Transfusion therapy

Definition

The process of transferring whole blood or blood components from one person (donor) to another (recipient).

Purpose

Transfusions are given to restore lost or depleted blood components, to improve clotting time, and to improve the ability of the blood to deliver oxygen to the body's tissues. Typical reasons cancer patients receive blood transfusions are for anemia (low red blood cell count) and for clotting factors or platelets (for example, in certain types of leukemia).

Precautions

For donors, the process of giving blood is very safe. Only sterile equipment is used and there is no chance of catching an infection from the equipment. There is a slight chance of infection at the puncture site if the skin is not properly washed before the collection needle is inserted. Some donors feel light-headed upon standing for the first time after donating. Occasionally, a donor will faint. Donors are advised to drink plenty of liquids to replace the fluid lost with the donation of blood. It is important to maintain the fluid volume of the blood so that the blood pressure will remain stable. Strenuous exercise should be avoided for the rest of the day. Most patients have very slight symptoms or no symptoms at all after donating blood. People who have cancer usually are not considered candidates for blood donation.

For recipients, a number of precautions must be taken by the blood bank. The blood given by transfusion must be matched with the recipient's blood type. Incompatible blood types can cause a serious adverse reaction (transfusion reaction). Blood is introduced slowly by gravity flow directly into the veins (intravenous infusion) so that medical personnel can observe the patient for signs of adverse reactions. People who have received many transfusions (such as leukemia patients) can develop an immune response to some factors in foreign blood cells. This immune reaction must be checked before giving new blood. Infectious diseases can also be transmitted through donated blood. However, many safeguards are in place in the United States to minimize the risk of transmission of blood-borne pathogens (agents in the blood that cause disease) to recipients.

Description

WHOLE BLOOD.

Either whole blood or blood components can be used for transfusion. Whole blood is used exactly as it was received from the donor. Blood components are parts of whole blood, such as red blood cells (RBCs), plasma, platelets, clotting factors, immunoglobulins, and white blood cells. Whole blood is used only when needed or when components are not available. Most of the time, whole blood is not used because the patient's medical condition can be treated with a blood component. Too much whole blood can fluid-overload a patient's circulatory system. This can create high blood pressure and congestive heart failure (overwork of the heart muscle to pump the extra fluid volume). The use of blood components is more efficient and effective because blood that has been fractionated (processed) into components can be used to treat more than one person.

PLASMA.

Plasma is the liquid portion of blood. It contains many useful proteins, especially clotting factors and immunoglobulins. After they are processed, plasma or plasma factors (fractions) are usually frozen. Some plasma fractions are freeze-dried. These fractions include clotting factors I through XIII. Some people have an inherited disorder in which the body produces too little of the plasma clotting factors VIII (hemophilia A) or IX (hemophilia B). Transfusions of these clotting factors help people with hemophilia to stop bleeding. Frozen plasma must be thawed before it is used and freeze-dried plasma must be mixed with liquid (reconstituted). In both cases, these blood fractions are usually small in volume and can be injected by syringe and needle.

RED BLOOD CELLS.

Red blood cells are the blood component most frequently used for transfusion. RBCs are the only cells in the body that transport oxygen. A transfusion of RBCs increases the amount of oxygen that can be carried to the tissues of the body. RBCs that have been separated from the liquid plasma (packed RBCs) are given to people who have anemia (low red cell count) or who have lost a lot of blood. There are many causes of anemia. In cancer, anemia is caused by the destruction of red blood cells by disease, by medications such as chemotherapy , or by disease in the bone marrow where red blood cells are produced. To determine how serious the anemia is, the physician will do a CBC (complete blood count) to look at the hemoglobin level (the oxygen-carrying capacity of the red blood cells), and a hematocrit (the percentage of RBCs in a given volume of blood).

PLATELETS.

Platelets are another component frequently given by transfusion. Platelets are a key factor in blood clotting. The clear fluid that carries blood cells (plasma) also contains blood-clotting factors. The platelets and plasma clotting factors are extracted from donated blood and concentrated for use. These factors are used to treat cancer patients whose bone marrow has been destroyed by disease. Cancer patients may need platelet transfusions when their bone marrow is not producing enough platelets, either because the bone marrow has been damaged by chemotherapy or because it has been replaced by the growth of cancer cells. Dangerous bleeding may occur if the platelet count is too low. However, if there is no evidence of bleeding (no clinical signs of bleeding), platelets may not be given even if the count is low.

IMMUNOGLOBULINS.

Immunoglobulins, also called gamma globulin or immune serum, are collected from plasma for use in temporarily boosting the immune capability of a patient. White blood cells (WBCs) are another infection-fighting component of the blood. White blood cells are given by transfusion only rarely. Immunoglobulins are the infection-fighting fraction of blood plasma. This blood fraction is given to people who have difficulty fighting infections, especially people whose immune systems are depressed by diseases, such as HIV/AIDS and cancer. Immmunoglobulins are also used to prevent tetanus after cuts, to treat animal bites when rabies infection is suspected, or to treat severe childhood diseases. Immunoglobulins can also be used to treat idiopathic thrombocytopenic purpura (ITP), a condition characterized by a low platelet count and excessive bruising.

COLONY-STIMULATING FACTORS OR GROWTH FACTORS.

Granulocytes are a type of white blood cell that fight infection. Granulocyte transfusion is no longer done because of the fever it produces and the potential transmission of infectious diseases through white cells. These infections (CMV or cytomegalovirus) would be particularly dangerous to a cancer patient with a weakened immune system. Chemotherapy patients can develop a low WBC (white cell count). A specific white blood cell called the neutrophil is carefully monitored because it is very important in fighting multiple types of infection. If neutrophil counts are very low, the physician may order special medications that stimulate the production of neutrophils in the bone marrow. These medicines are called colony-stimulating factors or growth factors, and include granulocyte colony-stimulating factor (G-CSF or filgrastim ), granulocyte macrophage colony-stimulating factor (GM-CSF or sargramostim ), and interleukin-3.

ALTERNATIVES TO BLOOD TRANSFUSION.

Researchers have been working to develop a substitute for blood that will avoid the risks associated with blood transfusion. Products are being developed that will perform the functions of red blood cells, such as carrying oxygen through the blood stream, but there is no real substitute for the transfusion of human blood. Two products that are currently available are known as hemoglobin-based oxygen carriers and perfluorochemical compounds. These products can be used on a short term basis to perform the function of blood, but are still considered experimental.

Other types of products that can help patients in need of large volumes of body fluids are volume expanders such as normal saline solution, lactated ringers, or dextran. These are IV (intravenous) solutions that can replace lost fluid volume but not the red blood cells' function of carrying oxygen to the body. Other volume expanders include albumin, a protein solution used to stabilize oncotic pressure (pressure within the veins) and prevent or treat shock. Growth factors, as mentioned earlier, help promote the production of specific white cells needed to fight infections. Erythropoietin and thrombopoietin are products available to help stimulate the production of red blood cells and platelets. None of these products replace the benefits of blood or blood component transfusions.

New cancer treatments under research

Researchers are looking at the efficacy of using sibling blood components, specifically transfusions of stem cells and T-cells, a part of the immune system that can attack and destroy cancer cells. Blood from tissue-matched sibling donors reduces the rejection rate by the patient's body chemistry. This technique is being studied in renal (kidney) tumors, and early results show promise. Researchers are particularly interested in this therapy for renal tumors with metastasis (spreading of the cancer to other parts of the body) because this type of cancer does not usually respond to standard cancer therapy protocols. While blood transfusions and bone marrow transplants have been used extensively for cancers of the blood, this is the first time transfusions have been successful in the treatment of solid tumors (such as renal tumors).

Researchers are also looking at the placenta and umbilical cord as a source for blood stem cells for transplant. This method is called cord blood transplantation. It offers an alternative for patients who do not have a sibling donor, or cannot locate a match in the National Marrow Donor Program (NMDP) registry.

Blood donation

Each year in the United States, about 14, 000, 000 pints of blood are donated. Blood collection is strictly regulated by the Food and Drug Administration (FDA). The FDA has rules for the collection, processing, storage, and transportation of blood and blood products. In addition, the American Red Cross, the American Association of Blood Banks, and most states have specific rules for the collection and processing of blood. The main purpose of regulation is to ensure the quality of blood and to prevent the transmission of infectious diseases through donated blood. Before blood and blood products are used, they are extensively tested for infectious agents, such as hepatitis and HIV/AIDS. Screening prevents blood donation by people who could transmit diseases or by people whose medical condition would place them at risk if they donated blood. Some geographical areas or communities have a high rate of hepatitis or HIV/AIDS. Blood collection in most of these areas has been discontinued.

SPECIAL DONATIONS: AUTOLOGOUS TRANSFUSION.

Autologous transfusion is a procedure in which patients donate blood for their own use. Patients who are to undergo surgical procedures for which a blood transfusion might be required may elect to donate a store of blood for the purpose ahead of time. The blood is stored at the hospital for the exclusive use of the patient. This procedure assures that the blood type is an exact match. It also assures that no infection will be transmitted through the blood transfusion. This is most helpful to cancer patients because of the reduction of risk for a transfusion reaction and for infection risks associated with transfusions. As with other forms of specialized blood donations, there is a processing fee for collection and delivering each unit of blood, which may not be reimbursed by health insurance .

SPECIAL DONATIONS: DIRECTED DONATION.

Directed donors are family or friends of the patient who needs a transfusion. Some people think that family and friends provide a safer source of blood than the general blood supply. Studies do not show that directed donor blood is any safer. Blood that is not used for the identified patient becomes part of the general blood supply.

SPECIAL DONATIONS: APHERESIS.

Apheresis is a special procedure in which only the necessary components of a donor's blood are collected. The remaining components are returned to the donor. A special blood-processing instrument is used in apheresis. It separates the blood into components, saves the desired component, and pumps the other components back into the donor. Because donors give only part of their blood, they can donate more frequently. For example, people can give almost ten times as many platelets by apheresis as they could give by donating whole blood.

Preparation

The person receiving a transfusion is made comfortable and vital signs (temperature, blood pressure, pulse and respirations) are monitored closely. The site where the needle will be inserted is carefully washed with a soap-based solution, followed by an iodine-containing antiseptic. The skin is then dried and the transfusion needle inserted into the recipient's vein. During the early stages of a transfusion, the recipient is monitored closely to detect any adverse reactions. If no signs of adverse reaction are evident, the patient is monitored routinely for the duration of the transfusion period. Upon completion of the transfusion, a pressure bandage is placed over the needle-insertion site to prevent bleeding.

Aftercare

Recipients of a blood transfusion have their vital signs monitored during and after the transfusion for signs of adverse reaction. The physician usually orders laboratory tests to check hemoglobin and hematocrit levels, as well as platelet count once the transfusion has ended. This data will help the physician determine if the transfusion of blood or blood products was sufficient.

Risks

Adverse reaction to mismatched blood (transfusion reaction) and transmission of infectious disease are the two major risks of blood transfusion. Transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them (hemolytic reaction). Transfusion reaction may also cause a hypersensitivity of the immune system that, in turn, may cause tissue damage within the patient's body. The patient may also have an allergic reaction to mismatched blood. The first symptoms of transfusion reaction are a feeling of general discomfort and anxiety. Breathing difficulties, flushing, a sense of pressure in the chest, and back pain may develop. Evidence of a hemolytic reaction can be seen in the urine, which will be colored from the waste of destroyed red blood cells. Severe hemolytic reactions are occasionally fatal. Reactions to mismatches of minor factors are milder. These symptoms include itchiness, dizziness, fever, headache, rash, and swelling. Sometimes, the patient will experience breathing difficulties and muscle spasms. Most adverse reactions from mismatched blood are not life-threatening.

Although transfusions are often necessary, some studies have noted a poorer prognosis if transfusions are done before surgery for breast cancer , colon cancer , non-small cell lung cancer, and sarcomas . A National Institutes of Health (NIH) consensus was that transfusion before surgery should not be given simply to raise the hemoglobin level above 10g/dl. The growth factor erythropoietin may be used more in the future to decrease the need for red blood cell transfusions.

Resources

BOOKS

Berkow, Robert, ed. Merck Manual of Medical Information. New York: Pocket Books, 2000.

Dailey, J.F. Dailey's Notes on Blood, 4th ed. Arlington, MA:Medical Consulting Group, 2000.

Klein, H.G. Standards for Blood Banks and Tranfusion Ser vices, 17th ed. Bethesda, MD: American Association of Blood Banks, 1996.

Larson, D.E., ed. Mayo Clinic Family Health Book. New York:William Morrow and Company, Inc., 1996.

PERIODICALS

Cerhan, James R., R. Wallace, F. Dick, and others. "Blood Transfusions and Risk of Non-Hodgkin's Lymphoma Sub-types and Chronic Lymphocytic Leukemia." Cancer Epi demiology, Biomarkers, & Prevention 10, no. 4 (2001).

Mullon, J., et al. "Transfusions of Polymerized Bovine Hemo globin in a Patient With Severe Autoimmune Hemolytic Anemia." New England Journal of Medicine 342 (1 June 2000): 1666-8.

Pysz, Maciej. "Blood Transfusions in Breast Cancer Patients Undergoing Mastectomy: Possible Importance of Timing." Journal of Surgical Oncology 75, no. 4 (2000).

Rios, J.A., D.N. Korones, J.M. Heal, and others. "WBC-reduced blood transfusions and clinical outcome in children with acute lymphoid leukemia." Transfusion 41, no. 7 (2001).

OTHER

"Blood Product Donation and Transfusion." ACS Cancer Resource Center. 17 July 2001 <http://www3.cancer.org/cancerinfo>.

John T. Lohr Molly Metzler, R.N.

KEY TERMS

ABO blood groups

—A system in which human blood is classified by whether the red blood cells contain A or B antigens. Type A blood has the A antigen; type B has the B antigen, AB has both, and 0 has neither.

Antibody

—A simple protein produced by the body to destroy bacteria, viruses, or other foreign bodies. Production of each antibody is triggered by a specific antigen.

Antigen

—A substance that stimulates the immune system to manufacture antibodies (immunoglobulins). The function of antibodies is to fight off intruder cells, such as bacteria or viruses, in the body. Antigens stimulate the blood to fight other blood cells that have the wrong antigens. If a person with blood type A is given a transfusion with blood type B, the A antigens will fight the foreign blood cells as though they were an infection.

Immunoglobulin

—An antibody.

Infusion

—Introduction of a substance directly into a vein or tissue by gravity flow.

Injection

—Forcing a fluid into the body by means of a needle and syringe.

Rh (rhesus) factor

—An antigen present in the red blood cells of 85% of humans. A person with Rh factor is Rh positive (Rh+); a person without it is Rh negative (Rh-). The Rh factor was first identified in the blood of a rhesus monkey.

QUESTIONS TO ASK THE DOCTOR

• Am I a candidate for autologous transfusion?
• Am I a candidate for a directed donation?
• How often will I have blood work done to determine my hemoglobin and hematocrit levels?
• Can I get a stem cell transfusion at this facility if I need one?
• Is a blood transfusion necessary before I have surgery?