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Blood Tranfusion Therapy

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Blood Tranfusion Therapy

  1. 1. Blood transfusionBlood 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
  2. 2. 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
  3. 3. 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
  4. 4. Functions of Blood  Regulation: – plasma contains pH buffers – plasma water absorbs heat – plasma solutes maintain osmolality
  5. 5. 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
  6. 6. Fluid compartmentsFluid compartments ICF ECF Interstitial PlasmaCapillary Membrane Cell Membrane ~ 15% of body weight ~ 40% of body weight ~ 5% of body weight
  7. 7. Blood volume plasma + cells and cell fragments ~ 5% ~ 2-3% of body weight+
  8. 8. Banked Whole bloodBanked Whole blood  No components have been removed.No components have been removed.  consists of red blood cells, white bloodconsists of red blood cells, white blood cells and platelets in plasmacells and platelets in plasma  can be stored for 5 weekscan be stored for 5 weeks
  9. 9. Banked Whole bloodBanked Whole blood  Transfusions of whole blood areTransfusions of whole blood are rarelyrarely required.required.  stored in the refrigeratorstored in the refrigerator, the platelets, the platelets are useless and factors V and VIII areare useless and factors V and VIII are greatly reduced.greatly reduced.
  10. 10. Banked Whole bloodBanked Whole blood  transfusion of whole blood may betransfusion of whole blood may be necessarynecessary – certain types of major surgerycertain types of major surgery  ACUTE BLOOD LOSS > 15%ACUTE BLOOD LOSS > 15% – major trauma such as a car accident ormajor trauma such as a car accident or gunshot wound requiring emergencygunshot wound requiring emergency surgerysurgery
  11. 11. Changes in rbcChanges in rbc  ReductionReduction – 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 sourcePoor source – PlateletsPlatelets – clotting factors V and VIIIclotting factors V and VIII
  12. 12. Changes in rbcChanges in rbc  Increase levelsIncrease levels – Lactic acid from 20 to 150mg/dlLactic acid from 20 to 150mg/dl – Potassium concentration to 32 mEq/dlPotassium concentration to 32 mEq/dl – Ammonium concentration from 50Ammonium concentration from 50 to 680 mg/dlto 680 mg/dl  Hemolysis is insignificantHemolysis is insignificant
  13. 13. Fresh whole bloodFresh whole blood  Blood that is administered within 24Blood that is administered within 24 hours of its donationhours of its donation  Rarely indicatedRarely indicated  Poor source of platelets and factor VIIIPoor source of platelets and factor VIII
  14. 14. Blood ComponentBlood Component TherapyTherapy  The process of transfusing only thatThe process of transfusing only that portion of the blood needed by theportion of the blood needed by the patientpatient  It allows a single unit (one pint) of donatedIt allows a single unit (one pint) of donated blood to benefit more than one patientblood to benefit more than one patient  Red blood cells and platelets are the mostRed blood cells and platelets are the most frequently transfused blood componentsfrequently transfused blood components
  15. 15. Packed red cellsPacked red cells  The red cells from a donor unit, dilutedThe red cells from a donor unit, diluted with plasma to a hematocrit of aboutwith plasma to a hematocrit of about 75%.75%.  Volume is about 200 mL.Volume is about 200 mL.  Storing red cells (just above freezing)Storing red cells (just above freezing) allows survival for 42 daysallows survival for 42 days – but unfortunately decreases 2,3-DPGbut unfortunately decreases 2,3-DPG – ruins the platelets and neutrophils.ruins the platelets and neutrophils.
  16. 16. Packed red cellsPacked red cells  Red blood cells contain hemoglobinRed blood cells contain hemoglobin – carries oxygen throughout the body.carries oxygen throughout the body. – Essentially provides oxygen-carryingEssentially provides oxygen-carrying capacitycapacity  Product of choice for most clinicalProduct of choice for most clinical situations  situations  
  17. 17. Packed red cellsPacked red cells  Recent advances have made itRecent advances have made it possible to store red blood cells for uppossible to store red blood cells for up to 42 days. to 42 days.   IndicationsIndications – acute trauma before surgeryacute trauma before surgery – people with anemia who are havingpeople with anemia who are having surgerysurgery
  18. 18. Packed red cellsPacked red cells  fastest way to increase the oxygen-fastest way to increase the oxygen- delivering capacity of the blood.delivering capacity of the blood.  A unit of whole blood or packed redA unit of whole blood or packed red cells willcells will raise the hematocrit by 3%raise the hematocrit by 3% and theand the hemoglobin by 1-1.5 gm/dLhemoglobin by 1-1.5 gm/dL
  19. 19. Frozen red cellsFrozen red cells  reduces the risk of infusing antigens,reduces the risk of infusing antigens, or foreign bodies, that the body mightor foreign bodies, that the body might regard as potentially dangerousregard as potentially dangerous – Previously sensitized patientsPreviously sensitized patients  Not available for use in emergencyNot available for use in emergency situationssituations  Rbc viability is improvedRbc viability is improved  ADP and 2,3 DPG maintainedADP and 2,3 DPG maintained
  20. 20. Platelet concentratesPlatelet concentrates  Component: platelets, 50 ml plasmaComponent: platelets, 50 ml plasma  cellular components that help in thecellular components that help in the clotting process. clotting process.   Platelets are stored for up to five daysPlatelets are stored for up to five days at room temperature.at room temperature.
  21. 21. Platelet concentratesPlatelet concentrates  IndicationIndication – used if there is a platelet disorderused if there is a platelet disorder – when massive blood loss has occurredwhen massive blood loss has occurred
  22. 22. Platelet concentratesPlatelet concentrates  Platelets must be stored at roomPlatelets must be stored at room temperature, so are good only for 5 days ortemperature, so are good only for 5 days or less.less.  One unit will usually raise the platelet countOne unit will usually raise the platelet count 5-10k/microliter.5-10k/microliter.  Check one hour after transfusion.Check one hour after transfusion. – If the platelet count does not increase asIf the platelet count does not increase as expected (“refractoriness”), suspect DIC orexpected (“refractoriness”), suspect DIC or immune platelet destruction (anti-HLA).immune platelet destruction (anti-HLA).
  23. 23. Fresh frozen plasmaFresh frozen plasma  From freshly donated bloodFrom freshly donated blood  Source of vit k- dependent clottingSource of vit k- dependent clotting factorsfactors  Only source of factor VOnly source of factor V
  24. 24. Fresh Frozen PlasmaFresh Frozen Plasma  IndicationIndication – For coagulopathy and deficient clottingFor coagulopathy and deficient clotting factorsfactors  1 unit FFP = 3% increase in CF levels1 unit FFP = 3% increase in CF levels  At least 30% to ensure adequate coagulationAt least 30% to ensure adequate coagulation
  25. 25. CryoprecipitatedCryoprecipitated antihemophilic factorantihemophilic factor  an antihemophilic concentratean antihemophilic concentrate  prepared from plasma and is rich inprepared from plasma and is rich in clotting factors clotting factors   used in people with hemophilia, vonused in people with hemophilia, von Willebrand's disease or other majorWillebrand's disease or other major coagulation abnormalities to preventcoagulation abnormalities to prevent or control bleedingor control bleeding
  26. 26. CryoprecipitatedCryoprecipitated antihemophilic factorantihemophilic factor  Its contents are the major portion ofIts contents are the major portion of the Factor VIII, von Willebrand factor,the Factor VIII, von Willebrand factor, fibrinogen, Factor XIII and fibronectinfibrinogen, Factor XIII and fibronectin present inpresent in freshly drawn andfreshly drawn and separated plasmaseparated plasma..
  27. 27. Replacement therapyReplacement therapy  Serologic compatibilitySerologic compatibility – A, B, O and Rh groupsA, B, O and Rh groups  CrossmatchingCrossmatching – Donors’ red cell and Recipients’ seraDonors’ red cell and Recipients’ sera  Major crossmatchMajor crossmatch
  28. 28. Serologic compatibilitySerologic compatibility
  29. 29. Rh groupsRh groups  Rh negative recipients should beRh negative recipients should be transfused with Rh negative bloodtransfused with Rh negative blood  Rh negative groupRh negative group –– 15% of the population15% of the population – Limited supplyLimited supply
  30. 30.  A 50M pedestrian was hit by a car whileA 50M pedestrian was hit by a car while crossing Commonwealth Ave. Hecrossing Commonwealth Ave. He sustained blunt trauma to the pelvis andsustained blunt trauma to the pelvis and an open femoral fracture on the L. At thean open femoral fracture on the L. At the ER, BP 90/50 HR 110 RR 28 with anER, BP 90/50 HR 110 RR 28 with an estimated blood loss of 1L.estimated blood loss 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
  31. 31.  After 2L of crystalloids, the BP 90/60After 2L of crystalloids, the BP 90/60 HR 120 RR 32. The SROD decided toHR 120 RR 32. The SROD decided to give blood. What is the best blood productgive blood. What is the best blood product to administer?to administer? – A. Fresh Whole BloodA. Fresh Whole Blood – B. packed RBCB. packed RBC – C. plasma expandersC. plasma expanders – D. plateletsD. platelets
  32. 32. 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 loss as % 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
  33. 33.  A CT scan of abdomen was done withA CT scan of abdomen was done with findings of Grade 2 renal injury, L withfindings of Grade 2 renal injury, L with incomplete fracture, L iliac. He underwentincomplete fracture, L iliac. He underwent ORIF, L femur and placed on completeORIF, L femur and placed on complete bed rest. He was transfused 2 ‘u’ WB andbed rest. He was transfused 2 ‘u’ WB and 4 ‘u’ pRBC.4 ‘u’ pRBC.  What are the possible complications ofWhat are the possible complications of blood transfusion?blood transfusion?
  34. 34. Risks from a unit ofRisks from a unit of ordinary red cellsordinary red cells  Non-hemolytic febrile transfusionNon-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 unknownmaybe 1 in ~20,000; fatality rate unknown
  35. 35. Transfusion reactionsTransfusion reactions  Hemolytic ReactionsHemolytic Reactions  Allergic ReactionsAllergic Reactions  Febrile ReactionsFebrile Reactions  Bacterial ContaminationBacterial Contamination  Circulatory OverloadCirculatory Overload  HypothermiaHypothermia
  36. 36. Transfusion reactionsTransfusion reactions  AlloimmunizationAlloimmunization  Graft Versus Host DiseaseGraft Versus Host Disease (GVHD)(GVHD)  Transfusion related acute lungTransfusion related acute lung injury (TRALI)injury (TRALI)
  37. 37. Allergic / urticarialAllergic / urticarial transfusion reactionstransfusion reactions  most common usually due to allergiesmost common usually due to allergies to specific proteins in the donor’sto specific proteins in the donor’s plasmaplasma  can be avoided with futurecan be avoided with future transfusions by pretreatment withtransfusions by pretreatment with antihistamines or steroids.antihistamines or steroids.
  38. 38. Allergic / urticarialAllergic / urticarial transfusion reactionstransfusion reactions  Some get “hay fever / hives /Some get “hay fever / hives / wheezing” from transfusionswheezing” from transfusions – you can continue the transfusion whenyou can continue the transfusion when they are betterthey are better – and in the future, pre-treat with anand in the future, pre-treat with an antihistamine.antihistamine.
  39. 39. Allergic / urticarialAllergic / urticarial transfusion reactionstransfusion reactions  For severe (anaphylaxis), RBC’s andFor severe (anaphylaxis), RBC’s and platelets are washed to remove allplatelets are washed to remove all plasma indicated.plasma indicated. – Very fast, spectacular illness afterVery fast, spectacular illness after transfusion only a few mL.transfusion only a few mL. – IgA deficiency should be considered inIgA deficiency should be considered in the case of anaphylactic reactions.the case of anaphylactic reactions.
  40. 40. Hemolytic ReactionsHemolytic Reactions  transfusion of an incompatible bloodtransfusion of an incompatible blood component.component.  Most are due to naturally occurringMost are due to naturally occurring antibodies in the ABO antigen systemantibodies in the ABO antigen system and Rh groupsand Rh groups  may cause hemoglobin induced renalmay cause hemoglobin induced renal failure and a consumptivefailure and a consumptive coagulopathy (DIC).coagulopathy (DIC).
  41. 41. Immediate hemolyticImmediate hemolytic transfusion reactiontransfusion reaction  1 in ~25,000 units; fatality rate 10%1 in ~25,000 units; fatality rate 10%  A disaster, almost always preventable.A disaster, almost always preventable.  Most often due toMost often due to ABO mismatch dueABO mismatch due to a clerical errorto a clerical error (i.e., the wrong blood(i.e., the wrong blood and/or the wrong recipient).and/or the wrong recipient).
  42. 42. Clinical presentationClinical presentation  fever, hypotension, nausea, vomiting,fever, hypotension, nausea, vomiting, tachycardia, dyspnea, chest or backtachycardia, dyspnea, chest or back pain, flushing and severe anxietypain, flushing and severe anxiety  pain at the infusion sitepain at the infusion site  Post-op site:Post-op site: diffuse bleedingdiffuse bleeding hypotensionhypotension
  43. 43. Intravascular destruction of RBCIntravascular destruction of RBC HemoglobinemiaHemoglobinemia free hemoglobin in the serumfree hemoglobin in the serum HemoglobinuriaHemoglobinuria may be noted and, may be themay be noted and, may be the firstfirst sign of hemolysissign of hemolysis Clinical presentationClinical presentation
  44. 44. Renal toxicityRenal toxicity Precipitation of free hemoglobin in thePrecipitation of free hemoglobin in the tubulestubules Acute tubular necrosisAcute tubular necrosis
  45. 45. DICDIC In the circulation, Ag-Ab complexesIn the circulation, Ag-Ab complexes Activates complement system,Activates complement system, factor XIIfactor XII DICDIC
  46. 46. TreatmentTreatment  Stop the transfusionStop 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 bleedingfluids, diuresis and transfusion support for bleeding
  47. 47. patient’s identificationpatient’s identification checked..checked..  repeat crossmatch, bacterial culturerepeat crossmatch, bacterial culture  most errors are clerical or due tomost errors are clerical or due to misidentification of a patient at the bedside.misidentification of a patient at the bedside.  mislabelled specimen sent to the blood bankmislabelled specimen sent to the blood bank  A fatal hemolytic transfusion reaction occursA fatal hemolytic transfusion reaction occurs about once in 100,000 transfusionsabout once in 100,000 transfusions
  48. 48. DO NOT ASSUME IT IS SOMEONEDO NOT ASSUME IT IS SOMEONE ELSE'S RESPONSIBILITY TOELSE'S RESPONSIBILITY TO CHECK!CHECK!
  49. 49. Laboratory criteriaLaboratory criteria  Free hemoglobin > 5mg/dlFree hemoglobin > 5mg/dl  Serum haptoglobulin of > 50 mg/dlSerum haptoglobulin of > 50 mg/dl  Serologic criteriaSerologic criteria – INCOMPATIBILITY OF THE DONORINCOMPATIBILITY OF THE DONOR THE RECIPIENTTHE RECIPIENT  Positive Coombs’ testPositive Coombs’ test
  50. 50. Delayed hemolyticDelayed hemolytic transfusion reactionstransfusion reactions  1 in ~6000; fatality rate 0.1%1 in ~6000; fatality rate 0.1%  previously sensitized to an antigenpreviously sensitized to an antigen through transfusion or pregnancythrough transfusion or pregnancy  can result in symptomatic orcan result in symptomatic or asymptomatic hemolysis several daysasymptomatic hemolysis several days (2-10 days) after a subsequent(2-10 days) after a subsequent transfusiontransfusion
  51. 51. Delayed hemolyticDelayed hemolytic transfusion reactionstransfusion reactions  Not preventable.Not preventable.  A new antibody or anamnesticA new antibody or anamnestic response has probably developed.response has probably developed.
  52. 52. Clinical presentationClinical presentation  Extravascular hemolysis, mild anemia,Extravascular hemolysis, mild anemia, indirect hemoglobinemiaindirect hemoglobinemia  These present with flu-like symptomsThese present with flu-like symptoms recurrent anemia and jaundicerecurrent anemia and jaundice
  53. 53. Delayed hemolyticDelayed hemolytic transfusion reactionstransfusion reactions  Most frequent: Transfusion of RhMost frequent: Transfusion of Rh positive red blood cells to an Rhpositive red blood cells to an Rh negative woman of childbearing agenegative woman of childbearing age can result in sensitization andcan result in sensitization and hemolytic disease of the newborn inhemolytic disease of the newborn in future pregnancies.future pregnancies.
  54. 54. Febrile nonhemolyticFebrile nonhemolytic transfusion reactiontransfusion reaction  Defined to be a rise in temperature of 1Defined to be a rise in temperature of 1 °°CC or more and >=38or more and >=38 °°C, within 24 hours ofC, within 24 hours of transfusiontransfusion  without evidence of a hemolytic transfusionwithout evidence of a hemolytic transfusion reaction.reaction.  due to cytokines in the blood itself and/ordue to cytokines in the blood itself and/or produced in the patient from sensitivity toproduced in the patient from sensitivity to the HLA molecules on platelets and whitethe HLA molecules on platelets and white cells.cells.
  55. 55. Febrile transfusionFebrile transfusion reactionsreactions  usually occur due to sensitization tousually occur due to sensitization to antigens on cell components,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
  56. 56. Bacterial contaminationBacterial contamination  RareRare  Acquired from contaminated collection bagsAcquired from contaminated collection bags  Poor cleaning of donor’s skinPoor cleaning of donor’s skin  reactions are quite severe with high feverreactions are quite severe with high fever  rigors and/or other systemic symptoms suchrigors and/or other systemic symptoms such as hypotension, nausea or vomiting.as hypotension, nausea or vomiting.
  57. 57. Bacterial contaminationBacterial contamination  Gram – organisms, Pseudomonas sp.,Gram – organisms, Pseudomonas sp., Coliforms and YersiniaColiforms 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 theDon’t transfuse the greengreen oror purplepurple units.units.
  58. 58. Bacterial contaminationBacterial contamination  Platelets (kept at room temperaturePlatelets (kept at room temperature during their 5-day shelf life) are a greatduring their 5-day shelf life) are a great culture mediumculture medium – especially for skin staphylococci from theespecially for skin staphylococci from the venipuncturevenipuncture
  59. 59. Bacterial contaminationBacterial contamination  Transfusion should be stopped andTransfusion should be stopped and the bag sent for gram stain andthe 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 culturesThe patient should have blood cultures obtained and, if appropriate, IVobtained and, if appropriate, IV antibiotic therapy begunantibiotic therapy begun
  60. 60. Transfusion Related AcuteTransfusion Related Acute Lung Injury (TRALI)Lung Injury (TRALI)  ““noncardiogenic pulmonary edema”noncardiogenic pulmonary edema”  Defined to be ARDS within 6 hours ofDefined to be ARDS within 6 hours of a transfusion with no other clear causea transfusion with no other clear cause  occurs when donor plasma containsoccurs when donor plasma contains an antibody, usually against thean antibody, usually against the patient's HLA or leukocyte specificpatient's HLA or leukocyte specific antigens.antigens.
  61. 61. Transfusion Related AcuteTransfusion Related Acute Lung Injury (TRALI)Lung Injury (TRALI)  1 in 1000; fatality rate <1% with estimates1 in 1000; fatality rate <1% with estimates varying widelyvarying widely  The cause is apparently antibodies in theThe cause is apparently antibodies in the donor plasma against the patient’sdonor plasma against the patient’s neutrophils (which, in the sick, areneutrophils (which, in the sick, are marginated in the lung vessels).marginated in the lung vessels).  The donor antibodies cause theseThe donor antibodies cause these neutrophils to release toxic products andneutrophils to release toxic products and thus produce ARDS.thus produce ARDS.
  62. 62. Clinical presentationClinical presentation  dyspnea, hypotension and feverdyspnea, hypotension and fever typically begin 30 minutes to 6 hourstypically begin 30 minutes to 6 hours after transfusionafter transfusion  chest x-ray shows diffuse non-specificchest x-ray shows diffuse non-specific infiltrates , “white out”infiltrates , “white out”
  63. 63. TreatmentTreatment  Therapy is primarily supportiveTherapy is primarily supportive  Ventillatory support may be requiredVentillatory support may be required for several days before resolution..for several days before resolution..  The Blood Center should be notifiedThe Blood Center should be notified so that the donor may be tested forso that the donor may be tested for antibodies against the patientantibodies against the patient
  64. 64. Electrolyte toxicity (i.e.,Electrolyte toxicity (i.e., potassium)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 administeredIf hemolyzed blood is administered (i.e., the blood was left on the radiator(i.e., the blood was left on the radiator or the warmer was too hot), the resultor the warmer was too hot), the result will bewill be catastrophiccatastrophic..
  65. 65. HypothermiaHypothermia  Red cells and fresh frozen plasma areRed cells and fresh frozen plasma are chilly.chilly.  An extra blanket is much safer than anAn extra blanket is much safer than an electric warming coilelectric warming coil – even “the special warmers for blood thateven “the special warmers for blood that don’t go over 104o F / 40o C.don’t go over 104o F / 40o C.
  66. 66. OvertransfusionOvertransfusion  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
  67. 67. Transmission ofTransmission 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
  68. 68. Transmission ofTransmission of diseasesdiseases  Hepatitis AHepatitis A – Very rare, no asymptomatic carrier stateVery rare, no asymptomatic carrier state  ““Pathogen in-activation system”Pathogen in-activation system” – Reduces infectious levels of all virusesReduces infectious levels of all viruses and bacteria transmissible by transfusionand bacteria transmissible by transfusion
  69. 69. Pathogen InactivationPathogen Inactivation TechnologyTechnology  for platelets and plasmafor platelets and plasma use the smalluse the small molecule amotosalen HClmolecule amotosalen HCl which penetrateswhich penetrates cells and pathogens and targets DNA andcells and pathogens and targets DNA and RNA. RNA.   Once docked inside DNA and RNA,Once docked inside DNA and RNA, amotosalen is activated by ultraviolet lightamotosalen is activated by ultraviolet light to form a chemical crosslink that locks-upto form a chemical crosslink that locks-up the strands of nucleic acid,the strands of nucleic acid, blockingblocking replicationreplication. .   for red cells uses a different moleculefor red cells uses a different molecule (S-(S- 303)303) that forms crosslinks when activatedthat forms crosslinks when activated by a change in pH. by a change in pH. 
  70. 70. Pathogen InactivationPathogen Inactivation TechnologyTechnology  Treated pathogens areTreated pathogens are inactivated by the process andinactivated by the process and can no longer multiply andcan no longer multiply and cause disease.cause disease.
  71. 71. Pathogen InactivationPathogen Inactivation TechnologyTechnology
  72. 72. Indications for bloodIndications for blood replacementreplacement  Improve in Oxygen-carrying capacityImprove in Oxygen-carrying capacity  Volume replacementVolume replacement  Replacement of clotting factorsReplacement of clotting factors
  73. 73. What are the indications for RBCWhat are the indications for RBC transfusion in the critically ill surgicaltransfusion in the critically ill surgical patient?patient?  No single measure can replace good clinicalNo single measure can replace good clinical judgement as the basis for decision-makingjudgement as the basis for decision-making regarding perioperative transfusionregarding perioperative transfusion  Mild-to-mod anemia does not contribute toMild-to-mod anemia does not contribute to perioperative morbidityperioperative morbidity
  74. 74. .... indications for RBC transfusionindications for RBC 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 cardiopulmonary10g/dL for patients with cardiopulmonary diseasedisease  Wound healing and postop infection is notWound healing and postop infection is not influenced by normovolemic anemiainfluenced by normovolemic anemia  Transfusion should not be consideredTransfusion should not be considered substitute for good surgical and anestheticsubstitute for good surgical and anesthetic techniquetechnique
  75. 75. Volume replacementVolume replacement  Most common indication for BloodMost 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 contractedNormal in spite of severely contracted blood volumeblood volume
  76. 76. Blood loss of 1L in aBlood 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
  77. 77.  The theoretical “The theoretical “transfusion triggertransfusion trigger,” or,” or the critical point at which a physicianthe critical point at which a physician decides to transfuse a patientdecides to transfuse a patient
  78. 78. RBC InfusionRBC Infusion  Rarely for Hgb>10g/dLRarely for Hgb>10g/dL Usually for Hgb <7g/dLUsually for Hgb <7g/dL Decision based on risk forDecision based on risk for complications related to inadequatecomplications related to inadequate oxygenationoxygenation
  79. 79. Platelet InfusionPlatelet Infusion  Rarely for PLT>100,000Rarely for PLT>100,000 Usually for PLT<50,000Usually for PLT<50,000 For PLT between 50,000 and 100,000For PLT between 50,000 and 100,000 decision based on assessment of riskdecision based on assessment of risk
  80. 80. FFP InfusionFFP Infusion  Microvascular bleeding present andMicrovascular bleeding present and PT or PTT is 1.5 times normalPT or PTT is 1.5 times normal  In the absence of lab results: AfterIn the absence of lab results: After transfusion of 1 total blood volumetransfusion of 1 total blood volume
  81. 81. Transfusion indicationsTransfusion indications
  82. 82. PACKED RED CELLSPACKED RED CELLS  Hemoglobin less than 7 gm/dLHemoglobin less than 7 gm/dL  Preoperative hemoglobin less than 9 gm/dLPreoperative hemoglobin less than 9 gm/dL and operative procedures or other clinicaland operative procedures or other clinical situations associated with major predictablesituations associated with major predictable blood lossblood loss  Symptomatic anemia in a normovolemicSymptomatic anemia in a normovolemic patientpatient  Acute loss of at least 15% of estimatedAcute loss of at least 15% of estimated blood volume with evidence of inadequateblood volume with evidence of inadequate oxygen delivery following volumeoxygen delivery following volume resuscitationresuscitation
  83. 83. FRESH FROZENFRESH FROZEN PLASMAPLASMA  PT or PTT greater than 1.5 times the meanPT or PTT greater than 1.5 times the mean of the reference range (PT>16, PTT>39) inof the reference range (PT>16, PTT>39) in a non-bleeding patient scheduled toa non-bleeding patient scheduled to undergo surgery or invasive procedureundergo surgery or invasive procedure  Massive transfusion (more than 1 bloodMassive transfusion (more than 1 blood volume or 10 units) and coag tests are notvolume or 10 units) and coag tests are not yet availableyet available  Emergency reversal of coumadinEmergency reversal of coumadin anticoagulationanticoagulation  Coagulation factor deficiencyCoagulation factor deficiency
  84. 84. PLATELETSPLATELETS  Platelet count less than 20,000 in a non-bleedingPlatelet 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 impendingPlatelet count less than 50,000 and impending surgery or invasive procedure, patient activelysurgery or invasive procedure, patient actively bleeding, or outpatientbleeding, or outpatient  Patients during or after open heart surgery or intra-Patients during or after open heart surgery or intra- aortic balloon pump with diffuse bleedingaortic balloon pump with diffuse bleeding  Massive transfusion (more than 1 blood volume orMassive transfusion (more than 1 blood volume or 10 units) when platelet counts are not available10 units) when platelet counts are not available  Qualitative platelet defect (bleeding time greaterQualitative platelet defect (bleeding time greater than 9 minutes) with bleedingthan 9 minutes) with bleeding
  85. 85. Platelet concentratesPlatelet concentrates  Transfusion Guidelines:Transfusion Guidelines: – Platelet count < 20,000/mm3Platelet count < 20,000/mm3 – Platelet count <50,000/mm3Platelet count <50,000/mm3 if withif with microvascular bleedingmicrovascular bleeding – Complicated surgeries with >10 units of bloodComplicated surgeries with >10 units of blood transfused, with signs of microvascular bleedingtransfused, with signs of microvascular bleeding – Documented platelet dysfunction(prolonged BT,Documented platelet dysfunction(prolonged BT, abnormal plt function tests)abnormal plt function tests)
  86. 86. CRYOPRECIPITATECRYOPRECIPITATE  Fibrinogen less than 100 mg/dLFibrinogen less than 100 mg/dL  Fibrinogen less than 120 mg/dL with diffuseFibrinogen less than 120 mg/dL with diffuse bleedingbleeding  Von Willebrand disease or hemophiliaVon Willebrand disease or hemophilia unresponsive to desmopressin (DDAVP)unresponsive to desmopressin (DDAVP) and no appropriate factor concentratesand no appropriate factor concentrates availableavailable  Uremic bleeding if desmopressin isUremic bleeding if desmopressin is ineffectiveineffective  Factor XIII deficiencyFactor XIII deficiency
  87. 87. major indication formajor indication for whole blood transfusionwhole blood transfusion  some cases of cardiac surgerysome cases of cardiac surgery  massive hemorrhage when more thanmassive hemorrhage when more than 10 units of red blood cells are required10 units of red blood cells are required in any 24-hour periodin any 24-hour period
  88. 88. Massive transfusionMassive transfusion  Death by exsanguination has beenDeath by exsanguination has been described as the loss of 150 mL ofdescribed as the loss of 150 mL of blood per minute, which results in lossblood per minute, which results in loss of half the blood volume in 20 minutesof half the blood volume in 20 minutes  It has also been classified as bloodIt has also been classified as blood loss of more than 5,000 mLloss of more than 5,000 mL  10 units of blood transfused within 2410 units of blood transfused within 24 hourshours
  89. 89. Massive transfusionMassive transfusion  replacement of one entire blood volumereplacement of one entire blood volume within 24 hourswithin 24 hours  50% blood volume replacement within 350% blood volume replacement within 3 hourshours  transfusion of more than 20 units oftransfusion of more than 20 units of erythrocyteserythrocytes  requiring 4 units of blood within an hour withrequiring 4 units of blood within an hour with anticipation of ongoing usageanticipation of ongoing usage
  90. 90. Massive transfusionMassive transfusion  Most MTPs call for the use ofMost MTPs call for the use of uncrossmatched type O negative (O-)uncrossmatched type O negative (O-) blood as the first-line infusionblood as the first-line infusion preference.preference.
  91. 91. O negative bloodO negative blood  universality and timely availability fromuniversality and timely availability from hospital blood bankshospital blood banks  when used during massivewhen used during massive exsanguination is potential problemsexsanguination is potential problems with crossmatching and incompatibilitywith crossmatching and incompatibility later in the patient’s hospital staylater in the patient’s hospital stay – more than 4 unitsmore than 4 units
  92. 92. O+ bloodO+ blood  It has been shown to be generally safeIt has been shown to be generally safe and can help prevent blood shortagesand can help prevent blood shortages  administer to men andadminister to men and postmenopausal womenpostmenopausal women  To woman of childbearing age canTo woman of childbearing age can result in sensitizationresult in sensitization
  93. 93. Massive transfusionMassive transfusion complicationscomplications  Coagulopathy is caused by a dilutionalCoagulopathy is caused by a dilutional effect on the host's clotting factors andeffect on the host's clotting factors and platelets, as well as the lack ofplatelets, as well as the lack of platelets and clotting factors in packedplatelets and clotting factors in packed red blood cells.red blood cells.  Volume overloadVolume overload  HypothermiaHypothermia
  94. 94. Massive transfusionMassive transfusion complicationscomplications  HyperkalemiaHyperkalemia may be caused by lysis ofmay be caused by lysis of stored red cellsstored red cells  Metabolic acidosisMetabolic acidosis and hypokalemia may beand hypokalemia may be caused by the transfusion of a large amountcaused by the transfusion of a large amount of citrated cells.of citrated cells.  Hypocalcemia due to citrate toxicityHypocalcemia due to citrate toxicity maymay occur in those with hepatic failure,occur in those with hepatic failure, congestive heart failure (CHF), or other low-congestive heart failure (CHF), or other low- output states.output states. – It is increasingly uncommon with the use ofIt is increasingly uncommon with the use of component therapy.component therapy.
  95. 95. Massive transfusionMassive transfusion complicationscomplications  Use of blood from multiple donorsUse of blood from multiple donors increases the risk of hemolyticincreases the risk of hemolytic reactions as a consequence onreactions as a consequence on incompatibilityincompatibility
  96. 96. 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 t ransf usion productuniversal t ransf usion product ””  Hemoglobin solutionsHemoglobin solutions  Autologous tansfusionAutologous tansfusion  hemodilutionhemodilution
  97. 97. Methods ofMethods 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
  98. 98. Methods ofMethods of administering bloodadministering blood
  99. 99. Special concernSpecial concern  Jehovah’s Witnesses cannot accept donorJehovah’s Witnesses cannot accept donor packed red cells, platelets, white cells orpacked red cells, platelets, white cells or plasma, and cannot accept autologous orplasma, and cannot accept autologous or cell-cycled intraoperative transfusion.cell-cycled intraoperative transfusion.  The sect leadership used to be militantlyThe sect leadership used to be militantly anti-immunization, anti-germ theory, andanti-immunization, anti-germ theory, and anti-transplantation as wellanti-transplantation as well
  100. 100. Blood transfusionBlood transfusion therapytherapy Raymund AG Ong, MD FPCS FPALESRaymund AG Ong, MD FPCS FPALES Department of SurgeryDepartment of Surgery FEU-NRMF Medical CenterFEU-NRMF Medical Center

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