Blood Tranfusion Therapy

Blood transfusion Blood transfusion therapytherapy

RENE PSA MENDOZA, MD, MHSARENE PSA MENDOZA, MD, MHSA

Associate Professor, Department of SurgeryAssociate Professor, Department of Surgery

FEU-NRMF Institute of MedicineFEU-NRMF Institute of Medicine

Functions and Properties of Blood A vehicular organ that perfuses

all other organs Blood and interstitial fluid deliver

nutrients to cells and remove wastes

Hemostatic governors are carried to and from appropriate sites

Functions of Blood

Transport:– suspended cells include rbc that

carry O2– Platelets that contributes to the

hemostatic process– chemicals dissolved in plasma

(nutrients, waste, hormones, etc)– metabolic heat for disposal

Functions of Blood

Regulation: – plasma contains pH buffers– plasma water absorbs heat– plasma solutes maintain osmolality

Functions of Blood

Protection: – plasma precursor proteins form

blood clot when stimulated– suspended wbc attack bacteria and

viruses ( body’s defense )– plasma contains antibodies and

opsonins for immunity

Fluid compartmentsFluid compartments

ICF

ECF

Interstitial

Pla

sma

Capillary Membrane Cell Membrane

~ 15% of

body weight

~ 40% of body weight

~ 5% of body weight

Blood volume

plasma + cells and cell fragments

~ 5% ~ 2-3% of body weight +

Banked Whole bloodBanked Whole blood

No components have been No components have been removed.removed.

consists of red blood cells, white consists of red blood cells, white blood cells and platelets in blood cells and platelets in plasmaplasma

can be stored for 5 weekscan be stored for 5 weeks


Transfusions of whole blood are Transfusions of whole blood are rarely required.rarely required.

stored in the refrigeratorstored in the refrigerator, the , the platelets are useless and factors platelets are useless and factors V and VIII are greatly reduced. V and VIII are greatly reduced.


transfusion of whole blood may transfusion of whole blood may be necessary be necessary – certain types of major surgery certain types of major surgery

ACUTE BLOOD LOSS > 15%ACUTE BLOOD LOSS > 15%

– major trauma such as a car accident major trauma such as a car accident or gunshot wound requiring or gunshot wound requiring emergency surgeryemergency surgery

Changes in rbc Changes in rbc

Reduction Reduction – pH from 7.00 to 6.68pH from 7.00 to 6.68– 2,3 DPG2,3 DPG– Intracellular ADPIntracellular ADP oxygen transportoxygen transport

Poor source Poor source – PlateletsPlatelets– clotting factors V and VIIIclotting factors V and VIII

Changes in rbcChanges in rbc

Increase levels Increase levels – Lactic acid from 20 to 150mg/dlLactic acid from 20 to 150mg/dl– Potassium concentration to 32 Potassium concentration to 32

mEq/dlmEq/dl– Ammonium concentration from Ammonium concentration from

50 to 680 mg/dl 50 to 680 mg/dl Hemolysis is insignificantHemolysis is insignificant

Fresh whole bloodFresh whole blood

Blood that is administered within Blood that is administered within 24 hours of its donation24 hours of its donation

Rarely indicatedRarely indicated Poor source of platelets and Poor source of platelets and

factor VIIIfactor VIII

Blood Component Blood Component TherapyTherapy The process of transfusing only that The process of transfusing only that

portion of the blood needed by the portion of the blood needed by the patient patient

It allows a single unit (one pint) of It allows a single unit (one pint) of donated blood to benefit more than donated blood to benefit more than one patientone patient

Red blood cells and platelets are the Red blood cells and platelets are the most frequently transfused blood most frequently transfused blood componentscomponents

Packed red cellsPacked red cells

The red cells from a donor unit, The red cells from a donor unit, diluted with plasma to a diluted with plasma to a hematocrit of about 75%. hematocrit of about 75%.

Volume is about 200 mL. Volume is about 200 mL. Storing red cells (just above Storing red cells (just above

freezing) allows survival for 42 freezing) allows survival for 42 daysdays– but unfortunately decreases 2,3-DPGbut unfortunately decreases 2,3-DPG– ruins the platelets and neutrophils.ruins the platelets and neutrophils.


Red blood cells contain Red blood cells contain hemoglobinhemoglobin– carries oxygen throughout the body.carries oxygen throughout the body.– Essentially provides oxygen-carrying Essentially provides oxygen-carrying

capacity capacity Product of choice for most clinical Product of choice for most clinical

situations situations


Recent advances have made it Recent advances have made it possible to store red blood cells possible to store red blood cells for up to 42 days. for up to 42 days.

IndicationsIndications– acute trauma before surgery acute trauma before surgery – people with anemia who are having people with anemia who are having

surgerysurgery


fastest way to increase the fastest way to increase the oxygen-delivering capacity of the oxygen-delivering capacity of the blood. blood.

A unit of whole blood or packed A unit of whole blood or packed red cells will red cells will raise the hematocrit raise the hematocrit by 3%by 3% and the and the hemoglobin by 1-hemoglobin by 1-1.5 gm/dL1.5 gm/dL

Frozen red cellsFrozen red cells

reduces the risk of infusing reduces the risk of infusing antigens, or foreign bodies, that antigens, or foreign bodies, that the body might regard as the body might regard as potentially dangerouspotentially dangerous– Previously sensitized patientsPreviously sensitized patients

Not available for use in emergency Not available for use in emergency situationssituations

Rbc viability is improvedRbc viability is improved ADP and 2,3 DPG maintainedADP and 2,3 DPG maintained

Platelet concentratesPlatelet concentrates

Component: platelets, 50 ml Component: platelets, 50 ml plasmaplasma

cellular components that help in cellular components that help in the clotting process. the clotting process.

Platelets are stored for up to five Platelets are stored for up to five days at room temperature.days at room temperature.


IndicationIndication– used if there is a platelet disorder used if there is a platelet disorder – when massive blood loss has when massive blood loss has

occurredoccurred


Platelets must be stored at room Platelets must be stored at room temperature, so are good only for 5 temperature, so are good only for 5 days or less.days or less.

One unit will usually raise the platelet One unit will usually raise the platelet count 5-10k/microliter. count 5-10k/microliter.

Check one hour after transfusion. Check one hour after transfusion. – If the platelet count does not increase as If the platelet count does not increase as

expected (“refractoriness”), suspect DIC or expected (“refractoriness”), suspect DIC or immune platelet destruction (anti-HLA).immune platelet destruction (anti-HLA).

Fresh frozen plasmaFresh frozen plasma

From freshly donated bloodFrom freshly donated blood Source of vit k- dependent Source of vit k- dependent

clotting factorsclotting factors Only source of factor VOnly source of factor V

Fresh Frozen PlasmaFresh Frozen Plasma

IndicationIndication– For coagulopathy and deficient For coagulopathy and deficient

clotting factorsclotting factors 1 unit FFP = 3% increase in CF levels1 unit FFP = 3% increase in CF levels At least 30% to ensure adequate At least 30% to ensure adequate

coagulationcoagulation

Cryoprecipitated Cryoprecipitated antihemophilic factorantihemophilic factor an antihemophilic concentratean antihemophilic concentrate prepared from plasma and is rich prepared from plasma and is rich

in clotting factors in clotting factors used in people with hemophilia, used in people with hemophilia,

von Willebrand's disease or other von Willebrand's disease or other major coagulation abnormalities major coagulation abnormalities to prevent or control bleedingto prevent or control bleeding

Cryoprecipitated Cryoprecipitated antihemophilic factorantihemophilic factor Its contents are the major portion Its contents are the major portion

of the Factor VIII, von Willebrand of the Factor VIII, von Willebrand factor, fibrinogen, Factor XIII and factor, fibrinogen, Factor XIII and fibronectin present in fibronectin present in freshly freshly drawn and separated plasmadrawn and separated plasma. .

Replacement therapyReplacement therapy

Serologic compatibilitySerologic compatibility– A, B, O and Rh groups A, B, O and Rh groups

CrossmatchingCrossmatching– Donors’ red cell and Recipients’ seraDonors’ red cell and Recipients’ sera

Major crossmatchMajor crossmatch

Serologic compatibilitySerologic compatibility

Rh groupsRh groups

Rh negative recipients should be Rh negative recipients should be transfused with Rh negative bloodtransfused with Rh negative blood

Rh negative group Rh negative group – – 15% of the population15% of the population– Limited supplyLimited supply

A 50M pedestrian was hit by a car A 50M pedestrian was hit by a car while crossing Commonwealth Ave. while crossing Commonwealth Ave. He sustained blunt trauma to the He sustained blunt trauma to the pelvis and an open femoral fracture pelvis and an open femoral fracture on the L. At the ER, BP 90/50 HR 110 on the L. At the ER, BP 90/50 HR 110 RR 28 with an estimated blood loss RR 28 with an estimated blood loss of 1L.of 1L.

The initial resuscitation fluid isThe initial resuscitation fluid is– A. Whole bloodA. Whole blood– B. packed RBCB. packed RBC– C. Plain Lactated RingersC. Plain Lactated Ringers– D. DextranD. Dextran

After 2L of crystalloids, the BP 90/60After 2L of crystalloids, the BP 90/60

HR 120 RR 32. The SROD decided to HR 120 RR 32. The SROD decided to give blood. What is the best blood give blood. What is the best blood product to administer?product to administer?– A. Fresh Whole BloodA. Fresh Whole Blood– B. packed RBCB. packed RBC– C. plasma expanders C. plasma expanders – D. plateletsD. platelets

Parameter Class I Class II Class III Class IV

blood loss in mL

<= 750 mL 750 − 1,500 mL

1,500 − 2,000 mL

>= 2,000 mL

blood lossas % TBV

<= 15% 15 − 30% 30 − 40% >= 40%

pulse > 100 > 100 > 120 >= 140

blood pressure

normal normal decreased decreased

capillary refill

normal delayed delayed delayed

respirations 14 − 20 20 − 30 30 − 40 > 35

urine output >= 30 mL/h

20 − 30 mL/h

5 − 10 mL/h minimal

mental status

slightly anxious

mildly anxious

anxious and confused

confused and

lethargic

A CT scan of abdomen was done with A CT scan of abdomen was done with findings of Grade 2 renal injury, L findings of Grade 2 renal injury, L with incomplete fracture, L iliac. He with incomplete fracture, L iliac. He underwent ORIF, L femur and placed underwent ORIF, L femur and placed on complete bed rest. He was on complete bed rest. He was transfused 2 ‘u’ WB and 4 ‘u’ pRBC. transfused 2 ‘u’ WB and 4 ‘u’ pRBC.

What are the possible complications What are the possible complications of blood transfusion?of blood transfusion?

Risks from a unit of Risks from a unit of ordinary red cellsordinary red cells Non-hemolytic febrile transfusion Non-hemolytic febrile transfusion

reaction: reaction: 1-5%1-5% Minor allergic: Minor allergic: 1-2%1-2% Real anaphylaxis: Real anaphylaxis:

– maybe 1 in ~20,000; fatality rate maybe 1 in ~20,000; fatality rate unknownunknown

Transfusion reactionsTransfusion reactions

Hemolytic ReactionsHemolytic Reactions Allergic ReactionsAllergic Reactions Febrile ReactionsFebrile Reactions Bacterial ContaminationBacterial Contamination Circulatory OverloadCirculatory Overload HypothermiaHypothermia

Transfusion reactionsTransfusion reactions

Alloimmunization Alloimmunization Graft Versus Host Disease Graft Versus Host Disease

(GVHD)(GVHD) Transfusion related acute Transfusion related acute

lung injury (TRALI)lung injury (TRALI)

Allergic / urticarial Allergic / urticarial transfusion reactionstransfusion reactions most common usually due to most common usually due to

allergies to specific proteins in allergies to specific proteins in the donor’s plasma the donor’s plasma

can be avoided with future can be avoided with future transfusions by pretreatment with transfusions by pretreatment with antihistamines or steroids. antihistamines or steroids.

Allergic / urticarial Allergic / urticarial transfusion reactionstransfusion reactions Some get “hay fever / hives / Some get “hay fever / hives /

wheezing” from transfusionswheezing” from transfusions– you can continue the transfusion you can continue the transfusion

when they are betterwhen they are better– and in the future, pre-treat with an and in the future, pre-treat with an

antihistamine. antihistamine.

Allergic / urticarial Allergic / urticarial transfusion reactionstransfusion reactions For severe (anaphylaxis), RBC’s For severe (anaphylaxis), RBC’s

and platelets are washed to and platelets are washed to remove all plasma indicated. remove all plasma indicated. – Very fast, spectacular illness after Very fast, spectacular illness after

transfusion only a few mL. transfusion only a few mL. – IgA deficiency should be considered IgA deficiency should be considered

in the case of anaphylactic in the case of anaphylactic reactions.reactions.

Hemolytic ReactionsHemolytic Reactions

transfusion of an incompatible transfusion of an incompatible blood component. blood component.

Most are due to naturally Most are due to naturally occurring antibodies in the ABO occurring antibodies in the ABO antigen system and Rh groupsantigen system and Rh groups

may cause hemoglobin induced may cause hemoglobin induced renal failure and a consumptive renal failure and a consumptive coagulopathy (DIC). coagulopathy (DIC).

Immediate hemolytic Immediate hemolytic transfusion reactiontransfusion reaction 1 in ~25,000 units; fatality rate 1 in ~25,000 units; fatality rate

10% 10% A disaster, almost always A disaster, almost always

preventable. preventable. Most often due to Most often due to ABO mismatch ABO mismatch

due to a clerical errordue to a clerical error (i.e., the (i.e., the wrong blood and/or the wrong wrong blood and/or the wrong recipient).recipient).

Clinical presentationClinical presentation

fever, hypotension, nausea, fever, hypotension, nausea, vomiting, tachycardia, dyspnea, vomiting, tachycardia, dyspnea, chest or back pain, flushing and chest or back pain, flushing and severe anxiety severe anxiety

pain at the infusion site pain at the infusion site Post-op site:Post-op site: diffuse bleeding diffuse bleeding

hypotensionhypotension

Intravascular destruction of RBCIntravascular destruction of RBC

HemoglobinemiaHemoglobinemiafree hemoglobin in the serumfree hemoglobin in the serum

Hemoglobinuria Hemoglobinuria may be noted and, may be the may be noted and, may be the first sign of hemolysis first sign of hemolysis


Renal toxicityRenal toxicity

Precipitation of free hemoglobin in Precipitation of free hemoglobin in the tubulesthe tubules

Acute tubular necrosisAcute tubular necrosis

DICDIC

In the circulation, Ag-Ab complexesIn the circulation, Ag-Ab complexes

Activates complement system, Activates complement system,

factor XIIfactor XII

DICDIC

TreatmentTreatment

Stop the transfusion Stop the transfusion Keep the vein open by running in salineKeep the vein open by running in saline Draw your post-transfusion samplesDraw your post-transfusion samples check the urine for hemoglobincheck the urine for hemoglobin notify the blood banknotify the blood bank Save the untransfused blood. Save the untransfused blood. Give mannitol to keep the kidneys openGive mannitol to keep the kidneys open monitor for DIC.monitor for DIC. fluids, diuresis and transfusion support for fluids, diuresis and transfusion support for

bleedingbleeding

patient’s identification patient’s identification checked..checked.. repeat crossmatch, bacterial culturerepeat crossmatch, bacterial culture most errors are clerical or due to most errors are clerical or due to

misidentification of a patient at the misidentification of a patient at the bedside. bedside.

mislabelled specimen sent to the blood mislabelled specimen sent to the blood bank bank

A fatal hemolytic transfusion reaction A fatal hemolytic transfusion reaction occurs about once in 100,000 occurs about once in 100,000 transfusionstransfusions

DO NOT ASSUME IT IS SOMEONE DO NOT ASSUME IT IS SOMEONE ELSE'S RESPONSIBILITY TO CHECK!ELSE'S RESPONSIBILITY TO CHECK!

Laboratory criteria Laboratory criteria

Free hemoglobin > 5mg/dlFree hemoglobin > 5mg/dl Serum haptoglobulin of > 50 Serum haptoglobulin of > 50

mg/dlmg/dl Serologic criteriaSerologic criteria

– INCOMPATIBILITY OF THE DONOR INCOMPATIBILITY OF THE DONOR THE RECIPIENTTHE RECIPIENT

Positive Coombs’ testPositive Coombs’ test

Delayed hemolytic Delayed hemolytic transfusion reactions transfusion reactions 1 in ~6000; fatality rate 0.1% 1 in ~6000; fatality rate 0.1% previously sensitized to an previously sensitized to an

antigen through transfusion or antigen through transfusion or pregnancypregnancy

can result in symptomatic or can result in symptomatic or asymptomatic hemolysis several asymptomatic hemolysis several days (2-10 days) after a days (2-10 days) after a subsequent transfusion subsequent transfusion

Delayed hemolytic Delayed hemolytic transfusion reactionstransfusion reactions Not preventable. Not preventable. A new antibody or anamnestic A new antibody or anamnestic

response has probably developed. response has probably developed.


Extravascular hemolysis, mild Extravascular hemolysis, mild anemia, indirect hemoglobinemiaanemia, indirect hemoglobinemia

These present with flu-like These present with flu-like symptoms recurrent anemia and symptoms recurrent anemia and jaundicejaundice

Delayed hemolytic Delayed hemolytic transfusion reactionstransfusion reactions Most frequent: Transfusion of Rh Most frequent: Transfusion of Rh

positive red blood cells to an Rh positive red blood cells to an Rh negative woman of childbearing negative woman of childbearing age can result in sensitization and age can result in sensitization and hemolytic disease of the newborn hemolytic disease of the newborn in future pregnancies.in future pregnancies.

Febrile nonhemolytic Febrile nonhemolytic transfusion reactiontransfusion reaction Defined to be a rise in temperature of Defined to be a rise in temperature of

1 1 °°C or more and >=38 C or more and >=38 °°C, within 24 C, within 24 hours of transfusionhours of transfusion

without evidence of a hemolytic without evidence of a hemolytic transfusion reaction. transfusion reaction.

due to cytokines in the blood itself due to cytokines in the blood itself and/or produced in the patient from and/or produced in the patient from sensitivity to the HLA molecules on sensitivity to the HLA molecules on platelets and white cells. platelets and white cells.

Febrile transfusion Febrile transfusion reactionsreactions usually occur due to sensitization usually occur due to sensitization

to antigens on cell components, to antigens on cell components, particularly leukocytes.particularly leukocytes.

chills and a temperature risechills and a temperature rise 60-90 mins after transfusion60-90 mins after transfusion

Bacterial Bacterial contamination contamination RareRare Acquired from contaminated collection Acquired from contaminated collection

bagsbags Poor cleaning of donor’s skinPoor cleaning of donor’s skin reactions are quite severe with high reactions are quite severe with high

feverfever rigors and/or other systemic symptoms rigors and/or other systemic symptoms

such as hypotension, nausea or such as hypotension, nausea or vomiting. vomiting.

Bacterial Bacterial contaminationcontamination Gram – organisms, Pseudomonas Gram – organisms, Pseudomonas

sp., Coliforms and Yersinia sp., Coliforms and Yersinia Pseudomonas sp can grow at 4Pseudomonas sp can grow at 4°C°C

– Are the most commonAre the most common– Don’t transfuse the Don’t transfuse the greengreen or or purple purple

units.units.

Bacterial Bacterial contaminationcontamination Platelets (kept at room Platelets (kept at room

temperature during their 5-day temperature during their 5-day shelf life) are a great culture shelf life) are a great culture mediummedium– especially for skin staphylococci especially for skin staphylococci

from the venipuncturefrom the venipuncture

Bacterial Bacterial contaminationcontamination Transfusion should be stopped and Transfusion should be stopped and

the bag sent for gram stain and the bag sent for gram stain and culture. culture.

The Blood Center should be notified. The Blood Center should be notified. The patient should have blood The patient should have blood

cultures obtained and, if cultures obtained and, if appropriate, IV antibiotic therapy appropriate, IV antibiotic therapy begun begun

Transfusion Related Transfusion Related Acute Lung Injury (TRALI)Acute Lung Injury (TRALI)

““noncardiogenic pulmonary edema”noncardiogenic pulmonary edema” Defined to be ARDS within 6 hours Defined to be ARDS within 6 hours

of a transfusion with no other clear of a transfusion with no other clear cause cause

occurs when donor plasma contains occurs when donor plasma contains an antibody, usually against the an antibody, usually against the patient's HLA or leukocyte specific patient's HLA or leukocyte specific antigens. antigens.

Transfusion Related Transfusion Related Acute Lung Injury (TRALI)Acute Lung Injury (TRALI)

1 in 1000; fatality rate <1% with 1 in 1000; fatality rate <1% with estimates varying widely estimates varying widely

The cause is apparently antibodies in The cause is apparently antibodies in the donor plasma against the patient’s the donor plasma against the patient’s neutrophils (which, in the sick, are neutrophils (which, in the sick, are marginated in the lung vessels). marginated in the lung vessels).

The donor antibodies cause these The donor antibodies cause these neutrophils to release toxic products neutrophils to release toxic products and thus produce ARDS.and thus produce ARDS.


dyspnea, hypotension and fever dyspnea, hypotension and fever typically begin 30 minutes to 6 typically begin 30 minutes to 6 hours after transfusion hours after transfusion

chest x-ray shows diffuse non-chest x-ray shows diffuse non-specific infiltrates , “white out”specific infiltrates , “white out”

TreatmentTreatment

Therapy is primarily supportive Therapy is primarily supportive Ventillatory support may be Ventillatory support may be

required for several days before required for several days before resolution.. resolution..

The Blood Center should be The Blood Center should be notified so that the donor may be notified so that the donor may be tested for antibodies against the tested for antibodies against the patientpatient

Electrolyte toxicity Electrolyte toxicity (i.e., potassium)(i.e., potassium) A real danger for newbornsA real danger for newborns

– one may prefer washed red cells.one may prefer washed red cells. If hemolyzed blood is If hemolyzed blood is

administered (i.e., the blood was administered (i.e., the blood was left on the radiator or the warmer left on the radiator or the warmer was too hot), the result will be was too hot), the result will be catastrophiccatastrophic. .

HypothermiaHypothermia

Red cells and fresh frozen plasma Red cells and fresh frozen plasma are chilly. are chilly.

An extra blanket is much safer An extra blanket is much safer than an electric warming coilthan an electric warming coil– even “the special warmers for blood even “the special warmers for blood

that don’t go over 104o F / 40o C.that don’t go over 104o F / 40o C.

Overtransfusion Overtransfusion

Rapid infusion of bloodRapid infusion of blood– Plasma expanders, iv fluidsPlasma expanders, iv fluids– Regulate BT 2-4 hrs each bagRegulate BT 2-4 hrs each bag– CVPCVP– diuresisdiuresis

Transmission of Transmission of diseasesdiseases Malaria, Chagas’, syphilisMalaria, Chagas’, syphilis

– Transmitted BTTransmitted BT CMVCMV Hepatitis C and HIV-1Hepatitis C and HIV-1

– Dramatically decreasedDramatically decreased Better antibody and nucleic acid screeningBetter antibody and nucleic acid screening

– 1 per 1,000,000 units1 per 1,000,000 units Hepatitis BHepatitis B

– 1 per 100,000 units1 per 100,000 units

Transmission of Transmission of diseasesdiseases Hepatitis AHepatitis A

– Very rare, no asymptomatic carrier Very rare, no asymptomatic carrier statestate

““Pathogen in-activation system”Pathogen in-activation system”– Reduces infectious levels of all Reduces infectious levels of all

viruses and bacteria transmissible viruses and bacteria transmissible by transfusionby transfusion

Pathogen Inactivation Pathogen Inactivation TechnologyTechnology for platelets and plasma for platelets and plasma use the small use the small

molecule amotosalen HClmolecule amotosalen HCl which which penetrates cells and pathogens and penetrates cells and pathogens and targets DNA and RNA. targets DNA and RNA.

Once docked inside DNA and RNA, Once docked inside DNA and RNA, amotosalen is activated by ultraviolet amotosalen is activated by ultraviolet light to form a chemical crosslink that light to form a chemical crosslink that locks-up the strands of nucleic acid, locks-up the strands of nucleic acid, blocking replicationblocking replication. .

for red cells uses a different molecule for red cells uses a different molecule (S-303)(S-303) that forms crosslinks when that forms crosslinks when activated by a change in pH. activated by a change in pH.

Pathogen Inactivation Pathogen Inactivation TechnologyTechnology Treated pathogens are Treated pathogens are

inactivated by the process inactivated by the process and can no longer multiply and can no longer multiply and cause disease.and cause disease.

Pathogen Inactivation Pathogen Inactivation TechnologyTechnology

Indications for blood Indications for blood replacementreplacement Improve in Oxygen-carrying Improve in Oxygen-carrying

capacitycapacity Volume replacementVolume replacement Replacement of clotting factorsReplacement of clotting factors

What are the indications for RBC What are the indications for RBC transfusion in the critically ill transfusion in the critically ill surgical patient?surgical patient?

No single measure can replace good No single measure can replace good clinical judgement as the basis for clinical judgement as the basis for decision-making regarding decision-making regarding perioperative transfusionperioperative transfusion

Mild-to-mod anemia does not Mild-to-mod anemia does not contribute to perioperative morbiditycontribute to perioperative morbidity

.. .. indications for RBC indications for RBC transfusion transfusion

““Universal trigger” Universal trigger” – 70g/dL for a healthy low risk patient70g/dL for a healthy low risk patient– 10g/dL for patients with cardiopulmonary 10g/dL for patients with cardiopulmonary

diseasedisease Wound healing and postop infection is Wound healing and postop infection is

not influenced by normovolemic anemianot influenced by normovolemic anemia Transfusion should not be considered Transfusion should not be considered

substitute for good surgical and substitute for good surgical and anesthetic techniqueanesthetic technique

Volume replacementVolume replacement

Most common indication for Blood Most common indication for Blood transfusiontransfusion– Acute blood lossAcute blood loss

Measures of hgb and hctMeasures of hgb and hct– Misleading in acute bleedingMisleading in acute bleeding– Normal in spite of severely Normal in spite of severely

contracted blood volumecontracted blood volume

Blood loss of 1L in a Blood loss of 1L in a healthy adulthealthy adult Venous hct falls byVenous hct falls by

– 3% in the first hour3% in the first hour– 5% at 24 hours5% at 24 hours– 6% at 48 hours6% at 48 hours– 8% at 72 hours8% at 72 hours

The theoretical “The theoretical “transfusion transfusion triggertrigger,” or the critical point at ,” or the critical point at which a physician decides to which a physician decides to transfuse a patient transfuse a patient

RBC InfusionRBC Infusion

Rarely for Hgb>10g/dLRarely for Hgb>10g/dLUsually for Hgb <7g/dLUsually for Hgb <7g/dLDecision based on risk for Decision based on risk for complications related to complications related to inadequate oxygenation inadequate oxygenation

Platelet InfusionPlatelet Infusion

Rarely for PLT>100,000Rarely for PLT>100,000Usually for PLT<50,000Usually for PLT<50,000For PLT between 50,000 and For PLT between 50,000 and 100,000 decision based on 100,000 decision based on assessment of risk assessment of risk

FFP InfusionFFP Infusion

Microvascular bleeding present Microvascular bleeding present and PT or PTT is 1.5 times and PT or PTT is 1.5 times normalnormal

In the absence of lab results: In the absence of lab results: After transfusion of 1 total blood After transfusion of 1 total blood volumevolume

Transfusion indicationsTransfusion indications

PACKED RED CELLSPACKED RED CELLS

Hemoglobin less than 7 gm/dLHemoglobin less than 7 gm/dL Preoperative hemoglobin less than 9 Preoperative hemoglobin less than 9

gm/dL and operative procedures or gm/dL and operative procedures or other clinical situations associated with other clinical situations associated with major predictable blood lossmajor predictable blood loss

Symptomatic anemia in a Symptomatic anemia in a normovolemic patientnormovolemic patient

Acute loss of at least 15% of estimated Acute loss of at least 15% of estimated blood volume with evidence of blood volume with evidence of inadequate oxygen delivery following inadequate oxygen delivery following volume resuscitationvolume resuscitation

FRESH FROZEN FRESH FROZEN PLASMAPLASMA PT or PTT greater than 1.5 times the mean PT or PTT greater than 1.5 times the mean

of the reference range (PT>16, PTT>39) in of the reference range (PT>16, PTT>39) in a non-bleeding patient scheduled to a non-bleeding patient scheduled to undergo surgery or invasive procedureundergo surgery or invasive procedure

Massive transfusion (more than 1 blood Massive transfusion (more than 1 blood volume or 10 units) and coag tests are not volume or 10 units) and coag tests are not yet availableyet available

Emergency reversal of coumadin Emergency reversal of coumadin anticoagulationanticoagulation

Coagulation factor deficiencyCoagulation factor deficiency

PLATELETSPLATELETS

Platelet count less than 20,000 in a non-bleeding Platelet count less than 20,000 in a non-bleeding patient with failure of platelet productionpatient with failure of platelet production

Platelet count less than 50,000 and impending Platelet count less than 50,000 and impending surgery or invasive procedure, patient actively surgery or invasive procedure, patient actively bleeding, or outpatientbleeding, or outpatient

Patients during or after open heart surgery or Patients during or after open heart surgery or intra-aortic balloon pump with diffuse bleedingintra-aortic balloon pump with diffuse bleeding

Massive transfusion (more than 1 blood volume Massive transfusion (more than 1 blood volume or 10 units) when platelet counts are not or 10 units) when platelet counts are not availableavailable

Qualitative platelet defect (bleeding time greater Qualitative platelet defect (bleeding time greater than 9 minutes) with bleedingthan 9 minutes) with bleeding


Transfusion Guidelines:Transfusion Guidelines:– Platelet count < 20,000/mm3Platelet count < 20,000/mm3– Platelet count <50,000/mm3 Platelet count <50,000/mm3 if with if with

microvascular bleedingmicrovascular bleeding– Complicated surgeries with >10 units of Complicated surgeries with >10 units of

blood transfused, with signs of blood transfused, with signs of microvascular bleedingmicrovascular bleeding

– Documented platelet Documented platelet dysfunction(prolonged BT, abnormal plt dysfunction(prolonged BT, abnormal plt function tests)function tests)

CRYOPRECIPITATECRYOPRECIPITATE

Fibrinogen less than 100 mg/dLFibrinogen less than 100 mg/dL Fibrinogen less than 120 mg/dL with Fibrinogen less than 120 mg/dL with

diffuse bleedingdiffuse bleeding Von Willebrand disease or hemophilia Von Willebrand disease or hemophilia

unresponsive to desmopressin unresponsive to desmopressin (DDAVP) and no appropriate factor (DDAVP) and no appropriate factor concentrates availableconcentrates available

Uremic bleeding if desmopressin is Uremic bleeding if desmopressin is ineffectiveineffective

Factor XIII deficiencyFactor XIII deficiency

major indication for major indication for whole blood whole blood transfusiontransfusion some cases of cardiac surgery some cases of cardiac surgery massive hemorrhage when more massive hemorrhage when more

than 10 units of red blood cells than 10 units of red blood cells are required in any 24-hour are required in any 24-hour period period

Massive transfusionMassive transfusion

Death by exsanguination has Death by exsanguination has been described as the loss of 150 been described as the loss of 150 mL of blood per minute, which mL of blood per minute, which results in loss of half the blood results in loss of half the blood volume in 20 minutesvolume in 20 minutes

It has also been classified as It has also been classified as blood loss of more than 5,000 mLblood loss of more than 5,000 mL

10 units of blood transfused 10 units of blood transfused within 24 hourswithin 24 hours


replacement of one entire blood replacement of one entire blood volume within 24 hoursvolume within 24 hours

50% blood volume replacement within 50% blood volume replacement within 3 hours3 hours

transfusion of more than 20 units of transfusion of more than 20 units of erythrocytes erythrocytes

requiring 4 units of blood within an requiring 4 units of blood within an hour with anticipation of ongoing hour with anticipation of ongoing usage usage


Most MTPs call for the use of Most MTPs call for the use of uncrossmatched type O negative uncrossmatched type O negative (O-) blood as the first-line infusion (O-) blood as the first-line infusion preference. preference.

O negative bloodO negative blood

universality and timely availability universality and timely availability from hospital blood banks from hospital blood banks

when used during massive when used during massive exsanguination is potential exsanguination is potential problems with crossmatching and problems with crossmatching and incompatibility later in the incompatibility later in the patient’s hospital stay patient’s hospital stay – more than 4 unitsmore than 4 units

O+ bloodO+ blood

It has been shown to be generally It has been shown to be generally safe and can help prevent blood safe and can help prevent blood shortages shortages

administer to men and administer to men and postmenopausal women postmenopausal women

To woman of childbearing age To woman of childbearing age can result in sensitizationcan result in sensitization

Massive transfusion Massive transfusion complicationscomplications Coagulopathy is caused by a Coagulopathy is caused by a

dilutional effect on the host's dilutional effect on the host's clotting factors and platelets, as clotting factors and platelets, as well as the lack of platelets and well as the lack of platelets and clotting factors in packed red clotting factors in packed red blood cells. blood cells.

Volume overload Volume overload Hypothermia Hypothermia

Massive transfusion Massive transfusion complicationscomplications HyperkalemiaHyperkalemia may be caused by lysis may be caused by lysis

of stored red cells of stored red cells Metabolic acidosisMetabolic acidosis and hypokalemia and hypokalemia

may be caused by the transfusion of a may be caused by the transfusion of a large amount of citrated cells. large amount of citrated cells.

Hypocalcemia due to citrate toxicityHypocalcemia due to citrate toxicity may occur in those with hepatic may occur in those with hepatic failure, congestive heart failure (CHF), failure, congestive heart failure (CHF), or other low-output states. or other low-output states. – It is increasingly uncommon with the use It is increasingly uncommon with the use

of component therapy. of component therapy.

Massive transfusion Massive transfusion complicationscomplications Use of blood from multiple donors Use of blood from multiple donors

increases the risk of hemolytic increases the risk of hemolytic reactions as a consequence on reactions as a consequence on incompatibilityincompatibility

Transfusion optionsTransfusion options

Type-specific, non-cross-matched bloodType-specific, non-cross-matched blood May be used in emergenciesMay be used in emergencies O-negative, type-specific is equally safeO-negative, type-specific is equally safe

– Also called the “Also called the “universal transfusion universal transfusion productproduct””

Hemoglobin solutionsHemoglobin solutions Autologous tansfusionAutologous tansfusion hemodilutionhemodilution

Methods of Methods of administering bloodadministering blood Rate depends on patient’s statusRate depends on patient’s status IntravenousIntravenous IntraperitonealIntraperitoneal

– 90% enters the circulation90% enters the circulation– Absorbtion for atleast a weekAbsorbtion for atleast a week

Medullary cavityMedullary cavity

Methods of Methods of administering bloodadministering blood

Special concernSpecial concern

Jehovah’s Witnesses cannot accept Jehovah’s Witnesses cannot accept donor packed red cells, platelets, white donor packed red cells, platelets, white cells or plasma, and cannot accept cells or plasma, and cannot accept autologous or cell-cycled autologous or cell-cycled intraoperative transfusion.intraoperative transfusion.

The sect leadership used to be The sect leadership used to be militantly anti-immunization, anti-germ militantly anti-immunization, anti-germ theory, and anti-transplantation as theory, and anti-transplantation as wellwell

Blood transfusion Blood transfusion therapytherapy

Raymund AG Ong, MD FPCS FPALES Raymund AG Ong, MD FPCS FPALES

Department of SurgeryDepartment of Surgery

FEU-NRMF Medical CenterFEU-NRMF Medical Center

Health & Medicine

Blood Tranfusion Therapy