Transfusion Therapy


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  • Objectives of BLT

    1. To increase circulating blood volume after surgery, trauma, or hemorrhage
    2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia
    3. To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets, albumin)

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Transfusion Therapy

  1. 1. Transfusion Therapy Dr. Shailendra.V.L. Specialist in Anaesthesia, Al Bukariya General hospital.
  2. 2. Introduction <ul><li>Commonly practiced be all specialties </li></ul><ul><li>Very, very important to understand basics </li></ul><ul><li>Know the implications & complications </li></ul><ul><li>Mandatory to know all the fine details to ensure safety of the patients </li></ul>
  3. 3. Indications for Transfusions <ul><li>To increase intravascular volume </li></ul><ul><li>To increase oxygen carrying capacity </li></ul>
  5. 5. Indications for blood transfusion <ul><li>↓ O 2 carrying capacity = difficult to determine </li></ul><ul><li>Hct & Hb = show extreme variability from one patient to another </li></ul><ul><li>Overall medical judgement mandatory </li></ul>
  6. 6. American College of Surgeons classes of Acute Hemorrhage
  7. 7. Clinical Judgment <ul><li>Cardiovascular status </li></ul><ul><li>Age </li></ul><ul><li>Anticipated additional blood loss </li></ul><ul><li>Arterial oxygenation </li></ul><ul><li>Mixed venous oxygen tension </li></ul><ul><li>Cardiac output </li></ul><ul><li>Blood volume </li></ul>
  8. 8. Documentation <ul><li>Increased scrutiny of transfusions needs proper documentation of the reasons for blood transfusions </li></ul><ul><li>Clear indications necessitating transfusion of blood or blood products need to be written in the case file </li></ul>
  9. 9. A.S.A practice guidelines <ul><li>Transfusion rarely indicated when Hb> 10 g/dl </li></ul><ul><li>Transfusion always indicated when Hb < 6 g/dl </li></ul><ul><li>Hb 6-10 : use packed cells </li></ul><ul><li>Use of single Hb trigger – not recommended </li></ul><ul><li>Preoperative autologus blood donation recommended </li></ul><ul><li>Intra operative & post operative blood recovery recommended </li></ul><ul><li>Acute normo-volemic hemodilution to be practiced </li></ul><ul><li>Measure to ↓ blood loss like deliberate hypotension to be practiced </li></ul>
  10. 10. Habibi et al guidelines <ul><li>Blood loss > 20% of blood volume when more than 100 ml </li></ul><ul><li>Hb < 8 g/dl </li></ul><ul><li>Hb < 10 g/dl with major disease </li></ul><ul><li>Hb 10 g/dl with autologus blood </li></ul><ul><li>Hb < 12 g/dl & ventilator dependent </li></ul>
  11. 11. <ul><li>“ We merely await advances in technology that will enable us to measure directly the value of concern & thereby free us from arguments over which surrogate (eg., Haemoglobin) to measure and what value indicates the need for augmented Oxygen delivery ” - Weiskoff </li></ul>
  12. 12. <ul><li>“ If given a choice, would you want your own blood or allogenic / bank blood ” ??? </li></ul>
  13. 13. Autologus blood <ul><li>Assumed to be safe (probably is) much safer than allogenic blood </li></ul><ul><li>Safe as it doesn’t transfer infection </li></ul><ul><li>Complications: </li></ul><ul><ul><li>Anaemia </li></ul></ul><ul><ul><li>Administration of wrong unit ( 1 in 100,000) </li></ul></ul><ul><ul><li>Post-transfusion immuno-suppresion </li></ul></ul>
  14. 14. Compatibility testing <ul><li>ABO grouping </li></ul><ul><li>Rh typing </li></ul><ul><li>Cross matching </li></ul><ul><li>Antibody screening </li></ul>
  15. 16. Compatibility testing <ul><li>Tests demonstrates harmful antigen-antibody interactions in vitro, so that in vivo reactions are prevented </li></ul><ul><li>ABO group specific </li></ul><ul><li>Rh + or – ( 85%= Rh +ve, 15% = Rh –ve) </li></ul><ul><li>Cross match: compatibility between recipient plasma & donor cells </li></ul><ul><li>Antibody screen for: </li></ul><ul><ul><li>Hepatitis B, C </li></ul></ul><ul><ul><li>HIV I , II </li></ul></ul><ul><ul><li>VDRL </li></ul></ul>
  16. 17. Cross match v/s Type & screen
  17. 18. Cross match <ul><li>Trial transfusion within test tube in which donor RBC are mixed with the recipient serum to detect a potential for serious transfusion reactions </li></ul>
  18. 19. Cross match <ul><li>3 phases: </li></ul><ul><ul><li>I phase: Immediate phase </li></ul></ul><ul><ul><li>II phase: Incubation phase </li></ul></ul><ul><ul><li>III phase: Anti-globulin phase </li></ul></ul>
  19. 20. I phase – Immediate phase <ul><li>Done @ room temperature </li></ul><ul><li>To check against ABO typing errors </li></ul><ul><li>Takes 1 – 5 minutes </li></ul><ul><li>Detects ABO, MN, P & Lewis system incompatibilities </li></ul>
  20. 21. II Phase – Incubation Phase <ul><li>Incubation @ 37 * C with Albumin or low-ionic strength system </li></ul><ul><li>Aids in detection of incomplete antibodies </li></ul><ul><li>Incubation with Albumin @ 37* C for 45” </li></ul><ul><li>With low-ionic-strength saline incubation @ 37*C for 10 – 20” </li></ul>
  21. 22. III Phase - Anti-globulin phase <ul><li>Addition of anti-globulin sera to incubated test tubes </li></ul><ul><li>Antihuman antibodies present in sera, attaches to antibody globulin on RBC causing agglutination </li></ul><ul><li>Detects most incomplete antibodies & Rh, Kell, Kid & Duffy groups </li></ul>
  22. 23. Antibody Screening <ul><li>Done to prevent reactions between transfused donor units </li></ul><ul><li>Trail transfusion between recipient serum & commercially supplied RBC’s </li></ul><ul><li>These RBC’s have optimal number of antigens </li></ul>
  23. 24. Type & Screen <ul><li>Here blood is set aside after: </li></ul><ul><ul><li>ABO & Rh grouping </li></ul></ul><ul><ul><li>Antibody screening </li></ul></ul><ul><ul><li>Cross matching is excluded </li></ul></ul>
  24. 25. Maximal Surgical blood order schedule <ul><li>Every hospital has its own schedule </li></ul><ul><li>Our Hospital: </li></ul><ul><ul><li>For Lap Cholecystectomy : 2 units </li></ul></ul><ul><ul><li>For LSCS : 2 units </li></ul></ul><ul><ul><li>For normal delivery : nil </li></ul></ul><ul><ul><li>Major Orthopaedic procedures : 2 units </li></ul></ul><ul><ul><li>Open Prostatectomy : 2 units </li></ul></ul>
  25. 26. Maximum Surgical blood order schedule <ul><li>Problems with this: </li></ul><ul><ul><li>Blood unavailable for 24 – 48 hours for others </li></ul></ul><ul><ul><li>Leads to outdating of blood </li></ul></ul><ul><ul><li>Blood bank needs large quantities of blood </li></ul></ul><ul><ul><li>Actual usage exceeds the cross matched blood </li></ul></ul>
  26. 27. Is Cross Match really needed??? <ul><li>Anti A, Anti B, Anti Rh (D) most common significant antibody </li></ul><ul><li>ABO – Rh typing = 99.80% safe </li></ul><ul><li>+ antibody screen = 99.94% safe </li></ul><ul><li>++ Cross match = 99.95% safe </li></ul>
  27. 28. Emergency Transfusion <ul><li>In Emergency situations: </li></ul><ul><ul><li>Type specific partially cross matched blood </li></ul></ul><ul><ul><li>Type specific un-cross matched blood </li></ul></ul><ul><ul><li>Type O, Rh negative, un-cross matched blood </li></ul></ul>
  28. 29. Type specific, partially cross matched blood <ul><li>Takes 1 – 5 minutes </li></ul><ul><li>Patient’s serum + Donor’s RBCs @ room </li></ul><ul><li>▼ temp </li></ul><ul><li>Centrifuge it </li></ul><ul><li>▼ </li></ul><ul><li>Look under microscope for </li></ul><ul><li>▼ </li></ul><ul><li>Agglutination </li></ul>
  29. 30. Type specific, uncross matched blood <ul><li>Relatively safe , but do not use indiscriminately </li></ul><ul><li>Caution in patients who were pregnant before / have received transfusions earlier </li></ul><ul><li>1 in 1000 patient have antibody detected in cross match </li></ul>
  30. 31. Type O, Rh - blood <ul><li>> 2 units if transfused, do not give type specific blood </li></ul><ul><li>If given causes major hemolysis of donor RBC </li></ul><ul><li>Type specific can be used only after blood bank certifies that the antibodies are low levels </li></ul>
  31. 32. Storage of blood <ul><li>ACD solution </li></ul><ul><ul><li>Acid-Citrate-Dextrose solution </li></ul></ul><ul><li>CPDA solution </li></ul><ul><ul><li>Citrate-Phosphate-Dextrose-Adenine solution </li></ul></ul><ul><li>Heparin </li></ul><ul><ul><li>Rarely used in neonates as blood has to be transfused within 4 hours after collection </li></ul></ul>
  32. 33. ACD solution <ul><li>Anti coagulant, preservative in which blood is stored @ 1 – 4* C </li></ul><ul><li>Tri-sodium citrate= 2.2 gram </li></ul><ul><li>Citric acid = 0.8 gram </li></ul><ul><li>Dextrose = 2.5 gram </li></ul><ul><li>Water to = 100ml </li></ul><ul><li>ph = 5.5 </li></ul><ul><li>67.5 ml of ACD solution mixed with 420 – 450 ml of blood </li></ul><ul><li>Blood can be stored for 21 days only </li></ul>
  33. 34. CPDA solution <ul><li>Citrate-Phosphate-Dextrose-Adenine CPDA </li></ul><ul><ul><li>Anti coagulant, preservative in which blood is stored @ 1-6*C </li></ul></ul><ul><ul><li>Citrate: anti coagulant , acts by binding Ca+ </li></ul></ul><ul><ul><li>Phosphate: buffer </li></ul></ul><ul><ul><li>Dextrose: red-cell energy source, continues glycolysis </li></ul></ul><ul><ul><li>Adenine: help RBCs to resynthesis ATPs extends storage time from 21 to 35days </li></ul></ul>
  34. 35. CPDA solution <ul><li>Tri-sodium citrate = 26.3 grams </li></ul><ul><li>Citric acid = 3.27 grams </li></ul><ul><li>Sodium dihydrogen=2.22 grams </li></ul><ul><ul><li>phosphate </li></ul></ul><ul><li>Dextrose = 25.5 grams </li></ul><ul><li>Adenine = </li></ul><ul><li>63 ml of CPD mixed with 450 ml of whole blood </li></ul><ul><li>Blood can be stored for 32 days only </li></ul>
  35. 36. CPDA + Adsol <ul><li>Addition of Adsol: </li></ul><ul><ul><li>Extends shelf-life to 42 days </li></ul></ul><ul><ul><li>Glucose </li></ul></ul><ul><ul><li>Adenine </li></ul></ul><ul><ul><li>Mannitol </li></ul></ul><ul><ul><li>Sodium chloride </li></ul></ul>
  36. 37. CPDA + Nutricel <ul><li>Addition of Nutricel : </li></ul><ul><ul><li>Extends shelf-life to 42 days </li></ul></ul><ul><ul><li>Glucose </li></ul></ul><ul><ul><li>Adenine </li></ul></ul><ul><ul><li>Citrate </li></ul></ul><ul><ul><li>Phosphate </li></ul></ul><ul><ul><li>Sodium chloride </li></ul></ul>
  37. 38. Blood Shelf-life <ul><li>ACD solution: 21 days </li></ul><ul><li>CPDA : 35 days </li></ul><ul><li>CPDA + Adsol As-1 : 42 days </li></ul><ul><li>CPDA + Nutricel As-3: 42 days </li></ul><ul><li>Criteria for shelf life of stored blood: 70% of transfused RBC should be in circulation @ 24 hours post - transfusion </li></ul>
  38. 39. Blood storage <ul><li>Stored at 1-5* C </li></ul><ul><li>Slows down rate of Glycolysis in RBCs by 40 times the body temperature </li></ul>
  39. 40. Properties of Stored Blood
  40. 41. Frozen storage <ul><li>RBC mixed with glycerol & frozen to -79*C </li></ul><ul><li>RBC’s are freed from glycerol before transfusion </li></ul><ul><li>Freeing from glycerol is complicated & expensive </li></ul><ul><li>Advantages: </li></ul><ul><ul><li>rarer groups can be stored for many years </li></ul></ul><ul><ul><li>2-3 DPG level maintained & hence useful </li></ul></ul>
  41. 42. Complications of blood transfusion <ul><li>Changes in O 2 transport </li></ul><ul><li>Coagulation problems </li></ul><ul><li>Dilutional thrombocytopenia </li></ul><ul><li>Low factors V & VII </li></ul><ul><li>Citrate toxicity </li></ul><ul><li>Disseminated Intravascular Coagulation </li></ul><ul><li>Hemolytic transfusion reaction </li></ul><ul><li>Hypothermia </li></ul><ul><li>Acid base imbalance </li></ul>
  42. 43. Changes in O 2 transport <ul><li>Stored Blood: </li></ul><ul><ul><li>ODC shifted to left { Valtis-Kennedy effect 1954} </li></ul></ul><ul><ul><li>ODC shifted to left in recipient depending on volume & storage time of transfused blood </li></ul></ul><ul><ul><li>Conflicting results of studies, difficult to conclude </li></ul></ul>
  43. 44. Effect on ODC curve
  44. 45. Coagulation problems <ul><li>Caused by combination of factors: </li></ul><ul><ul><li>Volume of blood transfused </li></ul></ul><ul><ul><li>Duration of hypotension – hypo perfusion </li></ul></ul><ul><ul><li>Dilution of coagulation factors – DIC </li></ul></ul><ul><li>Clinical features: </li></ul><ul><ul><li>Oozing from surgical field </li></ul></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><li>Gingival bleeding </li></ul></ul><ul><ul><li>Petechial hemorrhage </li></ul></ul><ul><ul><li>Bleeding from venepuncture sites </li></ul></ul><ul><ul><li>Ecchymosis </li></ul></ul>
  45. 46. Dilutional thrombocytopenia <ul><li>Stored blood @ 4*C damages platelets </li></ul><ul><li>On transfusion platelets are trapped in Reticulo-Endothelial system </li></ul><ul><li>6 hours stored blood = 50% platelet activity </li></ul><ul><li>24 – 48 hours stored blood = 5% platelet activity </li></ul>
  46. 47. Platelet transfusion <ul><li>Platelet count < 75000 causes bleeding </li></ul><ul><li>Studies with conflicting evidence </li></ul><ul><ul><li>Reed et al = showed no benefit of prophylactic platelet transfusion </li></ul></ul><ul><ul><li>Collin’s et al = emphasize on platelet count monitoring </li></ul></ul>
  47. 48. Low Factors V & VIII <ul><li>Factor V & VIII decrease 15 – 50 % by 21 days storage </li></ul><ul><li>Packed RBC’s have fewer coagulation factors </li></ul><ul><li>Only 5 – 20% of Factor V & 30 % of Factor VIII needed for hemostasis </li></ul><ul><li>Massive blood transfusion will not decrease Factor V, VIII below these levels </li></ul>
  48. 49. Citrate toxicity <ul><li>Not due to citrate ion but because citrate binds to ionic Ca+ </li></ul><ul><li>Signs of Citrate toxicity: </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Narrow pulse pressure </li></ul></ul><ul><ul><li>Elevated intraventricular end-diastolic pressure </li></ul></ul><ul><ul><li>Elevated CVP </li></ul></ul><ul><li>R x is with 1 gram Calcium Chloride IV </li></ul>
  49. 50. Citrate Toxicity <ul><li>Conditions promoting Citrate toxicity: </li></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Liver disease </li></ul></ul><ul><ul><li>Liver transplantation </li></ul></ul><ul><ul><li>Hyperventilation </li></ul></ul><ul><li>Rx is with 1gram 10% Calcium chloride slow IV </li></ul><ul><ul><li>Irritant to veins </li></ul></ul><ul><ul><li>CaCl 2 provides 3 times more Ca than Ca gluconate </li></ul></ul>
  50. 51. Temperature <ul><li>Blood stored @ 1-4*C in fridge </li></ul><ul><li>Easiest & safest is to pass blood through plastic coils immersed in warm water (38*C) bath </li></ul><ul><li>Many blood warmers available </li></ul><ul><li>Hypothermia ▼ 30*C = ventricular irritability & cardiac arrest </li></ul>
  51. 52. Temperature
  52. 53. Acid-Base abnormalities <ul><li>ph of ACD solution alone is 5.0 </li></ul><ul><li>ph of CPD solution alone is 5.5 </li></ul><ul><li>ph of CPD blood is 7.0 at start </li></ul><ul><li>ph of CPD blood @ 21 days storage is 6.9 </li></ul><ul><li>PaCO 2 @ 21 days is 150 – 200mm Hg </li></ul><ul><li>No role of prophylactic NaHCO3 administration </li></ul><ul><li>ABG must be done & NaHCO3 given as needed </li></ul>
  53. 54. Infusion of micro-aggregates <ul><li>Standard blood set filter is 170 micron size </li></ul><ul><li>Micropore filter with 40 micron size is suggested </li></ul><ul><ul><li>Clear advantages not established , still evolving </li></ul></ul><ul><ul><li>Claimed it will prevent micro-aggregates from reaching lungs </li></ul></ul>
  54. 55. Transfusion reactions <ul><li>Hemolytic transfusion reaction </li></ul><ul><ul><li>Early </li></ul></ul><ul><ul><li>Delayed </li></ul></ul><ul><li>Non-hemolytic transfusion reaction </li></ul>
  55. 56. Hemolytic transfusion reactions <ul><li>10 years: ’76 –’85 = 328 deaths reported to FDA in USA </li></ul><ul><ul><li>159 = acute hemolytic reactions </li></ul></ul><ul><ul><li>23 = delayed reactions </li></ul></ul><ul><li>Out of 159 = 137 due to errors in ABO compatibility </li></ul><ul><ul><li>> 50% errors occurred after blood issued from bank (errors committed by nurses & physicians in OR, ER & wards) </li></ul></ul><ul><li>Incidence of Hemolytic reaction is 1 in 300,000 to 1 in 700,000 </li></ul>
  56. 57. Hemolytic transfusion reaction <ul><li>Signs & symptoms: </li></ul><ul><ul><li>Chills </li></ul></ul><ul><ul><li>nausea </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Chest & flank pain </li></ul></ul><ul><li>Under GA signs: </li></ul><ul><ul><li>Hemoglobinuria (high colored urine) </li></ul></ul><ul><ul><li>Bleeding diathesis ( ↑ ooze @ surgical site) </li></ul></ul><ul><ul><li>Unexplained Hypotension </li></ul></ul>
  57. 58. Hemolytic transfusion reaction
  58. 59. Haptoglobin – Hemoglobin complex <ul><li>Haptoglobin-Protein binds about 100mg Hb/ml plasma </li></ul><ul><li>Later it is cleared in R-E system </li></ul><ul><li>Excess free Hb in circulation cause problems </li></ul>
  59. 61. Treatment <ul><li>Stop transfusion </li></ul><ul><li>Send blood & urine samples to lab </li></ul><ul><li>Blood bank to check all records </li></ul><ul><li>Main effect is on the kidney & coagulation system </li></ul>
  60. 62. Lab investigations for hemolytic transfusion reactions <ul><li>Serum Haptoglobin </li></ul><ul><li>Plasma Hb </li></ul><ul><li>Urine Hb </li></ul><ul><li>Serum bilirubin </li></ul><ul><li>Direct anti-globulin: confirms antibody attached to transfused RBC’s </li></ul><ul><li>Repeat ABO & Rh </li></ul><ul><li>Platelets </li></ul><ul><li>Prothrombin time - PT </li></ul><ul><li>Partial thromboplastin time – PTT </li></ul><ul><li>Send blood sachet to bank for confirmation </li></ul>
  61. 63. Effect on renal system <ul><li>Exact cause for acute renal failure not known </li></ul><ul><li>Common hypothesis is Hb in form of acid hematin precipitates in DCT causing mechanical tubal blockage </li></ul>
  62. 64. Treatment <ul><li>Maintain urinary output > 75ml / hour </li></ul><ul><li>IV fluids – Ringer Lactate </li></ul><ul><li>Diuretics: Mannitol & Lasix </li></ul><ul><li>Maintain CVP 10 – 15 cms H2o </li></ul><ul><li>Alkalization of urine to prevent precipitation of acid hematin in DCT is questionable but since it is easy – NaHCO3 – 40 – 70meq / liter </li></ul>
  63. 65. Effect on Coagulation system <ul><li> RBC stroma severed </li></ul><ul><li> ▼ releases </li></ul><ul><li> Erythropoietin </li></ul><ul><li>▼ activates </li></ul><ul><li>Intrinsic pathway </li></ul><ul><li>▼ </li></ul><ul><li> Fibrin formation </li></ul><ul><li>▼ consumption of </li></ul><ul><li> Platelets / Factors I, II, V, VII </li></ul><ul><li> (Consumption Coagulopathy) </li></ul><ul><li>▼ </li></ul><ul><li> D.I.C. </li></ul>
  64. 66. Delayed hemolytic transfusion reaction <ul><li>Occurs after variable delay (2-21days) </li></ul><ul><li>In reciepient’s sensitized to RBC antigens by previous blood transfusions/pregnancy </li></ul><ul><li>Antibody levels too low to cause RBC destructions </li></ul><ul><li>Anamaestic Response: RBC destruction occurs only when level of antobody is increased after secondary stimulus </li></ul><ul><li>Presents with ↓ Hct value / hemoglobinuria </li></ul><ul><li>Delayed reaction mostly due to Rh & Kidd systems </li></ul><ul><li>Pre-transfusion testing enable to detect very low levels of antibody in potential recipients </li></ul>
  65. 67. Non-hemolytic transfusion reactions <ul><li>Either febrile or allergic in nature </li></ul><ul><li>Symptoms: chills, fever, headache, myalgia, nausea, non-productive cough, urticaria with itching </li></ul><ul><li>Due to foreign protein in transfused blood </li></ul><ul><li>No clear consensus to discontinue transfusion </li></ul><ul><li>Treated with antihistamines </li></ul>
  66. 68. Infectivity of Blood <ul><li>Donor blood tested for: </li></ul><ul><ul><li>Hepatitis B </li></ul></ul><ul><ul><li>Hepatitis C </li></ul></ul><ul><ul><li>HIV – 1 </li></ul></ul><ul><ul><li>HIV – 2 </li></ul></ul><ul><ul><li>HIV – Ag ( P24 antigen) </li></ul></ul><ul><ul><li>HTLV I and II </li></ul></ul><ul><ul><li>Serologic test for syphilis </li></ul></ul>
  67. 69. Post transfusion disease transmission <ul><li>HIV </li></ul><ul><li>Hepatitis B </li></ul><ul><li>Hepatitis C </li></ul><ul><li>Infectious mononucleosis </li></ul><ul><li>Malaria </li></ul><ul><li>Brucellosis </li></ul><ul><li>Syphilis </li></ul><ul><li>Yersinia entercolitica infection </li></ul><ul><li>Toxoplasmosis </li></ul><ul><li>Trypanasomiasis </li></ul><ul><li>Leishmaniasis </li></ul><ul><li>Typhus </li></ul><ul><li>Filariasis </li></ul><ul><li>Measles </li></ul><ul><li>Salmonellosis </li></ul><ul><li>Colorado-tick fever </li></ul>
  68. 70. Blood component therapy <ul><li>“ Basic philosophy is based on the concept that patients are best treated by administration of specific fraction of blood that they lack ” </li></ul>
  69. 71. Blood Component therapy
  70. 72. Packed Red cells <ul><li>Blood loss < 25% of blood volume can be treated with P –RBC </li></ul><ul><li>> 25% blood loss to be treated with whole blood </li></ul><ul><li>Component therapy helps bank in retaining plasma & components which can be used for other patients </li></ul>
  71. 73. Packed RBC v/s Whole blood
  72. 74. Dilution of Packed RBCs <ul><li>Packed RBC’s contain 100 ml Adsol solution </li></ul><ul><li>Still if needed, crystalloid added (take care no Calcium in it, as it causes clot formation) </li></ul><ul><li>Ideal dilutent is 5% dextrose ½ saline or 5% dextrose in normal saline </li></ul>
  73. 75. Leukocyte reduced blood <ul><li>To minimize febrile, non-hemolytic reactions </li></ul><ul><li>To reduce allo-immunizations </li></ul><ul><li>To reduce transfusion transmitted infections </li></ul><ul><li>Methods: </li></ul><ul><ul><li>In–line filter in collection bag </li></ul></ul><ul><ul><li>Collected blood can be filtered </li></ul></ul><ul><ul><li>Blood filtered before transfusion </li></ul></ul>
  74. 76. Fresh Frozen Plasma <ul><li>Indications: </li></ul><ul><ul><li>Generalized bleeding in wound, which cannot be controlled with sutures /diathermy (oozing) </li></ul></ul><ul><ul><li>PTT > 1.5 times normal </li></ul></ul><ul><ul><li>Platelet count > 7OOOO (to make sure, it is not the cause of bleeding) </li></ul></ul>
  75. 77. Platelet concentrates <ul><li>Prepared by differential centrifugation </li></ul><ul><li>Whenever possible ABO-compatible platelets used </li></ul><ul><li>Each unit increases count by 10,000/m3 after one hour of transfusion </li></ul><ul><li>↓ platelet levels in spite of transfusions: </li></ul><ul><ul><li>Splenomegaly </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Active bleeding </li></ul></ul>
  76. 78. Indications for platelet concentrations <ul><li>Difficult to define </li></ul><ul><li>Platelet count < than 50000/m3 </li></ul>
  77. 79. Fresh Frozen Plasma <ul><li>Prepared at the time blood is obtained from the donor </li></ul><ul><li>Contains all plasma proteins & factors V and VIII </li></ul><ul><li>10 – 15 ml/kg body weight FFP is given </li></ul><ul><li>Not used for volume expansion </li></ul>
  78. 80. ASA Task Force guidelines for FFP <ul><li>Urgent reversal of Warfarin therapy </li></ul><ul><li>Correction of micro vascular bleeding when PT, PTT > than 1.5 times normal </li></ul><ul><li>Correction of micro vascular bleeding when PT & PTT cannot be done </li></ul>
  79. 81. Cryoprecipitate <ul><li>Contains Factor VIII, fibrinogen, fibrinectin & Von-Willerbrand factor </li></ul><ul><li>Given as ABO compatible </li></ul><ul><li>Given @ 200ml/hour infusion </li></ul><ul><li>Given by filter as rapidly as possible </li></ul><ul><li>Infusion completed by 6 hours of thawing </li></ul>
  80. 82. Plasma Protein <ul><li>From pooled donor plasma </li></ul><ul><li>Heat inactivated </li></ul><ul><li>Used as volume expanders </li></ul><ul><li>Source of plasma proteins in hypo protenimic states </li></ul>
  81. 83. Plasma Volume Expanders <ul><li>These are solutions with same osmolarity as plasma which are given instead of plasma or blood, in order to restore circulating volume </li></ul><ul><li>Ideal plasma expander: </li></ul><ul><ul><li>Be isotonic to plasma </li></ul></ul><ul><ul><li>Remain intravascularly for long time </li></ul></ul><ul><ul><li>Be easily eliminated from the body </li></ul></ul><ul><ul><li>Does not cause hypersensitivity </li></ul></ul><ul><ul><li>Does not interfere with blood group serology </li></ul></ul><ul><ul><li>Has a long shelf life </li></ul></ul>
  82. 84. Plasma Volume Expanders <ul><li>Haemaccel </li></ul><ul><li>Dextran 40; 70 </li></ul><ul><li>Hetastarch </li></ul>
  83. 85. Haemaccel <ul><li>3.5% Degraded Gelatin </li></ul><ul><li>Molecular weight is 35,000 </li></ul><ul><li>Intra-vascular half life of 4 hours </li></ul><ul><li>85% excreted by kidneys </li></ul><ul><li>It does not interfere with blood grouping & cross matching </li></ul><ul><li>Draw backs: </li></ul><ul><ul><li>Rarely causes acute hypersensitivity reaction </li></ul></ul><ul><ul><li>Hence not used nowadays </li></ul></ul>
  84. 86. Dextran - 40 <ul><li>Has molecular weight 40000 </li></ul><ul><li>Supplied as 10% solution in 5% dextrose </li></ul><ul><li>Used to ↓ blood viscosity & cellular aggregation </li></ul><ul><li>Used to improve micro-circulation during low flow states </li></ul><ul><li>Used prophylactically to ↓ incidence of DVT </li></ul>
  85. 87. Dextran - 70 <ul><li>Polysaccharides – long chains of glucose units </li></ul><ul><li>Available as 6% solution with 5% dextrose or normal saline </li></ul><ul><li>Dextran-70 has molecular weight 70000 </li></ul><ul><li>Causes platelet adhesiveness & interfere with clotting </li></ul><ul><li>Can cause anaphylactic reaction </li></ul>
  86. 88. Hydroxy-ethyl starch <ul><li>6% solution starch molecule resembles glycogen </li></ul><ul><li>Very effective volume expander like 5% Albumin </li></ul><ul><li>Dose not more than 20ml/kg/day </li></ul><ul><li>Interferes with blood grouping & antibody screening </li></ul>
  87. 89. Artificial blood <ul><li>Perfluro chemical emulsion – Fluosoa –DA </li></ul><ul><li>Used in patients who refuse blood transfusion (Jevohah’s witness) </li></ul><ul><li>Carries small amount O2 only when PaO2 is > than 300mm Hg </li></ul>
  88. 90. Genetic engineering <ul><li>Ray of hope for blood products in future </li></ul><ul><ul><li>Stroma free Hb </li></ul></ul><ul><ul><li>Genetically engineered Hb </li></ul></ul><ul><ul><li>Liposome encapsulated Hb </li></ul></ul>
  89. 91. Informed Consent <ul><li>A well explained informed consent is mandatory prior to all blood or component therapy </li></ul><ul><li>Clear documentations in the chart for the need for transfusion is mandatory </li></ul><ul><li>Intra operative transfusion necessitates clear reason for transfusion of blood or component therapy in the anesthesia record </li></ul>
  90. 92. Jehovah’s Witness <ul><li>Object for administration of blood or any blood products due to religious belief </li></ul><ul><li>Objections stems from their interpretation of the Bible (… to keep abstaining from … blood) & not any medical reasons </li></ul><ul><li>They refuse autologous blood too </li></ul><ul><li>They accept non-blood containing products like crystolloids </li></ul><ul><li>They clearly consent for abstaining from transfusions and relieve the Doctor from damages arising from it </li></ul>
  91. 93. Thank you