Immune Serum Globulin

Immune serum globulin is a concentrate of plasma gamma globulins in an aqueous solution. It is prepared from pooled plasma by cold ethanol fractionation. Preparations are in the form of intravenous (IV) or intramuscular (IM) solutions. The IV preparation generally contains more IgG protein than the IM preparation, with a half-life of 18 to 32 days. Immune globulin preparations are indicated for patients with immunodeficiency diseases (i.e. severe combined immunodeficiency and Wiskott-Aldrich syndrome) and for providing passive antibody prophylaxis against hepatitis and herpes. IVIg is also used in patients with idiopathic thrombocytopenic purpura, post-transfusion purpura, HIV-related thrombocytopenia, and neonatal alloimmune thrombocytopenia. Individuals with a history of IgA deficiency or anaphylactic reactions should not receive immune globulin because of the presence of trace amounts of IgA. Whereas there are no documented cases of HIV or Hepatitis B transmission, transmission of hepatitis C has been reported with IVIg preparations. This has led to preparations of immune globulin treated with solvent/detergent for viral inactivation.

NSA
NSA is prepared from salvaged plasma, pooled and fractionated by a cold alcohol process, then treated with heat inactivation (60_C for 10 hours), which removes the risk of hepatitis or HIV infection. It is composed of 96 percent albumin and 4 percent globulin. It is available in 25 percent or 5 percent solutions. NSA is indicated in patients who are hypovolemic and hypoproteinemic and in clinical settings of shock and burn patients. The 25 percent preparation is contraindicated in patients who are dehydrated, unless it is followed with crystalloid infusions (e.g., normal saline) for volume expansion.

Plasma Protein Fraction

The preparation of plasma protein fraction (PPF) is similar to that of NSA, with fewer purification steps. PPF contains 83 percent albumin and 17 percent globulins. PPF is available in a 5 percent preparation; its uses parallel that of NSA. PPF, however, is contraindicated for infusion during cardiopulmonary bypass procedures. Both PPF and NSA can be stored for 5 years at 2_ to 10_C and have not been reported to transmit HIV or hepatitis.

Rho(D) Immune Globulin

Rh immunoglobulin (RhIg) is a solution of concentrated antiRho(D). It is prepared from pooled human plasma of patients who have been hyperimmunized and contains predominantly IgG anti-D. RhIg has two primary uses: treatment of ITP and prevention of Rh HDN. The FDA has approved two doses for treatment of ITP and immunization against the D antigen: a 120-_g dose and 300_g dose.106,107 These are IV preparations that have been heattreated. An IM preparation is available as a 50-_g dose and a 300-_g dose. The latter is considered a full dose protective against 15 mL of D-positive RBCs. In preventing immunization to the D antigen during gestation, a number of scenarios with varying dosages apply. During the first 12 weeks of pregnancy, a 50-_g

dose of RhIg is indicated for D-negative females for abortion or miscarriage. After 12 weeks gestation, a full dose (300 _g) is indicated for abortion or miscarriage in Dnegative women. The 120-_g dose is advised after 34 weeks gestation when amniocentesis is performed or in the event of obstetric complication or following termination of pregnancy. An antepartum dose (300 _g IM or IV) should be given to nonimmunized D-negative females at 28 weeks gestation. Following delivery, a postpartum blood sample is drawn from the mother. The sample undergoes a screening test for fetomaternal hemorrhage (FMH) in which D-positive RBCs from the newborn are detected. Additionally, the newborns Rh status is determined. If the newborn is D-positive or if the Rh type cannot be determined on the newborn (i.e., positive DAT), the mother should receive a full dose of RhIg unless she has demonstrated previous active immunization to the D antigen. If the screening test is negative for the presence of Dpositive RBCs of fetal origin, the mother should receive a full dose of RhIg within 72 hours of delivery. If the screening test is positive, the FMH must be quantified using the KleihauerBetke test. RhIg is also used in the event Rh-positive components are transfused to Rh-negative patients. A 300-_g dose IM (120-_g dose IV) is sufficient to protect against D-positive RBCs contained in 10 units of random platelets.

Synthetic Volume Expanders

There are two categories of the synthetic volume expanders: crystalloids and colloids. Ringers lactate and normal isotonic saline comprise the crystalloids, and dextran and HES make up the colloid solutions. Normal saline consists only of sodium and chloride ions; Ringers lactate consists of sodium, chloride, potassium, calcium, and lactate ions. These solutions are useful in burn patients because of their ability to rapidly cross the capillary membrane and