.32,33 Patients that are actively hemorrhaging benefit from immediate supplementation of clotting factors in FFP.34,35 Fresh and stored whole blood also contain vitamin K-dependent coagulation factors II, V, VII, and X and may be used if an animal's RBC count or PCV is decreased.

    Disseminated intravascular coagulopathy (DIC) is a secondary syndrome characterized by hemostatic dysfunc­tion. Correcting the primary pathology is specific therapy for DIC. Supportive therapy for patients with DIC in­cludes administering FFP to supplement clotting factors, an­ti­thrombin, C-reactive protein (an acute-phase pro­tein), and fibronectin (a glycoprotein that aids cellular adhesion).3,32

    Dilutional coagulopathy may occur with acute massive hemorrhage (e.g., trauma, hemoabdomen)36 or when large volumes of fluids are rapidly administered during resuscitation (e.g., shock). In these situations, immediately administering FFP may not be warranted unless there is clinical evidence of hemorrhage; however, the coagulation profile of patients with dilutional coagulopathy should be monitored closely.

    Transfusing specific coagulation factors for congenital coagulation factor defects is not commonly performed in veterinary medicine. The exception is using cryoprecipitate for surgical prophylaxis or to treat active hemorrhage in vWF- or factor VIII-deficient patients.37,38 FFP transfusions do not predictably increase the concentration and duration of activity of vWF and factor VIII; thus large volumes of FFP may be required to control hemorrhage, placing patients at risk for hypervolemia.37,38

    Hypoproteinemia

    Increased morbidity and mortality are well documented in humans with hypoalbuminemia (<2.5 g/dl) compared with those with normal albumin levels,39 although total proteins, rather than albumin alone, contribute to colloid osmotic pressure.40 In chronic conditions, FFP transfusions have only a transient effect on albumin concentrations, and the volume of plasma required to achieve a measurable increase in albumin is quite large, placing patients at risk for volume overload.40 Because nutrition and colloid osmotic pressure have the most influence on albumin synthesis, the most effective way to increase long-term albumin concentrations is with nutritional support.39,41 In the short term, hypoproteinemic patients may benefit from a mild increase in albumin from FFP in combination with oncotic support from synthetic colloids.3

    Pancreatitis

    FFP transfusion has been advocated in treating pancreatitis to provide coagulation factors, maintain albumin concentrations, and supplement plasma protease inhibitors (e.g., α2-macroglobulins, α1-antitrypsins).42 However, human clinical trials have not shown consistent improvement in morbidity and mortality when FFP is administered to patients with pancreatitis.43,44

    Antioxidant Properties

    The primary mechanism whereby plasma has antioxidant properties is through iron sequestration, which limits the production of free hydroxyl radicals and prevents subsequent cellular injury.45 There are no current guidelines for FFP administration with regard to its antioxidant effects.

    Platelet Products

    Platelets are extremely labile in serum and may be lost from blood within a few hours of collection. Prophylactic platelet transfusion is not recommended because platelet products are difficult to store24 and transfused platelets are not retained for long periods in circulation, especially if the primary cause of thrombocytopenia is platelet destruction.33 However, if platelet loss or dysfunction is causing ongoing bleeding, transfusion of platelet-rich plasma or platelet concentrates may be indicated.46,47 Platelet concentrates frozen in DMSO (canine frozen platelet concentrate with 6% DMSO, Midwest Animal Blood Services, Stockbridge, MI) are available for use in veterinary medicine. There have not been studies on the efficacy of these products in veterinary patients.

    Hemoglobin-Based Oxygen Substitutes

    Hemoglobin-based oxygen carriers (HBOCs) have been under investigation as a type of blood substitute, principally to augment oxygen delivery to tissues.48,49 Oxyglobin (hemoglobin glutamer-200 [bovine], Bio­pure) is a purified, polymerized bovine hemoglobin solution with an average hemoglobin concentration of 13 g/dl. It is considered a universally compatible blood product because it lacks cell surface antigens and re­duces the risk of contamination with infectious disease. Bovine hemoglobin does not rely on 2,3-DPG for influencing oxygen affinity; thus Oxyglobin has a lower oxygen tension (P50) at a given oxygen saturation than do canine or feline RBCs and has enhanced carbon dioxide and oxygen affinity. This leads to improved uptake and transport at a given oxygen tension.49,50 Economically appealing qualities include its long shelf life (i.e., 3 years), ability to be stored at room temperature, and abundant supply.49

    The oxygen-carrying effects of Oxyglobin last up to 3 days in circulation. However, in the absence of hemo­lytic processes, transfused RBCs should remain in circulation more than 28 days. Oxyglobin also has significant colloidal properties,51 and patients should be monitored for signs of volume overload during administration.

    Adverse gastrointestinal effects have been reported.52 After infusion, patients can demonstrate transient discoloration (i.e., yellow-orange, orange-brown) of their mucous membranes and, less frequently, skin. Urine may be similarly discolored, making interpretation of a urine dipstick inaccurate. After administration, total hemoglobin, rather than hematocrit, levels should be evaluated. Depending on the dose administered, serum may appear red-tinged or red-brown. This color change may influence chemistry analyzers by causing interference with colorimetric assays but does not alter noncolorimetric tests, including most electrolyte panels, hemo­grams, and coagulation assays.49,53 This effect is manufacturer and machine dependent and is discussed in detail in the package insert.

    The manufacturer's recommended dose of Oxyglobin is 10 to 30 ml/kg IV up to a maximum rate of 10 ml/kg/hr.54 In general, an initial dose of 10 ml/kg is recommended. Patients should be monitored because the colloidal effects of Oxyglobin in circulation may lead to decreased cardiac output, increased systemic vascular resistance, and hemodilution.51,55 Oxyglobin is currently not registered for use in cats but has been used as an off-label product at a dose of 5 to 15 ml/kg IV at a rate of 5 ml/kg/hr.56 Cats are prone to volume overload and should be monitored closely during Oxyglobin infusion.56

    Administering Blood Components

    RBC products should be transfused to attain a PCV of 25% to 30% in dogs or 20% in cats.8,29 This corresponds to results in human studies that do not recommend transfusion above hemoglobin concentrations of 7 to 10 g/dl (PCV: 21% to 30%), depending on a patient's clinical status.27,57 The volume of whole blood or pRBC required can be calculated using the following equation:

    Volume to be transfused (ml) =

    kg x 90 (Dogs) Or 70 (Cats) x Desired PCV - Recipient PCV ÷ Donor PCV

    As a guideline, 2 ml/kg of whole blood raises the PCV 1% (therefore, 20 ml/kg raises the PCV 10%). For pRBC, 1 ml/kg raises the PCV 1% (therefore, 10 ml/kg raises the PCV 10%)29 (see box). These general guidelines depend on the PCV of the donor blood and may underestimate the amount of blood required for transfusion.

    It is not necessary to warm pRBC or stored whole blood before transfusion, except for very small or pediatric patients, which are at greater risk of hypothermia.32 Blood products should not be warmed to higher than 98.6°F (37°C) because this leads to hemolysis of cells, precipitation of fibrinogen, and degradation of serum coagulation factors and proteins.22

    Blood products should be administered via a dedicated IV fluid line or in combination with 0.9% sodium chloride (NaCl). The line should always contain a 170-µm filter. pRBCs, in particular, may require dilution with fluids to facilitate administration. Fluids containing calcium, such as lactated Ringer's solution, should not be administered with blood products. Calcium deactivates the citrate in the anticoagulant solution, possibly leading to thrombus formation.29 Coadministering hypotonic or dextrose-containing fluids with blood products may result in hemolysis of RBCs and is therefore not recommended.29

    All blood products should be transfused within 4 hours to reduce the risk of contamination and bacterial colonization.22,58 More rapid transfusion may be indicated if there is ongoing blood loss or hypovolemia. Care should be taken in patients with concurrent cardiac or renal disease because of the risk of volume overload.29,32

    Plasma products should be thawed in a warm-water bath at 98.6°F (37°C) before transfusion. The access ports in the bag should be covered with plastic to avoid contamination with water. Plasma products should be administered through a dedicated IV line with a 170-µm filter. Once FFP has been thawed, it should be used within 4 hours because the labile clotting factors deteriorate quickly and there is increased risk of subsequent bacterial contamination. The recommended starting dose for FFP is 6 to 10 ml/kg3,29,31 (Table 1). Plasma infusion should continue in coagulopathic patients until hemorrhage is controlled or clotting times are within 1.5 times the upper limit of normal. A dose of 45 ml/kg is required to raise the albumin concentration 1 g/dl in hypoproteinemic patients,3 thus making FFP administration for hypoalbuminemia generally unfeasible.

    In cases of known canine von Willebrand's disease, administering cryoprecipitate is recommended at an initial dose of 1 unit/10 kg before a surgical procedure or as needed to stop ongoing hemorrhage.33,38

    Platelet-rich plasma should be administered within 12 hours of collection at a dose of 1 unit/3 kg. Platelet concentrates frozen in DMSO should be allowed to thaw at room temperature, with gentle mixing every 5 minutes. The initial dose of platelet concentrate should be 1 unit/10 kg.33

    Transfusion Reactions

    Transfusion reactions can be classified as immunologic or nonimmunologic. Acute immunologic reactions usually occur within the first 1 to 2 hours of transfusion but can be seen up to 48 hours later.4,14 Common clinical signs are listed in Table 2 . Acute hemolysis can also be seen if incompatible blood is administered, and this reaction can be life threatening.4,9

    Fever is a common acute transfusion reaction that is usually transient and does not require treatment.4,7 However, fever may also indicate acute hemolysis or bacterial contamination of the blood product, both of which require prompt intervention. Evaluating the blood bag for evidence of infection is warranted. Vomiting, diarrhea, abdominal pain, hypotensive shock, or DIC may develop with bacterial contamination.4

    Delayed immunologic reactions usually involve hemolysis and shorten the life span of transfused RBCs. The normal life span of a transfused RBC is 21 to 48 days. A delayed transfusion reaction may result in an RBC life span of 2 to 5 days.30

    Nonimmunologic reactions occur because of either changes in blood products during storage or administering excessive volumes or rates of fluids4 (Table 2). Changes in blood products may include hyperammonemia,28 hypophosphatemia, hyperkalemia,59 bacterial ­contamination, or clot formation within the unit. Circulatory (volume) overload, erythrocytosis, or hyper­proteinemia are also possible complications of blood product transfusion.4 Massive transfusions (greater than one blood volume) can lead to dilutional coagulopathy (thrombocytopenia and prolonged coagulation times) or cause citrate intoxication, which leads to clinical signs of hypocalcemia or hypomagnesemia.60

    Preventing Transfusion Reactions

    Preventing transfusion reactions begins with screening blood donor animals and aseptically collecting and administering blood products. For cats, recipient blood should always be crossmatched with donor blood before a transfusion.7 Dogs that have had a previous transfusion or pregnancy also require crossmatching.10 Before transfusion, blood products should be examined for changes in color or consistency that may indicate hemolysis, clotting, or microbial infection. Transfusions should be started at half the calculated rate for 15 minutes, and animals should be constantly monitored for signs of tachypnea, increased heart rate, fever, urticaria, or vomiting.8 Once the administration rate increases, animals should be monitored every 15 to 30 minutes for signs of transfusion reactions. Some authors recommend administering an antihistamine before any transfusion to prevent type 1 hypersensitivity reactions.4,29

    Managing Transfusion Reactions

    If signs of acute transfusion reaction are detected, the transfusion should be stopped immediately and crystalloid fluids infused to maintain blood pressure, heart rate, and diuresis4 (Table 2). If the reaction is mild, the transfusion may be restarted at a lower rate and the animal monitored closely for progression of clinical signs.4

    Downloadable PDF

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    59. Price GS, Armstrong PJ, McLeod DA, et al: Evaluation of citrate-phosphate-dextrose-adenine as a storage medium for packed canine erythrocytes. J Vet Intern Med 2:126-132, 1988.

    60. Jutkowitz LA, Rozanski EA, Moreau JA, et al: Massive transfusion in dogs. JAVMA 220:1664-1669, 2002.

    References »

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