Blood TransfusionBrig Shabbir Rana

Human blood replacement therapy was accepted in the late nineteenth century

introduction of blood grouping by Dr. Karl Landsteiner, who identified the major A, B, and O groups in 1900

In 1939 Dr. Philip Levine and Dr. Rufus Stetson followed with the concept of Rh grouping

Background

Whole blood was considered the standard in transfusion until the late 1970s

Goal-directed component therapy

Serologic compatibility for A, B, O, and Rh groups is established routinely

Cross-matching between donors' red blood cells and recipients' sera (the major cross-match) is performed

Rh-negative recipients should receive transfusions only of Rh-negative blood

Typing and Cross-Matching

Human RBC have mainly 2 types of antigen ABO and Rhesus

Blood group O is universal donor and AB group is universal recipient

Rh antigen is strongly antigenic present in 85% of population

Typing and Cross-Matching

Rh negative group represents only 15% of the population

The administration of Rh-positive blood is acceptable if Rh-negative blood is not available

Rh-positive blood should not be transfused to Rh-negative females who are of childbearing age

Typing and Cross-Matching

In emergency situations, type O-negative blood may be transfused to all recipients

Patient with multiple transfusions developed alloantibodies, typing and cross-matching is often difficult

Sufficient time should be allotted preoperatively to accumulate blood that might be required during the operation

Up to 5 units can be collected for subsequent use during elective procedures

Patients can donate blood if their hemoglobin concentration exceeds 11 g/dL or if the hematocrit is >34%

The donation is performed 40 days before the planned operation and the last one is performed 3 days before the operation

Autologous transfusion

Donations can be scheduled at intervals of 3 to 4 days

Administration of recombinant human erythropoietin accelerates generation of red blood cells and allows for more frequent harvesting of blood

Autologous transfusion

Banked whole blood, once the gold standard, is rarely available

Shelf life is now around 6 weeks At least 70% of the transfused erythrocytes

remain in the circulation for 24 hours after transfusion and are viable

Banked Whole Blood

Changes in the red blood cells that occur during storage include reduction of intracellular ADP and 2,3-diphosphoglycerate

Alters the oxygen dissociation curve of hemoglobin and results in a decrease in oxygen transport

Clotting factors are relatively stable in banked blood except for factors V and VIII

Fresh whole blood refers to blood that is administered within 24 hours of its donation

Use of fresh whole blood may improve outcomes in patients with trauma-associated coagulopathy

Advantage to the use of fresh whole blood is that it provides greater coagulation activity than equal units of component therapy.

Fresh Whole Blood

Packed red blood cells are the product of choice for most clinical situations

Concentrated suspensions of red blood cells can be prepared by removing most of the supernatant plasma after centrifugation

This preparation reduces, but does not eliminate, reaction caused by plasma components

Packed Red Blood Cells

It also reduces the amount of sodium, potassium, lactic acid, and citrate administered

Each unit is approximately 330 ml and hematocrit of 50-70% stored in sag-m solution self life 5 wks at 4-6C

They are used for patients who are known to have been previously sensitized

Packed Red Blood Cells

freezing red blood cells viability is theoretically improved

ATP and 2,3-diphosphoglycerate concentrations are maintained

Frozen Red Blood Cells

Leukocyte-reduced and leukocyte-reduced/washed red blood cell products are prepared by filtration that removes approximately 99.9% of the white blood cells and most of the platelets

Saline washing (leukocyte-reduced/washed red blood cells). Leukocyte reduction prevents almost all febrile, reactions

Leukocyte-Reduced /Washed Red Blood Cells

Indications for platelet transfusion include thrombocytopenia caused by massive blood loss

Thrombocytopenia caused by inadequate platelet production

Qualitative platelet disorders shelf life of platelets is 120 hours from time

of donation

Platelet Concentrates

One unit of platelet concentrate has a volume of approximately 50 Ml

Platelet preparations are capable of transmitting infectious diseases and can provoke allergic reactions

Platelet are stored at 20-24C Prevention of HLA alloimmunization can be

achieved by leukocyte reduction through filtration

Platelet Concentrates

Fresh-frozen plasma (FFP) prepared from freshly donated blood is the usual source of the vitamin K–dependent factors

only source of factor V FFP has come to the forefront with the

inception of damage control resuscitation in patients with trauma-associated coagulopathy`

Fresh-Frozen Plasma

FFP is stored at -40---- -50C Shelf life is 2 yrs Ist line treatment of hemorrhage due to

coagulopathy

FFP

Human polymerized hemoglobin (PolyHeme) is a universally compatible

Immediately available, disease-free, oxygen-carrying resuscitative fluid

used in massively bleeding patients Advantages of an artificial oxygen carrier

include the absence of blood-type antigens (no cross-match needed)

Human Polymerized Hemoglobin (Polyheme)

No incidence of viral infections long-term stability, which allows prolonged

periods of storage Disadvantages include shorter half-life in the

bloodstream and the potential to increase cardiovascular complication

Oxygen-carrying capacity is primarily a function of the red blood cells

Transfusion of red blood cells should augment oxygen-carrying capacity

Hemoglobin is fundamental to arterial oxygen content and thus oxygen delivery

Indications for Replacement of Blood

Acute blood loss to replace circulating volume

Perioperative anaemia Symptomatic chronic anaemia without

hemorrhage

Indications for Replacement of Blood

Maintaining hemoglobin levels between 7 and 9 g/dL had no adverse effect on mortality

Patients with acute myocardial infarctions with ST elevation may, however, benefit from receiving red blood cell transfusions for anemia

Most common indication for blood transfusion in surgical patients is the replenishment of the blood volume

A healthy adult can lose up to 15% of total blood volume (class I hemorrhage or up to 750 mL) with only minor effects on the circulation

Volume Replacement

Loss of 15 to 30% of blood volume (class II hemorrhage or 750 to 1500 mL) is associated with tachycardia and decreased pulse pressure but, importantly, a normal blood pressure

Loss of 30 to 40% (class III hemorrhage or 1500 to 2000 mL) results in tachycardia, tachypnea, hypotension, oliguria, and changes in mental status

Volume Replacement

Class IV hemorrhage is loss of >40% of blood volume and is considered life-threatening

Loss of blood in the operating room can be evaluated by estimating the amount of blood in the wound and on the drapes

weighing the sponges, and quantifying blood suctioned from the operative field

In patients with normal preoperative values, blood loss of up to 20% of total blood volume can be replaced with crystalloid solution

LOSS OF BLOOD IN OR

Blood loss above this amount may require the addition of packed red blood cells

Transfusion of platelets and/or FFP may be indicated in specific patients before or during an operative procedure

Fresh-frozen plasma (FFP)  As soon as the need for massive transfusion is recognized. For every 6 units of red blood cells (RBCs), give 6 units of FFP (1:1 ratio). Platelets For every 6 units of RBCs and plasma, give one 6-pack of platelets

Component Therapy Administration during Massive Transfusion

CryoprecipitateAfter first 6 units of RBCs, check fibrinogen level. If ≤100 mg/dL, give 20 units of cryoprecipitate

Transfusion-related events are estimated to occur in approximately 10% of all transfusions

<0.5% are serious Transfusion-related deaths 0.5%

Complications of Transfusion

acute lung injury (16 to 22%), ABO hemolytic transfusion reactions (12 to

15%) Bacterial contamination of platelets (11 to

18%).

Transfusion complication

Defined as an increase in temperature >1°C associated with a transfusion and are fairly common

Approximately 1% of all transfusions Preformed cytokines in donated blood and

recipient antibodies reacting with donated antibodies are postulated causes

Febrile nonhemolytic reactions

Febrile reactions can be greatly reduced by the use of leukocyte-reduced blood products

Pretreatment with acetaminophen reduces the severity of the reaction

Bacterial contamination of infused blood is rareGram-negative organisms, especially

Yersinia enterocolitica and Pseudomonas species capable of growth at 4°C

Most cases, however, are associated with the administration of platelets that are stored at 20°C

Bacterial contamination results in sepsis and death in up to 25% of patients

Bacterial contamination

Clinical manifestations include systemic signs such as fever and chills, tachycardia

Hypotension, and GI symptoms (abdominal cramps, vomiting, and diarrhea)

If the diagnosis is suspected, the transfusion should be discontinued

The blood is send for culture

Emergency treatment includes administration of oxygen

Adrenergic blocking agents, and antibiotics Prevention includes avoidance of out-of-date

platelets

Allergic reactions are relatively frequent Reactions usually are mild and consist of

rash, urticaria, and fever occurring within 60 to 90 minutes of the start of the transfusion

Allergic reactions are caused by the transfusion of antibodies from hypersensitive donors or the transfusion of antigens to which the recipient is hypersensitive

Allergic Reactions

Treatment and prophylaxis consist of the administration of antihistamines

In more serious cases, use of epinephrine or steroids may be indicated.

Respiratory compromise may be associated with transfusion-associated circulatory overload

Occur with rapid infusion of blood, plasma expanders, and crystalloids, particularly in older patients with underlying heart disease

Central venous pressure monitoring should be considered whenever large amounts of fluid are administered

Respiratory Complications

Treatment consists of initiating diuresis Slowing the rate of blood administration Minimizing delivery of fluids while blood

products are being transfused

noncardiogenic pulmonary edema related to transfusion

It can occur with the administration of any plasma-containing blood product

Symptoms are similar to those of circulatory overload with dyspnea and associated hypoxemia

Transfusion-related acute lung injury

Accompanied by fever, rigors, and bilateral pulmonary infiltrates on chest radiograph

Commonly occurs within 1 to 2 hours after the onset of transfusion, but virtually always before 6 hours

Related to anti-HLA or anti–human neutrophil antigen antibodies in transfused blood that primes neutrophils in the pulmonary circulation

Treatment includes discontinuation of transfusion

Provision of pulmonary support

Acute hemolytic reactions occur with the administration of ABO-incompatible blood and are fatal in up to 6% of cases

Technical or clerical errors in the laboratory and administration of blood of the wrong blood type

Hemolytic reactions are characterized by intravascular destruction of red blood cells and consequent hemoglobinemia and hemoglobinuria

Hemolytic Reactions

DIC can be initiated activation of factor XII and complement by antibody-antigen complexes

Acute renal insufficiency

occur 2 to 10 days after transfusion Individual has a low antibody titer at the time

of transfusion but the titer increases after transfusion

Immunoglobulin G–mediated Pain at the site of transfusion, facial flushing,

and back and chest pain In anesthetized patients, diffuse bleeding and

hypotension are the hallmarks

Delayed hemolytic transfusion reactions

The Coombs' test usually yields a positive result

Urine output should be monitored and adequate hydration maintained to prevent precipitation of hemoglobin within the tubules

malaria, Chagas' disease, brucellosis Transmission of hepatitis C virus and HIV-1

has been dramatically minimized by the introduction of better screening for these pathogens

The infection rate for these pathogens is now estimated to be <1 per 1,000,000 units transfused

Transmission of Disease

Hepatitis B virus transmission may still occur in about 1 in 100,000 transfusions in nonimmune recipients

Hypocalcemia Hyperkalamia Hypothermia coagulopathy

Complication of massive transfusion