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Leukoagglutinin Reactions
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Most transfusion reactions are not hemolytic but represent reactions to antigens present on white blood cells in patients who have been sensitized to the antigens through previous transfusions or pregnancy Most commonly, patients will develop fever and chills within 12 hours after transfusion In severe cases, cough and dyspnea may occur and the chest x-ray may show transient pulmonary infiltrates Because no hemolysis is involved, the hematocrit rises by the expected amount despite the reaction Leukoagglutinin reactions may respond to acetaminophen and diphenhydramine; corticosteroids are also of value Removal of leukocytes by filtration before blood storage will reduce the incidence of these reactions
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Rarely, patients will develop urticaria or bronchospasm during a transfusion These reactions are almost always due to plasma proteins rather than white blood cells Patients who are IgA deficient may develop these reactions because of antibodies to IgA Patients with such reactions may require transfusion of washed or even frozen red blood cells to avoid future severe reactions
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Rarely, blood is contaminated with gram-negative bacteria Transfusion can lead to septicemia and shock from endotoxin If this is suspected, the offending unit should be cultured and the patient treated with antibiotics as indicated
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Silliman CC et al Transfusion-related acute lung injury Blood 2005 Mar 15;105(6):2266 73 [PMID: 15572582] Slichter SJ et al Factors affecting posttransfusion platelet increments, platelet refractoriness, and platelet transfusion intervals in thrombocytopenic patients Blood 2005 May 15;105 (10):4106 14 [PMID: 15692069] Triulzi DJ Transfusion-related acute lung injury: an update Hematology Am Soc Hematol Educ Program 2006:497 501 [PMID: 17124105]
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mcL Leukocyte depletion of platelets has been shown to delay the onset of alloimmunization
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Granulocyte transfusions are seldom indicated and have largely been replaced by the use of myeloid growth factors (GCSF and GM-CSF) that speed neutrophil recovery However, they may be beneficial in patients with profound neutropenia (< 100/mcL) who have gram-negative sepsis or progressive soft tissue infection despite optimal antibiotic therapy In these cases, it is clear that progressive infection is due to failure of host defenses In such situations, daily granulocyte transfusions should be given and continued until the neutrophil count rises to above 500/mcL Such granulocytes must be derived from ABO-matched donors Although HLA matching is not necessary, it is preferred, since patients with alloantibodies to donor white blood cells will have severe reactions and no benefit The donor cells usually contain some immunocompetent lymphocytes capable of producing graft-versus-host disease in HLA-incompatible hosts whose immunocompetence may be impaired Irradiation of the units of cells with 1500 cGy will destroy the lymphocytes without harm to the granulocytes or platelets
TRANSFUSION OF PLASMA COMPONENTS
Fresh-frozen plasma is available in units of approximately 200 mL Fresh plasma contains normal levels of all coagulation factors (about 1 unit/mL) Fresh frozen plasma is used to correct coagulation factor deficiencies and to treat TTP The risk of transmitting viral disease is comparable to that associated with transfusion of red blood cells Cryoprecipitate is made from fresh plasma One unit has a volume of approximately 20 mL and contains approximately 250 mg of fibrinogen and between 80 and 100 units of factor VIII and vWF Cryoprecipitate is used to supplement fibrinogen in cases of congenital deficiency of fibrinogen or DIC One unit of cryoprecipitate will raise the fibrinogen level by about 8 mg/dL
CMDT 2008
Gastrointestinal Disorders
Kenneth R McQuaid, MD
SYMPTOMS & SIGNS OF GASTROINTESTINAL DISEASE DYSPEPSIA
Dyspepsia refers to acute, chronic, or recurrent pain or discomfort centered in the upper abdomen The discomfort may be characterized by or associated with upper abdominal fullness, early satiety, burning, bloating, belching, nausea, retching, or vomiting Heartburn (retrosternal burning) should be distinguished from dyspepsia Patients with dyspepsia often have heartburn as an additional symptom When heartburn is the dominant complaint, gastroesophageal reflux is nearly always present Dyspepsia occurs in 25% of the adult population and accounts for 3% of general medical office visits
The prevalence of H pylori-associated chronic gastritis in patients with dyspepsia without peptic ulcer disease is 20 50%, the same as in the general population
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