King Louis XIV personal physician…..First recorded transfusion – lamb to human
Very mixed results with transfusions from 1818 - 1900
Deptt. Of Emergency medicine,
Peerless hospital and B.K.Roy research centre
A 22 yr old man sustain multiple penetrating wounds to
upper rt.chest,his wounds are all above the nipple. He is
intubated,closed tube thoracostomy is performed, and
1500ml of blood has drained from rt.chest,2 liters of
crystalloid are infused. His BP is now 60/?,HR-160b/m
The most appropriate next step in managing this pt. is
a. Perform FAST
b. Obtain a CT chest
c. Perform an angiography
d. Arrange transfusion & transfer to OT.
e. Infuse colloids
First successful human-human transfusion
1902– Karl Landsteiner
Won the 1930 Nobel
Isolated the A, B, & O
Type AB blood was
identified two years
Beginning of safe and effective transfusion medicine
RELATIONSHIP BETWEEN BLOOD TYPE & ANTIBODIES
Blood type Antigen on RBC Can
A A A & AB ANTI B A ,O
B B B & AB ANTI A B ,O
AB A &B AB NONE A ,B,O
O NONE ALL ANTI A & ANTI B O
Well, it gets more complicated here, because there's
another antigen to be considered –
the Rh antigen.
• Rh was 1st identified of a rhesus monkey → rhesus factor
• A person with Rh factor on his RBC said to be Rh+ve
• Will not make anti Rh antibodies
• A person with out Rh factor on his RBC said to be Rh –ve
• This will produce anti Rh antibodies
• Rh incompatibility dangerous in pregnancy.
BLOOD PRODUCT :Any therapeutic substance prepared from
WHOLE BLOOD :Unseparated blood
BLOOD COMPONENT : A constituent of blood ,separated from
Red cell concentrate
→ Leucoreduced / Irradiated / washed
Why Separation of blood components ????
• The storage life of whole blood is less than that
of individual components
• Allows optimal survival for each component.
• Allows transfusing specific blood components.
• Several patients can be treated from one unit.
• Whom to transfuse?
• What to transfuse?
• How much to transfuse?
So…whom you would transfuse !!!!
i. 23 yo asymptomatic, healthy woman with
menorrhagia,Hb 8.0 g/dl,MCV- 72 fl
ii. 61 yo,k/c/o Htn,with severe gram negative sepsis –
BP-100/70,cold periphery,AMS & Hb 8.0 g/dl.
iii. 54 yo woman post hemicolectomy Hb 8.0g/dl.
iv. 73 yo man presenting with acute upper GI bleed;
BP 80/60, Pulse 120 thready – Hb 8.0 g/dl,MCV- 90fl
Objectives of transfusion therapy
• Maintain blood volume
• Maintain O2 carrying capacity
• Maintain coagulation
• Red Cell Transfusion SHOULD not be solely used as a
‘plasma expander’ – but primarily as a method to
increase oxygen carrying capacity.
So…what is threshold for transfusion ???
• Difficult to set a transfusion threshold that holds true for all
• Depends upon clinical status & co-morbidities.
• Use "10/30― rule.
American society of Anaesthesiologists (ASA) state that:
“Red blood cell transfusion is rarely indicated when
the hemoglobin concentration is greater than 10
g/dl and is almost always indicated when it is less
than 6 g/dl”
Transfusion guidelines have been published by the
• American Society of Anesthesiology
• British Committee for Standards in Hematology
• Australian and New Zealand Society of Blood Transfusion
• Eastern Association for Surgery of Trauma (EAST) & American
College of Critical Care Medicine of the Society of Critical Care
• European Society of Cardiology (ESC)
• AABB (formerly the American Association of Blood Banks)
• American College of Physicians
Some recommended threshold
• Hgb <6 g/dL – Transfusion recommended .
• Hgb 6 to 7 g/dL – Transfusion generally likely to be indicated
• Hgb 7 to 8 g/dL – Transfusion should be considered in postoperative
• Hgb 8 to 10 g/dL – Transfusion generally not indicated, but should be
considered for some populations (eg, those with symptomatic
anemia, ongoing bleeding, acute coronary syndrome with ischemia)
• Hgb >10 g/dL – Transfusion generally not indicated except in exceptional
• Transfusion Requirements in Critical Care (TRICC)
Hebert PC, et al. N.Engl J Med. 1999;340(6):409-17
A multicenter, randomized, controlled clinical trial of transfusion requirements in
critical care has demonstrated that you can adopt a
• transfusion threshold of 7 g/dL and maintain critically ill
patients between 7 and 9 g/dL
• Patients with acute MI and unstable angina may possibly
benefit from Hb> 8 g/dL
component indication Approx / U typical
Acute ongoing hemorrhage
Sever symptomatic anaemia
2 units or
<10000/mm3 in asymptomatic pt.
<20000/mm3 in major bleeding
<50000/mm3 for invasive
<100,000/mm3 with neoro/cardiac
1 unit or
but less in
Destruction due to
3–6 x 1011
1 U=250 ml
1 u of each
replacement, DIC, liver
disease, exchange transfusion
massive transfusion, warfarin
Four units or
factor VIII /
vWF / factor
10 units or
1 unit/5 kg
Bleeding with a fibrinogen level
of <100 milligrams/dL
Factor VIII or XIII deficiency
Special processing of RBC
•↓nonhemolytic febrile reactions.
•↓ risk of virus transmission.
•to prevent sensitization in pt. for bone
Irradiated PRBCs should be considered in transplant patients,
neonates, and immunocompromised
•↓risk of anaphylaxis in IgA deficient pt.
•↓risk of reaction in pt.with recurrent /
severe allergic reaction to blood products.
• 10 units of PRBCs within a 24-hour period.
• Replacement of a blood volume equivalent within 24hr
• >10 unit within 24 hr
• Transfusion > 4 units in 1 hr
• Replacement of 50% of blood volume in 5 hrs
• A rate of loss >150ml/hr
Importance of Massive Transfusion
• 39% of trauma related deaths – uncontrollable
bleeding (Leading cause of preventable death)
• 2% of trauma patients – need massive
• Bleeding 2 main causes
• Vascular injury (surgical)
• Coagulopathy (non-surgical)
So.....What is Haemostatic /damage
• A ground breaking concept!
• Prevents post traumatic coagulopathy
• Aims to reduce use of blood products in the intensive
FFP : INR >1.5
Crypts : fibrinogen
Evidence of Haemostatic Resuscitation
• Massive transfusion practices around the globe and a
suggestion for a common massive transfusion protocol
Debra L Malone, John R Hess, Abe Fingerhut ;The Journal of trauma. 01/07/2006; 60(6
Suggested – RBC:FFP - 1:1
• Indications for early fresh frozen
plasma, cryoprecipitate, and platelet transfusion in
Lloyd Ketchum, John R Hess, Seppo Hiippala; The Journal of trauma. 01/07/2006; 60(6 Suppl):S51-8.
Early use of FFP,PLT - ↓ incidence of coagulopathy
• Up to 20% may lead to some type of adverse reaction.
• Mostly within 24 h.
• Most are minor reactions./ don’t miss the life threatening
• Acute vs Delayed reaction.
• Infectious & non infectious.
• Difficult to recognized in Critically ill patient
1 to 4 per 1 million units transfused.
Most commonly by ABO incompatibility.
Transfused cells are destroyed
↓ ↓ ↓
Activation of the coagulation system
with DIC & release of Anaphylotoxins &
other vasoactive amines
↓ ↓ ↓
• High fever/chills
• Back/abdominal pain
• Oliguria / Hemoglobinuria
• requires a high degree of
suspicion in critically ill
What to do? If an AHTR occurs
• STOP TRANSFUSION
• A /B /C’s
• Maintain IV
• Give diuretic
• Blood & urine transfusion reaction workup
• Send remaining blood back to Blood Bank
Renal st-BUN/ Creat
Febrile transfusion reaction
Commenst among all
1 per 300 units of PRBC infused & 20%
Result from a combination of recipient
antibody against donor leukocytes
and the release of cytokines that are
produced during storage.
Pretreatment with acetaminophen can
mask this reaction.
• Rise in patient temperature >1 C
(associated with transfusion without
other fever precipitating factors)
• fever / chills,
• Headache / myalgias,
• Tachycardia /dyspnea /chest pain.
• difficult to differentiate from more
serious hemolytic transfusion
reaction or sepsis.
What to do?If an FNHTR occurs
• STOP TRANSFUSION
• Use of Antipyretics
• Suspect and manage as AHTR
• Initially difficult to distinguish
between the two.
• Use of Corticosteroids for severe
• Use of Narcotics for shaking chills
• Future considerations
• May prevent reaction with
• Use single donor platelets
• Use fresh platelets.
• Washed RBC’s or platelets
Transfusion Related Acute Lung injury
• Clinical syndrome similar to ARDS
• Transfusion related noncardiogenic pulmonary edema
• Usually after FFP & Platelets transfusion
• Rare but , most common cause of transfusion related death
• Caused by WBC antibodies present in donor blood that result in
• Occurs 1-6 hours after receiving plasma-containing blood products
• High mortality
• Acute onset dyspnea during or within 6 hours of
• Clinical evidence of hypoxemia
• Bilateral infiltrates on frontal chest radiograph
• No evidence of left atrial hypertension (i.e. circulatory
• Absence of other attributable causes
Treatment is supportive
• Can occur with erythrocytes or platelets
• Antigen disparity of minor antigens (Kell, Duffy, Kidd)
• Minor antigens D, K, E seen in Sickle patients
• Usually due to HLA antigens
• May reduce alloimmunization by leukoreduction
(since WBC’s present the HLA antigens)
Transfusion Associated GVHD
• Mainly seen in infants
• Etiology—Results from engraftment of donor
lymphocytes of an immunocompetent donor into an
• Symptoms—Diarrhea, skin rash, pancytopenia
• Usually fatal—no treatment
• Prevention—Irradiation of donor cells
Etiology Estimated Frequency: One Infection
per Number of Units Transfused
HIV-1 1 per 2–3 million
HIV-2 Unknown, but extremely low
Human T-cell lymphotrophic virus type I
1 per 640,000
Hepatitis B 1 per 100,000–200,000
Hepatitis C 1 per 1–2 million
Parvovirus B19 1 per 10,000
Bacterial sepsis 1 per 6 million platelet concentrates
1 per 500,000 packed red blood cells