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Blood Transfusion
Presentation by
Dr.Faisal ZiaResident Surgeon
Lady reading Hospital Peshawar
History……… 1901
Karl Landsteiner discovers the ABO system.
History………
1926……..The British Red Cross instituted the first blood transfusion service in the world.
1939……….The Rhesus system was identified and recognised as major cause of transfusion reactions.
Introduction
An adult human has about 4-6 litres of blood circulating in the body.
Among other things blood transport oxygen to various tissues of the body.
Blood consists of several types of cells floating around in a fluid called plasma.
Intro…………… The red blood cells contain
hemoglobin,a protein that binds oxygen. Red blood cells transport oxygen to,and
remove carbon dioxide from the body tissues.
The white blood cells(neutophils,eosinophils,basophils,monocytes,lymphocytes) fight infection.
Platelets help in blood clotting.
Intro……………
The plasma contains salts and various kinds of plasma proteins(albumin,globulin,clotting factors etc).
Plasma makes 55 percent of the blood volume approximately.
Intro……….
DEFINATION:A blood
transfusion is the infusion of whole blood or blood components such as plasma,red blood cells or platelets into the venous circulation of the patient.
Intro……….. Purposes: To replace blood lost during surgery or a
serious injury. To restore oxygen carrying capicity of
the blood. To provide plasma factors to prevent or
treat bleeding. If patients body is not capable of making
blood properly because of an illness.
IndicationsIndications are as follows: Acute blood loss, to replace circulating
volume and maintain oxygen delivery.
Perioperative anemia to ensure adequate oxygen delivery during the perioperative phase.
Symptomatic chronic anemia,without hemorrhage or impending surgery.
Human blood is commonly classified into four main groups .
(A, B, AB, and O). The surface of an individual’s red blood cells
contains a number of proteins known as antigens that are unique for each person. Many blood antigens have been identified, but the antigens A, B, and D(Rh) are the most important in determining blood group or type.
Blood groups
Blood groups
The A antigen or agglutinogens is present on the RBCs of people with blood group A , the B antigen is present in people with blood group B, and both A and B antigens are found on the RBC surface in people with group AB blood .Neither antigen is present in people with group O blood .
Blood groups
People with blood group A have B antibodies (agglutinins ), A antibodies are present in people with blood group B , and people with blood group O have antibodies to both A and B antigens .People with group AB blood do not have antibodies to either A or B antigens .
Blood groups
If a person with type O blood is transfused with blood from a person with either group A or group B blood, there would be destruction of the recipient’s red blood cells because his or her anti-A or anti-B agglutinins would react with the A or B antigens in the donor’s red blood cells.
Blood groups
This example shows why individuals with type AB blood are often called Universal recipients (because people in this blood group have no agglutinins for either A or B antigens) and group O people are often called Universal donors (because they have neither A nor B antigens).
Blood groups
Blood groups
Blood groups
Blood groups
A,B,AB & O BLOOD GROUP
The Rh factor is an inherited antigen in human blood. Blood that contains the Rh factor is known as Rh positive, when
it is not present the blood is said to be Rh – negative. Rh blood does not naturally contain Rh antibodies. If Rh-positive blood is injected into an Rh-negative person, the
recipient develops Rh antibodies. Subsequent transfusion with Rh-positive blood may cause
serious reactions with clumping and hemolysis of red blood cells.
Rhesus Rh Factor
Blood Typing Before any blood can be given to a patient, it must
be determined that the blood of the donor is compatible with the patient.
The laboratory examination to determine a
person’s blood group and Rh factor is called Blood Typing.
Cross matching The process of determining compatibility
between blood specimens is crossmatching. RBCs from the donor blood are mixed with
serum from the recipient, a reagent (Coombs’ serum) is added, and the mixture is examined for visible agglutination.
If no antibodies to the donated RBCS are present in the recipient’s serum, agglutination does not occur and the risk of transfusion reaction is small.
Transfusion trigger Historically patients were transfused to
achieve hemoglobin >10g/dl.This has been shown to not only be unnecessary but also be associated with an increased morbidity and mortality compared to low target values.
A hemoglobin level of 6g/dl is acceptable in patients who are not actively bleeding,not about to undergo major surgery and not symptomatic.
Transfusion triggerThere is some controversy as to optimal
hemoglobin level in some patient groups,such as those with cardiovascular disaease,sepsis and traumatic brain injury.
Although conceptually a higher hemoglobin improves oxygen delivery,there is little clinical evidence at this stage to support higher levels in these groups.
Transfusion triggerHemoglobin level(g/dl)
Indications
<6 Probably will benefit from transfusion.
6-8 Transfusion unlikely to be of benefit in the absence of bleeding or impending surgery.
>8 No indication for transfusion in the absence of other risk factors.
Administering blood
Blood transfusions take place in either a Doctors office or a hospital.
They can be done at the patients home,but this is less common.
Administering blood
A needle is used to insert an intravenous(IV) line into a blood vessel,through this line blood is transfuse.
The procedure usually takes one to four hours.
The time depends on how much blood is needed,which blood product is given,and whether the patients body can safely receive blood quickly or not.
Administering blood
During blood transfusion,a doctor or nurse carefully watches the patient,especially for the first 15 minutes,this is when bad reactions are most likely to occur.
Administering blood
After blood transfusion vital signs are checked(such as temprature,blood pressure,respiration rate and heart rate).
Follow up blood tests may be necessary to show how the body is reacting to the transfusion.
BLOOD PRODUCTS
PLATELETS FRESH FROZEN PLASMA
Whole blood:
• Indicated for Rx of acute Hemorrhage.• Transfusion should complete within 4 hrs.• Warmer is used if large volume in a short time.• Coagulation factor rich. • If fresh more metabolically active then store
blood.• Unwanted features in Store blood. 1 .Citrate anticoagulant. 2 .Acidic PH. 3 .High K. 4 .Ammonia. 5 .Dec 2,3-DPG level.
Red cell preparation:
• Packed RBC’s are spun down and concentrated.
• Obtained from single donor. • Ideal for anemia Rx.• 1 Unit = 330 ml and inc HCT by 3% & HB
1g.
Frozen Red cells:
Storage at -80 to – 196 C through cytoprotective agents like Glycerol.
Result in removal of Leukocytes , Platlets and any viral particles.
Reduce disease transmission incidence.
Platelets:• Available as concentrates from single or
multiple donors.• Indicated for thrombocytopenia, to
cover surgery if count is below 40,000, in pt with platelet dysfunction.
• HLA expression and may lead to Alloimmunization in pt requiring repeated platelet transfusion.
• Patient with platelets alloimmunization can only receive HLA matched platelet conc.
Platelets:
• 1 unit= 50 ml and increase platelet count by abt 10,000.
• Stored at 20 to 24 C.
• Shelf life 5 days.
Fresh-frozen plasma:• Coagulation factors rich.• Stored at -40 to -50 C (shelf life of 2 yrs).• 1 unit= 200 ml.• Dose = 15 to 25 ml/kg.Indicated in:
○ Coagolupathic Hemorrhage.○ Reverse oral anticoagulation ( warfarin/
coumarin).○ Provide haemostatic support & to cover
liver disease procedures.○ DIC.○ Massive Transfusion.○ Burns.
Cryoprecipitate:
• Supernatant ppt of FFP.
• Concentrate of factor VIII, von Willebrand’s factor and fibrinogen.
• Stored at -30 C (shelf life 2 yrs).
Indications of Cryoprecipitate:
• Factor 8 deficiency.
• Fibrinogen deficiency.• • Von Willebrand’s disease.
Prothrombin complex conc:
Highly purified conc prep from pooled plasma contains Factor 2, 7, 9, 10.
Indicated for emergency reversal of anticoagulant therapy ( warfarin), in uncontrolled hemorrhage.
FACTOR 8 CONCENTRATE: Haemophilia
FACTOR 9 CONCENTRATE: Christmas disease
Autologous blood Transfusion Autologous Predonation
It is possible for patients undergoing elective surgery to predonate their own blood upto 3 weeks before surgery for retransfusion during the operations.
Intraoperative AutotransfusionDuring operations blood can be collected in
a cell saver which washes and collects red blood cells which can then be returned to the patient.
Massive TransfusionDefinitions: Transfusion of blood products that are
greater in volume than a patients normal blood volume in less than 24 hrs.
Transfusion of >10 units RCC in 24 hours.
Replacement of >50% of the total blood volume within 3 hours.
Massive Transfusion
Settings:• Trauma • Obstetric• Surgical• Medical
Transfusion complicationsThey can be categorised into:
Complications from a single transfusion.
Complications from massive transfusion.
Transfusion ComplicationsComplications from a single transfusion:1. Infectious complications.2. Non infectious complications: Acute(<24 hrs): Immunological Non-immonological Delayed(>24 hrs): Immunological & non-
immunological
Infectious complications
• Bacterial (brucellosis, syphilis)• Helminthic (filariasis)• Protozoal (malaria, toxoplasmosis)• Rickettsial • Viral (HIV, CMV, Epstein-Barr virus,
hepatitis A, B and C and yellow fever)
Non infectious complication
Acute(<24 hrs): Immunological: Urticarial/Allergic. Anaphylactic. Non-hemolytic febrile transfusion
reactions. Hemolytic transfusion reactions. Trasfusion related acute lung
injury(TRALI).
Non infectio…………Acute(<24 hrs): Non immunological: Circulatory overload. Hypocalcemia. Hypothermia. Air embolism. Septic shock(bacteremia)
Acute immunological reactions
Urticarial/Allergic reactions: The most common type of transfusion
reactions and occur when the patient reacts to donated plasma proteins in the blood.
Symptoms include itching or hives and can be treated with antihistamines(diphenhydramine 25-50mg orally or IV).
Prophylactic administration of benadryl and prednisolone prior to transfusion should be considered in patients with previous history of allergic reactions.
Acute immuno…………. Anaphylactic reactions:
• Rare, fatal,severe reaction caused by antibodies to IgA in patients who have extremely low levels of this immunoglobulin in plasma.
• Causes hypotension,cutaneous flushing and even bronchospasm or laryngospasm,which should prompt discontinuation of infusion.
Acute immuno……….Treatment:• Cessation of transfusion.• IV crystalloids.• Maintain airway and O2.• Adrenaline 0.5 – 1 mg i.m.• IV anti histamine/IV steroids. • salbutamol nebulization.
Acute immuno…….. Non-haemolytic febrile transfusion reactions:
• Result of alloimmunization to leucocyte and platelet antigens.
• Symptoms: general malaise,chills,nausea,or headache accompanied by fever usually during or within 24 hrs of transfusion.
• Managed by cessation or slowing of the transfusion and administration of an antipyretic.
• If above measures fail, leukocyte-depleted cell components are given.
Acute immuno………… Acute hemolytic transfusion reaction:
• Result of ABO or Rh incompatibility• Serious complication mostly due to clerical
error.• Mortality is high when more than 200 ml has
transfused Symptoms include nausea,chills,anxiety,flushing and chest or back pain.
• Anesthetized or comatosed patients may show signs of excessive incisional bleeding or oozing from mucous membranes.
• The reaction may progress to shock or renal failure with hemoglobinuria.
Acute immuno………Management :
○ Immediate recognition and cessation of transfusion.○ Replacement of the giving set.○ Adequate hydration with IV crystalloids.○ Urine output should be maintained at greater than 100
ml/hr using volume resuscitation and possibly diuretics.
○ Force diuresis with furosemide 150mg, mannitol 100ml 20%, haemodialysis.
○ Alkanization of urine to a pH greater than 7.5 by adding sodium bicarbonate to IV fluids helps to prevent precipitation of hemoglobin in the renal tubules.
Acute immuno………..Further investigations:
• Re-cross matching and serological testing.
• Blood unit for culture.• Blood sample for clinical
chemistry.• Coagulation screen.
Acute immuno……….. Transfusion-related acute lung injury(TRALI):
TRALI is a serious reaction that typically occurs within 1 to 2 hours of transfusion but can occur anytime upto 6 hrs later.
TRALI is an infrequent complication caused by anti-HLA and/or anti-granulocyte antibodies in donor plasma that agglutinate and degranulate recipient granulocytes within the lung.
Patient complains of shortness of breath and may have a fever.
Acute immuno………..
Chest x-ray has a characteristic pattern of noncardiogenic pulmonary edema.
After ABO incompatibility, this is the 2nd most common cause of transfusion-related death.
Incidence is 1:5,000–10,000, but many cases are mild.
Mild to moderate transfusion-related acute lung injury probably is commonly missed.
Acut immuno…………Management: Support may vary from supplemental
oxygen, to intubation and ventilation.
Acute non-immnological Circulatory overload: The high osmotic load of blood products
draws volume into the intravascular space over the course of hours, which can cause volume overload in susceptible patients (eg, those with cardiac or renal insufficiency).
RBCs should be infused slowly.
Acute non-immuno……… The patient should be observed and, if
signs of heart failure (eg, dyspnea, rales) occur, the transfusion should be stopped and treatment for heart failure begun.
Judicious use of diuretic therapy can reduce the risk of this complication.
Acute non-immuno……… Air embolism: Air infusion via line Rare Cough, dyspnea, chest pain, shock If suspected…
• Pt. placed on left side with head down.• Displace air bubble from pulmonary
valve.
Non infectious complicationsDelayed(>24)hrs: Immunological: Delayed hemolytic transfusion reactions. Graft versus host disease(GVHD). Immune-modulation. Non immunological: Transfusion iron overload(haemosiderosis).
Delayed immunologicalDelayed hemolytic transfusion reaction: It results from an anamnestic antibody
response to antigens other than the ABO antigens to which the recipient has been previously exposed.
Transfused blood cells may take days or weeks to hemolyze after transfusion.
Typically there are few signs and symptoms other than a falling RBCs count and elevated bilirubin.
Delayed immuno……….Management:
Specific treatment is rarely necessary.
Severe cases shoud be treated like acute hemolytic reactions,with volume support and maintanace of urine output.
Delayed immuno…………
Graft-versus-host disease:• Rare, but fatal complication,having associated
mortality of greater than 80 percent.• Occurs mainly in immunocompromised
patients or HLA-identical family members.• Caused by immuno competent T-lymphocytes,
immunologicaly competent transfused cells attack host environment.
• Starts 3-30 days after the transfusion.
Delayed immuno………….
• Develop high fever, diffuse erythematous skin rash, desquamation, GI symptoms, severe hepatic dysfunction and pancytopenia.
• Prevented by administering gamma-irradiated cellular components.
Delayed immuno……….. Immuno-modulation: Increases risk of recurrent cancer and
bacterial infections. WBCs release cytokines during storage
which interfere with immune function. Uncertain clinical significance.Treatment: Leukoreduction of blood products.
Delayed non-immunological
Transfusion iron overload(haemosiderosis): Each unit of packed red cells 200-250 mg of Fe. Repeated transfusions over a long period of
time(e.g in childeren with thalesemia and in patients with chronic refractory anemia).
> 50-100 units of PRBC Storage in RE sites saturation other sites
Heart, liver, endocrine glands (pancreas)
Delayed non-immunological
Treatment: Removal of Fe
Desferoxamine – Fe-chelating agent
Transfusion complications Complications from Massive
transfusion: Dilutional thrombocytopenia Coagulopathy Hypocalcemia Hypothermia Hyperkalemia Hypokalemia Acidosis Citrate toxicity
Complications of massive transfusion
Dilutional thrombocytopenia: When a patient receives stored blood in such
large volume, the patient's own blood may be, in effect, “washed out.”
In circumstances uncomplicated by prolonged hypotension or DIC, dilutional thrombocytopenia is the most likely complication.
Platelets in stored whole blood are not functional. Clotting factors (except factor VIII) usually remain sufficient.
Microvascular bleeding (abnormal oozing and continued bleeding from raw and cut surfaces) may result.
Complications of mas…....Treatment: Five to 8 (1 unit/10 kg) platelet
concentrates are usually enough to correct such bleeding in an adult.
Complications of mas………..
Coagulopathy:
Coagulopathy might arise as a result of platelet and coagulation factors depletion.
Coagulopathy following or during massive transfusion should be anticipated and managed aggressively.
Complications of mas……….Management:
Standard guidelines are as follows: FFP if PT or APTT > 1.5 times normal. Cryoprecipitate if fibrinogen < 0.8g/l. Platelets if platelet count < 50×109/ml.
Complications of mas……. Hypocalcemia: When large volumes of FFP, whole blood,
plts. transfused rapidly plasma citrate levels may rise binds to Ca+2.
Symptoms include Periorbital/peripheral tingling,paresthesias, shivering, light headedness, tetanic symptoms, hyperventilation, depressed cardiac function.
Treatment: IV 10% calcium gluconate.
Complications of mas…….. Hypothermia: Rapid infusion of large volumes of chilled
blood products leads to hypothermia. More likely to occur via central catheters. It can lead to cardiac dysrhythmias and
coagulopathy. It can be prevented by using blood warmers.
Effect of Hypothermia on coagulation factor activity
0
20
40
60
80
100
25° 27° 29° 31° 33° 35° 37°Temperature
Fact
or A
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I I VVIIVII IIXXXIXII
Complications of mas…….. Citrate toxicity can develop after massive
transfusion in patients with hepatic dysfunction.
Elecrolyte abnormalities,including Acidosis and Hyperkalemia,occur rarely after massive transfusions,especially in patients with pre-existing hyperkalemia.
Blood substitutes They are an attractive alternative to the
costly process of donating,checking,storing and administering blood –and due to the complications associated with transfusion.
Several oxygen-carrying blood substitutes are under investigation in animal or early clinical trials.
They are either Biomimetic or Abiotic.
Blood sub……….. Biomimetic substitutes mimic the
standard oxygen carrying capicity of blood and are haemoglobin based.
Various engineered molecules are under clinical trials,based on human,bovine or recombinant technlogies.
Abiotic substitutes are synthetic oxygen carriers and are currently primarily perfluorocarbon based.
A 29 year old woman on oral conraceptives presents with abdominal pain. A CT scan of the abdomen demonstrates a large hematoma of the right liver with the suggestion of a underlying liver lesion. Her Hb = 6 and she is transfused 2 units of packed RBC 2 units of FFPs. 2 hr after starting the transfusion, she Develops respiratory distress and requires and requires intubation. She is not volume overloaded clinically, but her x-ray shows bilateral Pulmonary inFiltrates. Which of the following is the the management strategy of Choice??
A. continue the transfusion and administer an antihistamine
B. Stop the transfusion and administer a diuretic
C. Stop the transfusion and continue supportive Respiratory care
C. Stop the transfusion and send a Coombs test
Answer = C The patient has TRALI which manifests
as respiratoy disress, hypoxemia and bilateral infiltrates not due to volume overload.
The treatment is respiratory support including mechanical ventilation, as needed.
Take Home Message Next time, when u transfuse Blood, u should take care of all the
following points. Check the blood bag identification number, ABO Blood group and Rh
compatibility. Check the expiry date on the blood bag. Observe for abnormal color, RBC clumping, & extraneous material. Return outdated or abnormal blood to the blood bank. Before starting transfusion, make sure u r aware and Ready for any
Reaction. i-e u should have Steroid (Dexamethasone) and Antihistamine (AVil) on ur Emergency Tray.
Ask about previous transfusion and Reaction if Occured Write down the Transfusion Notes and counsil the patient about
reaction Observe the patient Vitally and Generally ( Skin Rash et) for any
reaction specially in first 15 min. coz most reactions occur in 1st 15 min.
After transfusion, DO HB to Check for attainment of Desired HB. Also DO S.E for any Abnormality if previously deranged SE.
