Your SlideShare is downloading. ×
Blood component therapy iccco
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Saving this for later?

Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime - even offline.

Text the download link to your phone

Standard text messaging rates apply

Blood component therapy iccco

2,935
views

Published on

I missed the Critical Care Congress at Pune. Couldn't make it because of certain personal reasons. However, I was to deliver a talk on ROLE OF BLOOD COMPONENTS & rFVIIa IN OBSTETRICS on 21 Jul 13 at …

I missed the Critical Care Congress at Pune. Couldn't make it because of certain personal reasons. However, I was to deliver a talk on ROLE OF BLOOD COMPONENTS & rFVIIa IN OBSTETRICS on 21 Jul 13 at 11 am. Feel duty bound to share the presentation with all who wanted to hear it there. I have uploaded it at Slideshare and queries, if any, may be addressed to navneetmagon@gmail.com.

Published in: Health & Medicine, Business

2 Comments
3 Likes
Statistics
Notes
No Downloads
Views
Total Views
2,935
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
2
Likes
3
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. USE OF BLOOD PRODUCTS & rFVIIa in OBSTETRICS Navneet Magon
  • 2. Should BLOOD be an Essential Medicine?NM 2
  • 3. James Blundell NM 3
  • 4. NM 4
  • 5. RED BLOOD CELLS NM 5
  • 6. NM 6 What they do…………....?
  • 7. NM 7 ………….make the blood carry more oxygen
  • 8. RED BLOOD CELLS • Approved name: Red Blood Cells • Also referred to as Packed Cells, Red Cells, Packed Red Blood Cells, RBCs • Erythrocytes concentrated from whole blood donations by centrifugation or collected by apheresis • Anticoagulated with CPDA NM 8American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
  • 9. RED BLOOD CELLS • Hematocrit ranges from about 50-65% to about 65-80% ( depends on preservative-anticoagulant used) • 50-65% in case AS, 65-80% in case CPDA, CPD • One pack contains ~ 50 mL of donor plasma • Increase of Hb in an adult (who is not bleeding or hemolyzing) by ~ 1 g/dL or Hct by 3% NM 9 American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007
  • 10. RBC: Transfusion Trigger • Historically, transfused to keep Hb > 10 g/dL 1 • Hb > 10 g/dL: NO 2 • Hb < 6 g/dL: TRANSFUSE 2 • Hb 6-10 g/dL: CONSIDER 2 - Any indication of organ ischemia - Rate and magnitude of any potential or actual bleeding - Patient’s intravascular volume status and risk of complications due to inadequate oxygenation NM 10 1. Goodnough et al. Transfusion medicine: first of two parts N Engl J Med 1999;340(6):438–47 2. Practice guidelines for perioperative blood transfusion and adjuvant therapies. An updated report by the ASA task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology 2006;105:
  • 11. RBC: Transfusion Trigger • 50% incidence of silent MI in patients admitted in ICU with PPH & hypovolemic shock [1] • Risk factors: Hb < 6.0 g/dL SBP < 88 mm Hg or DBP < 50 mm Hg HR > 115 bpm • Obstetricians trigger: 8 g/dl [2] NM 1. Karpati et al. High incidence of MI during PPH Anesthesiology 2004;100(1): 30-6 2. Matot et al. A survey of physicians’ attitudes toward blood transfusion in patients undergoing cesarean section. Am J Obstet Gynecol 2004;190(2):462–7 11
  • 12. RBC Transfusion: Take care !!! • Follow electrolytes, esp potassium levels • Give calcium after every 4-5 packs of PRBCs NM Foley: Obstetric Intensive care manual; 2nd Ed 13
  • 13. NM 14 PLATELETS
  • 14. PLATELETS • Approved names: Platelets; Platelets Pheresis • Platelets: RDPs, whole blood derived platelets, randoms, platelet concentrates • Platelets Pheresis: SDPs. NM 15
  • 15. PLATELETS: RDPs • Derived from Whole Blood • Contains ≥5.5 x 1010 platelets in ~ 50 mL of plasma • Stored at 220 C for 5 days / 7 days, continuous agitation • No viable platelets in stored blood at 40 C after 48 hrs • Platelet viability (pH< 6.0) & bacterial contamination NM 16 Hoffbrand: Postgraduate Haematology 5th Ed 2005, Clinical blood transfusion
  • 16. PLATELETS: SDPs • Obtained using automated instrumentation by Plateletpheresis • Contains ≥3.0 x 1011 platelets in about 250 mL of plasma • Reduce donor exposure, HLA compatability • Leukoreduced because of apheresis collection NM Hoffbrand: Postgraduate Haematology 5th Ed 2005, Clinical blood transfusion 17
  • 17. PLATELETS: Transfusion Trigger Surgical and obstetric patients with microvascular bleeding ◦ Usually require transfusion if the platelet count is <50 x 109 /l ◦ Rarely require therapy if it is >100 x 109 /l ◦ With intermediate platelet counts (50-100 x 109 /l)-based on the patient's risk for more significant bleeding ◦ Massive transfusions Vaginal deliveries may be undertaken with platelet counts less than 50 x 109 /l Platelet transfusion may be indicated despite an apparently adequate platelet count if there is known platelet dysfunction and microvascular bleeding NM Practice guidelines for perioperative blood transfusion and adjuvant therapies. An updated report by the ASA task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology 2006;105: 18
  • 18. PLATELETS: Response to therapy • Measure platelet count from 10 minutes to 3 hours after transfusion. • Expect an adult platelet count increment of: ~ 5-10,000/ mm3 for each RDP ~ 30-60,000/ mm3 for each SDP • ~ 7.1 x 109 platelets/L (~1 RDP) are consumed daily in endothelial support functions NM Slichter et al. Factors affecting post transfusion platelet increments, platelet refractoriness, and platelet transfusion intervals in thrombocytopenic patients. Blood 2005;105:4106-14. 19
  • 19. PLATELETS: Response to therapy • Response to platelet transfusion is adversely affected by Fever Sepsis Splenomegaly Severe bleeding Consumptive coagulopathy HLA alloimmunization Certain drugs e.g. amphotericin NM Slichter et al. Factors affecting post transfusion platelet increments, platelet refractoriness, and platelet transfusion intervals in thrombocytopenic patients. Blood 2005;105:4106-14. 20
  • 20. PLATELETS: Response to therapy • ABO-incompatible platelets may be transfused, but have a shorter life span 1 • Rh compatibility should be considered in the obstetric population • Rh immune globulin should be administered if Rh-positive platelets are administered to an Rh- negative individual 2 NM 1. Yazer MH. The blood bank ‘‘black box’’ debunked: pretransfusion testing explained.CMAJ 2006;174(1) 2. Menitove JE. Immunoprophylaxis for D- patients receiving platelet transfusions from D+ donors? 21
  • 21. NM 22
  • 22. NM 23FROZEN PLASMA
  • 23. FROZEN PLASMA • Approved name: Fresh frozen plasma (FFP) • Noncellular portion of blood, prepared from whole blood or collected by apheresis • Volume of the unit ~ 250 mL but variations expected • FFP when frozen at -180 C to - 300 C within 6-8 h of collection, contains all coagulation factors • Plasma frozen within 24 hours (FP24) and thawed plasma may contain variably reduced levels of Factor V and Factor VIII NM 24
  • 24. FROZEN PLASMA • Must be ABO-compatible with the recipient’s red cells 1 • Group AB Plasma is suitable for all blood types • Frozen Plasma must be thawed (20-30 min); infused immediately or stored at 1-6o C for up to 24 hours 2 • FFP and FP24 may be relabeled as Thawed Plasma & used as a source of stable coagulation factors for up to 5 days 2 NM 1. Yazer MH. The blood bank ‘‘black box’’ debunked: pretransfusion testing explained.CMAJ 2006;174(1) 2. American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007 25
  • 25. FROZEN PLASMA: Transfusion Trigger • Correct multiple coagulation factor deficiencies • Plasma transfusion should be guided by coagulation testing • INR > 2 (some > 1.5) or aPTT > 1.5 • Clinical evidence of bleeding, if assays not available • Dosage ~ 10-20 mL/kg NM American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007 26
  • 26. NM 27
  • 27. NM 28
  • 28. NM 29
  • 29. Learning from the wars………. NM Shaz et.al. Transfusion management of trauma patients. Anesth Analg. 2009; 108:219-22 30 RBC to FFP ratio close to 1
  • 30. FROZEN PLASMA: Indications • Active bleeding or risk of the same due to deficiency of multiple coagulation factors • Severe bleeding due to warfarin therapy, or urgent reversal of warfarin effect • Massive transfusion with coagulopathic bleeding • Bleeding or prophylaxis of bleeding for a known single coagulation factor deficiency for which no concentrate is available NM American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007 31
  • 31. FROZEN PLASMA: Contraindications • Increasing blood volume or albumin concentration • Coagulopathy that can be corrected with administration of Vitamin K • Normalizing abnormal coagulation screen results, in the absence of bleeding NM 32
  • 32. NM 33 CRYOPRECIPITATE
  • 33. CRYOPRECIPITATE • Approved name: Cryoprecipitated Antihemophilic Factor (AHF) • Also referred to as cryoprecipitate, cryo • Prepared by thawing one unit of FFP between 1- 6o C and recovering the cold insoluble precipitate • Cryo is refrozen within 1 hour NM 34
  • 34. CRYOPRECIPITATE • Concentrated levels of Fibrinogen (~150 mg) Factor VIII:C (~80IU) Factor VIII:vWF Factor XIII Fibronectin • 5-20mL of plasma NM 35
  • 35. CRYOPRECIPITATE • An acellular blood component • Compatibility testing is unnecessary, & Rh type need not be considered • CMV testing and leukoreduction are not required • Frozen cryoprecipitate has to be thawed • Thawed cryo to be kept at room temperature and transfused as soon as possible after thawing (4 h, if units pooled after thawing; 6 h, if single unit, or pooled before thawing) NM 36
  • 36. CRYOPRECIPITATE • Two units of Cryo (150-250mg/unit) contains as much fibrinogen as one unit of FFP (2-4mg/ml) • One unit of cryoprecipitate per 10 kg of body weight raises plasma fibrinogen concentration by ~ 50 mg/dL in the absence of continued consumption or massive bleeding NM Practice guidelines for perioperative blood transfusion and adjuvant therapies. An updated report by the ASA task force on perioperative blood transfusion and adjuvant therapies. Anesthesiology 2006;105: 37
  • 37. CRYOPRECIPITATE: Transfusion Trigger • Fibrinogen <40 mg/dl • Fibrinogen <100 mg/dl with bleeding or surgery • DIC in obstetric patient • Factor XIII deficiency • vWD with bleeding or surgery NM 38
  • 38. Know Your Blood bank WellNM 39
  • 39. NM 40
  • 40. rFVIIa • Acts by TF dependent & TF independent pathway • 30 to 90 mcg/kg i/v every 2 hours until hemostasis is achieved • Adequate levels of platelets and clotting factors • Risk of thrombosis NM Fuller et al. Blood Component Therapy in Obstetrics Obstet Gynecol Clin N Am 34 (2007) 443–458 41
  • 41. NM Magon N, Babu KM. Recombinant factor VIIa in post-partum hemorrhage: A new weapon in obstetrician's armamentarium. North Am J Med Sci 2012;4:157-62. 42
  • 42. NM Magon N, Babu KM. Recombinant factor VIIa in post-partum hemorrhage: A new weapon in obstetrician's armamentarium. North Am J Med Sci 2012;4:157-62. 43
  • 43. rFVIIa • Role? • How to monitor its clinical effect? • How safe is it? • How cost effective? NM 44
  • 44. Massive Transfusion Bloody vicious cycle NM Cosgriff N et al. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma 1997;42(5): 857–62 45
  • 45. Transfusions: How innocuous are they? Immunologic Complications: Immediate • Hemolytic transfusion reaction • Immune-mediated platelet destruction • Febrile non-hemolytic reaction • Allergic reactions • Anaphylactoid reactions • TRALI NM American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007 46
  • 46. Transfusions: How innocuous are they? Immunologic Complications: Delayed • Alloimmunization to antigens of red cells, white cells, platelets, or plasma proteins • Delayed hemolytic reaction • Post-transfusion purpura (PTP) • Graft-vs-host disease (GVHD) NM American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007 47
  • 47. Transfusions: How innocuous are they? Non-immunologic Complications • Transmission of infectious disease • Bacterial contamination • Circulatory overload • Hypothermia • Metabolic complications NM American Red Cross: Practice Guidelines for Blood Transfusion II Ed 2007 48
  • 48. BLOOD TO GIVE OR NOT TO GIVE NM 49
  • 49. THANK YOU NM 50