Blood product

BLOOD & PRODUCTS INDICATIONS RISK AND

COMPLICATIONS

Mallika SinhaMallika Sinha

ModeratorModerator

DR. VINOD KUMARDR. VINOD KUMAR

Introduction• Blood transfusion is a double edged sword, thus

transfuse only when benefits outweigh the risk.

• Restricted availability is the major limiting factor hence, use of blood component improve the overall economy of blood.

• Most of the associated complications are preventable!!

• Description - Increase haemoglobin by 1%

No functional platelets

No labile coagulation factors

• Indications– Acute blood loss with hypovolemia– Exchange transfusion– Red cell transfusion when red cell

concentrate/suspensions are not available.

• Contraindication– Chronic anemia – Incipient cardiac failure

Whole Blood

• Risk : Capable of transmitting any agent present in cells or plasma not detected by routine screening.

• Storage : Between +20C to +60C

35 days with CDPA.

• Administration– Must be ABO and Rh compatible – Transfusion should be started within 30 minutes .– Transfusion should completed within 4 hours of starting.– Medication should never be added to blood.

Whole Blood

• Effects of storage PH

K+

2,3DPG Platelets, platelet function lost by 48 hours. Coagulations factors (V & VIII)

Whole Blood

Adverse effects of transfusion• Acute complications

– Within 24 hours of transfusion

1. Mild reaction

2. Moderately severe reaction

3. Life threatening reactions

• Delayed complications of transfusion

– Transfusion transmitted infections

– Other delayed complications

• Iron overload (repeated transfusion recipients)

• Graft-Vs-host disease

• Delayed haemolytic reaction

Mild Reaction

• Signs –Localized cutaneous reactions:

– Urticaria

– Rash

• Symptoms –

– Pruritus (itching):

• Possible cause –

– Hypersensitivity (mild):

Adverse effects of transfusion

Category 2 – Moderately severe

• Signs –: Flushing, Urticaria, Rigors, Fever,

Restlessness, Tachycardia

• Symptoms – Anxiety, Pruritus, Palpitation,

Mild Dyspnoea, Headache

• Possible cause –

Hypersensitivity (moderate - severe)

Febrile non haemolytic transfusion reactions:

1. Antibodies to WBC & Platelets.

2. Antibodies to proteins including IgA

Possible contamination with pyrogens and/or bacteria

Adverse effects of transfusion

Management of Moderately Severe Reaction

Stop transfusion

Maintain vitals

Antihistamines

Corticosteroids + bronchodilators

(if anaphylactoid features)

If clinical improvement

Yes No Restart Treat as category 3

Category 3 – Life threatening reaction

Adverse effects of transfusion

• Signs –: Rigors, Fever, Restlessness, Tachycardia (>20%), Hypotension (>20%), Haemoglobinuria, Unexplained bleeding (DIC)

• Symptoms – Anxiety, Chest Pain, Pain near infusion site, Respiratory distress, Loin/Back pain, Dyspnoea, Headache.

• Possible cause –

Acute intravascular haemolysis

Bacterial contamination and septic shock

Fluid overload,

Anaphylaxis,

Transfusion associated lung injury.

Management of Life threatening reaction

Stop transfusion

Maintain vitals / airway / oxygen

adrenaline

Diuretics

Corticosteroids + bronchodilators

(if anaphylactoid features)

Management of Life threatening reaction contd…

• Notify doctor & blood bank • Fluid balance charting• Close observation • Watch for the signs of

– DIC

– Hypotension

– Endotoxemia

– Renal failure

When to transfuse if transfusion reaction occurs?

• Mild reaction – – Transfuse slowly with antihistamines

• Moderate reaction – Transfuse new blood unit with close

observation

• Life threatening reactions– Clinical improvement + coombs test

Transfusion transmitted infections

• HIV-1 And HIV-2

• HTLV-1 and II

• Viral hepatitis B and C

• Syphilis

• Malaria

• Chagas disease

• Cytomegalovirus(CMV)

• Other rare infections e.g. Human Parvovirus B19 and hepatitis A

Adverse effects of transfusion

Massive Blood transfusion

Adverse effects of transfusion

• Complications –– Alkalosis– Hyperkalaemia– Citrate toxicity and hypocalcaemia– Depletion of fibrinogen and coagulation factors – Depletion of Platelets.– Disseminated intravascular coagulation (DIC)– Hypothermia 2,3,DPG– Microaggregates

Blood Products Whole blood

Red cell component

Platelet component

Plasma products

Component derivatives

Red cell concentrate

Single donation unit

Fresh frozen plasma

Albumin

Red cell suspension

Pooled unit Liquid plasma Coagulation factors

Buffy coat depleted red cells

Single donor apheresis product (SDAP)

Cryoprecipitate immunoglobulin

Leucocyte depleted red cells

Cryo poor plasma

Viral inactivated plasma

Red Cell Concentrate/Suspension• Description –

150-200 ml Red cell (Plasma removed)

Suspension with added diluent

1 unit increases haemoglobin by 1.5 – 2% • Risk – Same as whole blood• Storage - +20C – +60C• Indications- Severe chronic anemia

- With crystalloids/colloids in Acute blood loss.

- Hypoplastic anemia

- Hemolytic anemia specially in aplastic crisis

Red Cell Concentrate/Suspension

Administration – To improve transfusion flow normal saline (50-100ml) given with Y-pattern giving set.

• Advantages – Less blood group antibody so, ‘O’ negative blood or

(group non specific) can be given.– Less anaphylactic reactions (less plasma proteins)

Red Cell Components

Composition Whole blood Red cell concentrate (PRBC)

Red cell suspension

Preparation Separate plasma at 2-60C under gravity/centrifugation

Separate plasma and add additive soln. E.g. ADSOL

1 unit increase Hb by 1% 1.5-2% 1.5-2%

Packed red cells(ml) 120-250 120-250 120-250

Maximum storage time at 2-60C

21 days: CPD 35 days:CPDA

21 days:CPD

35 days: CPDA

42 days-ADSOL

Advantages Easy to prepare Low viscosity, more shelf life

Disadvantages High viscosity Expensive

Leucocyte-depleted Red Cells• Description –

– Red cell suspension/concentrate with <5 x 106 white cells per bag by using leukocyte filters.

– No risk of CMV transmission.

• Risk – Same as whole blood• Indications-

– Patients requiring repeated transfusion– Patients > 2 previous febrile reactions to red cell

transfusion. • Administration – Pre storage filtration should be done.• Alternative – Buffy coat depleted red cells.

Buffy coat depleated red blood cells

• Buffy coat = white cells + platelets + Debris.– Interface between red cells and plasma.

• Description – – Red cell suspension with <5 x 108 white cells per pack,

• Advantage – – Prevents Febrile Non-hemolytic Transfusion Reaction

(FNHTR).– Platelets cant be harvested Buffy Coat

• Indications- – Same as red blood cells.

Platelet Concentrate (Random Donor Platelets• Description –

– Derived from single blood donation – 65-80ml– At least 55 x 109 Platelets – <1.2 x 109 red cells (No visible RBC contamination)

– Single donor Unit, Pooled Unit• Risk – Same as whole blood, Bacterial contamination in 1%

• Adult dose – 4-6 donor exposures,

• Dosage – 1 unit/10kg body weight

• Storage – 20-240C(with agitation) for upto 5 days.– Longer storage – Bacterial proliferation and septicemia.

• Administration – – Patients requiring multiple platelets transmission – set with lecuocyte filters.– No crossmatching required .– Platelets don’t carry Rh antigen.– Group specific platelets desired.

Guidelines for platelet transfusions• Adults –

a. Non bleeding patients with failure of platelet production.a. Platelet count <15,000/lb. Invasive procedure with platelet count <50,000/l

b. Bleeding patients.a. DIC with platelet count <50,000/l b. Massive transfusion and platelet count (<50,000/l)c. Active bleeding and platelet counts –20 –x 1011/L.d. Diffuse bleeding following cardiopulmonary bypass

and platelets and count not available or < 1,00,000/le. Platelet function defect

Fresh Frozen Plasma• Description –

– Contains stable coagulation factors, albumin & immunoglobulin– Factor VIII – Fibrinogen 150-230mg

• Dosage : 15ml/kg body weight

• Risk – In untreated, same as whole blood

Methylene blue/ultraviolet light inactivation – very low risk

• Storage – <-250C for upto 1 year

• Indications - Multiple coagulation factor deficiency in : Liver disease, Massive blood transfusion, Oral anticoagulants over

dose

DIC and TTP

• Administration – – Should be ABO compatible, No cross matching required. – Before use, thawing should be done in water at 30-370 C.

– Once thawed should be used within 6 hours

• Precaution – Acute allergic reaction with rapid infusion.

• Hypovolemia alone is not an indication for use.

Cryoprecipitate• Description –

– Contains factor VIII 80-100 I.U. Fibrinogen 150-300mg and Von Willebrand factor.

• Dosage : Depend on severity, normally 4-6 packs repeated 12 hourly

• Risk – Same as plasma.

• Storage – <-300C for upto 1 year

• Indication – As an alternative to factor VIII concentrate in – Von Willebrand disease

– Hemophillia A

– Factor XIII deficiency

– Fibrinogen deficiency e.g. DIC

• Administration – – Infuse as soon as possible after thawing

– Must be infused within 6 hrs after thawing

– No compatibility testing required, Use ABO compatible product.

Cryo Poor Plasma• Description –

– Plasma after removing cryoprecipitate deficient in factor VIII and fibrinogen but contains all other plasma constituents.

• Risk – Same as whole blood.

• Indication – – For volume replacement – As replacement fluid in exchange transfusion– As a source of plasma proteins

Human Albumin Solution• Prepared by fractionation of large pools of donated human

plasma.– Albumin 5% contains 50mg/ml of albumin

• Risk – No risk of viral infections.

• Indications – – Replacement fluid in therapeutic plasma exchange : albumin 5%

– Treatment of diuretic resistant oedema in hypoproteinemia : Nephrotic syndrome or ascites : albumin 20% with diuretic

– Burn and hypoalbuminaemia & volume replacement albumin 5%.

• Contraindications – • Not use for IV nutrition.

• Precautions - • Risk or pulmonary oedema with albumin 20%.

Apheresis blood Components

• Advantages–

– Adequate adult dose from single donor.

– Reduced donor exposure

– Reduced bacterial contamination, specially in platelets

– Low chances of refractoriness to blood components.

Irradiated Blood Components

• Radiation dose 15 - 25Gy

• Indications–

– Bone marrow transplant patients.

– Premature new born.

– Haematological malignancies

– Peripheral blood progenitor cell transplant patients.

– Intrauterine transfusion.

Autologous Blood Transfusion

• Preoperative donation of blood– 2 or more units blood are drawn and stored prior to

anticipated need.

• Intra-operative blood collection.– Blood is collected prior to or during surgery.

• Perioperative hemodilution (Acute normo volemic hemodilution)

– 1 or 2 units drawn before surgery concomitant replcement with crystalloid/colloid.

• Intraoperative blood– Blood is collected (SALVAGE) from the surgical field, then

processed and then returned.

• Post operative blood collection

Guidelines for use of blood/blood products in surgery & haemorrhage

• Blood/Blood products should only be infuse if other modes of therapy have been proven ineffective and if benefits outweigh the risk.

• Average healthy adult can withstand loss of 10% blood volume.

• Average healthy adult can afford 20% blood loss without any ill effect, if circulatory blood volume is maintained.

• Proper assessment and management of patients required before surgery.

• Autologous blood transfusion should be used wherever appropriate.

• Adopt policy of Blood sparing techniques .

• Obtain typing and screening in all elective surgical cases

SummaryPacked red cells or suspension

Platelet concentrate FFP Cryoprecipitate

Contents Hb 20 g/100 ml Platelet

No visible RBC contamination

Stable coagulation factors + plasma proteins

Factor VIII

vW

Factor XIII

Fibrinogen

Dosage 10 ml/kg 1 unit/10 kg 10-15 ml/kg 5-10 ml/kg

Storage Temp 2 to 60C 20-240C with agitation

-300C -300C

TIME FOR INFUSION

Start 30 mins As soon as possible

Infuse as soon as possible after thawing -do-

Completion 4 hrs 4 hrs 6 hrs -do-

Shelf life 35 days

42 days with Adsol

5 days 1 yr 1 yr

Improvement Hb by 1.5-2% 10% count5000-10000 platelets

Coagulation factor by 2%

Synthetic Oxygen Carriers• Perfluorocompounds

– Fluosol-DA– Oxygent

• Stroma Free Haemoglobin• Stroma Free Hb products

– Hemassist (Diaspirin-crosslinked Hb) (DCL Hb)– Optro (recombinant Hb) rHb1.1– Liposome – encapsulated Hb (LEH)– Hemopure (Hb OC-201)– PolyHeme (Poly-SFH)– Polyethylene glycol (PEG) Hb– Hemolink

Conclusion

• Appropriate use of blood/blood products should be done.

• Transfusion carries risk of adverse reactions and transfusion transmissible infections.

• Need of blood transfusion can be avoided by-– Prevention/early diagnosis and treatment of anaemia– Correction of anaemia and the replacement of

depleted iron stores before planned surgery.– Use of simple alternatives to transfusion.– Good anaesthetic and surgical management.

Thanks