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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