SURGERY TRANSFUSION INDICATIONS

1. BLOOD COMPONENTS AVAILABLE FOR CLINICAL
USE AND INDICATIONS FOR THEIR USE
PRESENTER: RAVI BHUSHAN
SIR GANGARAM HOSPITAL NEW DELHI
MODERATOR : DR NEERAJ DHAMIJA

2. OBJECTIVES OF TODAY’S TALK
Some background thoughts
Define the 4 basic blood components
Describe the contents “in the bag”
Overview of indications for use
Preliminary commentary on Patient Blood Management principles

3. WW II MEDIC ADMINISTERS IV BLOOD TO WOUNDED SOLDIER: THE
VALUE OF BLOOD TRANSFUSION WAS RECOGNIZED BEFORE
RANDOMIZED CONTROLLED TRIALS

4. BLOOD TRANSFUSION IS “UNAVOIDABLY UNSAFE”
High volume
High cost
High Risk
Problem prone

5. BASIC BLOOD COMPONENTS

6. BLOOD COMPONENTS
Prepared Sequentially , in a Hermetically Sealed Sterile System

7. BLOOD COMPONENTS
Whole blood
Separated from whole blood by centrifugation
Red Blood Cells (“The Red Stuff”)
Hemostatic components (“The Yellow Stuff”)
Plasma
Platelet concentrates
Cryoprecipitate

9. RED BLOOD CELL UNITS
Up to 510 ml total volume (volume may vary in accordance with local policies)
450 ml donor blood
63 ml anticoagulant preservative
(CPD-Adenine-1)
Hb% approx. 12g/dl
No functional platelets
No Labile coagulation factors(V and VIII)
42-day Shelf Life

10. RED BLOOD CELL UNITS
Infection risk: Not sterilized, so capable of transmitting any agent
Storage : Between +2°C and +6°C , Transfusion should be started
within 30 minutes of removal from refrigerator
Indications:
Red cell replacement in acute blood loss with hypovolemia
Exchange transfusion
Patients needing red cell transfusions where red cell
concentrates or suspensions are not available

11. RED BLOOD CELL UNITS
Contraindications:
Risk of volume overload in patients with:
Chronic anaemia
Incipient cardiac failure
Complete transfusion within 4 hours of commencement
Administration:
Must be ABO and Rh compatible with the recipient
Never add medication to a unit of blood
Complete transfusion within 4hrs

12. PACKED RBC
150-200 mL red cells from which most of plasma been removed
Hb content = 20g/100ml
Residual plasma = ~15 – 20 mL
Citrate anticoagulant / preservative = ~ 100 mL
Transfused to a “70-Kg man”, 1 unit of RBC raises the Hct ~ 3% and Hgb ~ 1.0
g/dL
To improve transfusion flow normal saline may be added using Y-pattern
transfusion set

13. LEUCOCYTE DEPLETED RBC
Concentrate containing <5 x106
WBC prepared by filtration through leucocyte depleting
filter
Hb concentration depend upon the product
Leucocyte significantly reduces risk of transmission of CMV
Minimizes WBC immunisation in repeated transfusions
Start transfusion within 30 mins
Complete transfusions within 4 hrs

14. RBC DOSING APPROPRIATE MANAGEMENT
Hemoglobin threshold < 7 g/dL
Stable non-bleeding adults for symptomatic anemias
Includes Hematology / Oncology patients receiving chemotherapy / radiation
therapy
Hemoglobin threshold < 8 g/dL
Acute coronary syndrome with ischemia
Traumatic brain injury or intracranial hypertension

15. RBC DOSING APPROPRIATE MANAGEMENT
“Don’t Give 2 when 1 will do!”
Transfuse what patients need, but not more
Transfuse 1 unit at a time; re-evaluate the patient & the laboratory response
Generally, most patients do not need to be transfused to ≥ 10 g / dL

16. UNITS OF PLASMA
On Average, 220 mL – 250 mL
FFP: Plasma separated from donated
whole blood by centrifugation, frozen
≤ 8 hours of collection
FP24: Frozen ≥ 8 hours, but ≤ 24
hours of collection
Thawed plasma: (5-day shelf life)

17. FRESH FROZEN PLASMA
Infection rate : Same as whole blood
Plasma separated from whole blood donation within 6 hrs of collection and rapidly
frozen to -25 degree or cooler
Normal plasma levels of stable clotting factors
Factor VIII level is 70% of normal fresh plasma levels
Storage: -25 degree or cooler upto 1 year
Before use, should be thawed in blood bank at 30-37 degree celcious
Once thawed should be stored at +2 to + 6 degree

18. FRESH FROZEN PLASMA
Indications:
Replacement of multiple coagulation deficiencies
Warfarin overdose
Large volume transfusions
DIC
TTP
Infuse as soon as possible after thawing

19. DEFINING THE INR
International Normalized Ratio:
(PTpatient / Geometric Mean PT Reference Range)ISI ,
INR are designed specifically for Coumadin treatment control, not as a criterion to
transfuse plasma!!
ISI used by local laboratories performing the ex vivo PT tests
The ISI reflects the responsiveness of a given thromboplastin to a reduction in Vitamin
K-dependent coagulation factors compared to WHO reference material.

20. LAB SCREENING TESTS NOT A TRIGGER TO TRANSFUSE
PLASMA
No increased risk of hemorrhage / oozing if the PT / aPTT is no more prolonged than
1.3 X upper limit of reference range
- or -
1.5 X midpoint of reference range
Lab Abnormality Clinical Coagulopathy

21. INR
Mean change of 0.03 INR units / unit of FFP transfused
Mildly abnormal PT’s don’t change much with FFP transfusion
INR’s above 3 have a more significant change per unit of FFP
Mildly prolonged PT values (13 – 17 sec) do not correlate with RBC loss
Only 10% of patients had the PT re-checked after transfusion!!
HOLLAND, ET AL, TRANSFUSION 2005;45:1234-5

22. INR
Pre-procedure coagulation tests are lousy predictors of who is going to bleed
Prophylactic plasma transfusion does not result in fewer bleeding events
J SEGAL, W DZIK, ET AL., TRANSFUSION 2005;45 (9): 1413-25

23. THE INR OF FRESH FROZEN PLASMA
The INR of FFP is 1.1 (0.9 to1.3)
Not surprising that giving FFP will
have little effect on minimally
elevated PT’s
FFP will affect the INR only if there
is a big difference between the FFP
and the patient’s plasma

24. WHAT TO DO WITH AN ELEVATED INR?
An elevated INR has NEVER been an “indication” to transfuse plasma or platelets!!
Practice Clinical Correlation:
How “elevated” is the value?
Why is the PT / INR elevated?
Is the patient bleeding?
Is the patient at risk for bleeding (e.g. planned invasive procedure)?
Is there any evidence that plasma transfusion will improve patient outcome?
Decision to transfuse is multi-factorial, never based solely on some
“number”.

25. REVIEW OF RCTS ON PLASMA EFFECTIVENESS
TRANSFUSION 2012;52: 1673-86.
• 80 trials (1966 – 2012),
covering prophylactic &
therapeutic plasma use
• Conditions such as
liver disease, cardiac
surgery, warfarin
reversal, burns,
shock, head injury
• No significant benefit
for use across a range of
indications!
.

26. PROPHYLACTIC PLASMA USE IN CRITICAL
CARE A RANDOMIZED CONTROLLED TRIAL
• Prolonged INR (1.5 – 3.0)
• CV catheter insertion
• Tracheostomy
• Chest tube
• Abscess drainage
• Outcomes:
 INR correction
 bleeding complications
 occurrence of lung injury
• Plasma (12 mL/Kg) reduced INR to < 1.5 in only 54%
• No difference in post-procedural bleeding
• No difference in lung injury scores, regardless
whether plasma was administered or not
Transfusion 2014, ePub June 9

27. PLASMA INDICATIONS
APPROPRIATE USAGE
(“Customary Dose” = 12 – 15 mL / Kg)
Thrombotic microangiopathies (TTP, HUS, etc.)
Multiple clotting factor deficiencies with INR ≥ 1.7
Bleeding not related to surgery
Ongoing bleeding, acute or chronic liver disease
Active bleeding with DIC
Prevention of intra-operative bleeding in patients with DIC or liver disease
Correction of micro-vascular bleeding in massive recipients
Single clotting factor deficiencies (specific factors not commercially available)
To correct congenial deficiencies of clotting factors

28. MISUSES OF PLASMA
As a volume expander
As a nutritional source
To enhance wound healing
Not a suitable source of immunoglobulins (e.g., in patients with severe
hypogammagloubulinemia)
Mild to moderate prolongation of PT or aPTT prior to invasive procedures

29. CRYOPRECIPITATE
Prepared from FFP collecting
precipitate formed during
controlled thawing at +4
degree and resuspending it
in 10-20 ml plasma
Stored at -25 degree for upto
1 year
Thawed upto 6 hrs

30. CRYOPRECIPITATE : CLINICAL INDICATIONS
Hypofibrinogenemia (< 200 mg/dL)
Fibrinogen deficiency with active bleeding or in patients at risk
Consumptive coagulopathies (e.g., DIC)
Uremic bleeding
Evident hemorrhagic stroke or intracranial bleeding in patients receiving TPA
Von Willebrand Disease or Hemophilia A (use only when commercial factor
concentrates are unavailable)
Dysfibrinogenemia (normal fibrinogen level)
Factor XIII deficiency

31. PLASMA DERIVATIVES
Human Albumin solutions:
Prepared by fractionation of large pools of donated plasma
Albumin 5% :50 mg/ml of albumin
Albumin 20%: 200 mg/ml of albumin
Indications: Replacement fluid in therapeutic plasma exchange
Diuretic resistant edema(Nephrotic syndrome)
Volume replacement in burn
Donot use for IV nutrition

32. PLASMA DERIVATIVES
Coagulation Factors:
Factor VIII concentrate:
Prepared from large pool of plasma
Chemically treated to reduce transmission of viruses
Vials of freeze dried proteins at 2-6 degree C
Treatment of Hemophilia A

33. PLASMA DERIVATIVES
Coagulation Factors:
Factor IX Concentrate:
Contains factor II, IX, X
Also called prothrombin complex concentrate
Infection risk and storage as per Factor VIII
Indication: Hemophilia B
Immediate correction of PT
Not advised in patients with liver disease of Thrombotic tendency

34. PLATELET CONCENTRATES
Volume: 45 – 65 ml/unit
Platelets (> 5.5 x 1010 in 90% tested per AABB
Standards)
Suspended in ~50ml volume of plasma
Collected, unrefrigerated whole blood is centrifuged
at low speed (soft spin) to separate platelet rich
plasma (PRP).
PRP is subjected to another centrifugation (hard
spin), then all but 50-60ml of supernatant plasma is
removed.

35. PLATELET CONCENTRATES
Random Donor Platelets(RDP):
Storage: Store at room temp (20-24C) with continuous gentle agitation upto 72 hrs
Do not store at 2-6 degree C
May go up to 24 hour without agitation
Shelf life: up to 5 days after collection (But should be transfused as soon after pooling )
Prepared from 4-6 donors pooled into 1 pack
Contains 5.5 x 1010 platelets in approx 50 ml of plasma
Adult : one unit / 10 kg body weight

36. PLATELET CONCENTRATES
Single Donor Platelets (SDP)
Collected from single donor using apheresis technique using blood cell separators
Contains > 3 X 1011 platelets in 150-300 ml
1 unit (equivalent to 6 units of RDP)
Storage : upto 72 hours at 20-24 degree
Therapeutic dose of RDP/SDP raises the platelet count by 30,000 -50,000/ l
in 70 kg in adult

37. APHARESIS
Removal of Whole Blood from a patient or donor => centrifuge => separate the
components => remove required component =>
return the others to the donor
Components that are usually separated
Plasma - Plasmapheresis
Platelets - Plateletpheresis
Leucocytes – Leucopharesis

38. DECIDING TO TRANSFUSE PLATELETS:
Why is your patient thrombocytopenic?
Medical vs. Surgical patient
Bleeding vs. Non-bleeding
Risks in surgical / obstetric patients
Type and extent of surgery
The ability to control bleeding
Actual / anticipated rate of bleeding
Factors affecting platelet function, such as medications, renal failure, extra-
corporeal circulation (e.g., bypass or ECMO), etc.

39. BLEEDING RISKS & PLATELET COUNT ARE
APPROXIMATELY CORRELATED
Platelet Count
(109
Likelihood of
Spontaneous Hemorrhage
< 5 High
5 – 10
Increased with
Trauma
Surgery
Ulceration
10- 50 Variably Increased
> 50 Exceedingly Unlikely

40. RECOMMENDATIONS FOR PLATELET TRANSFUSION
(“TRIGGER POINTS”)
Platelet Count
(109 / L) Transfusion Decision
< 5 Almost Always
≤ 10 – 20
Prophylaxis Window
for Medical Patients
< 50
Usually Indicated for major surgery,
endoscopic biopsies, liver biopsy
≤ 50 Active bleeding during massive transfusion,
cardiopulmonary bypass or DIC
50 – 100 Based on risk of bleeding
≥ 100
Uncommonly Indicated: Consider with
known platelet dysfunction, anti-platelet
drugs & microvascular bleeding

41. AVOID TRANSFUSING PLATELETS
In thrombocytopenia due to increased platelet destruction (immune / microangiopathic)
Idiopathic thrombocytopenic purpura (ITP)
Thrombotic thrombocytopenic purpura (TTP)
Other microangiopathies (HUS, HELLP syndrome)
In end-stage (cirrhotic) liver disease with splenomegaly
Platelet transfusion in these settings are rarely indicated and usually ineffective – the
patient incurs all the risks, all cost, little or no benefit

42. SURGERY AND ANAESTHESIA
 Most elective surgery do not result in sufficient blood loss to require transfusion
 There is rarely justification for use of preoperative blood transfusion to facilitate
elective surgery
 Minimize operative blood loss by:
 Meticulous surgery technique
 Use of vasoconstrictors
 Use of tourniquets
 Anaesthetic techniques
 Use of antifibrinolytic drugs

43. SURGERY AND ANAESTHESIA
 Identify and treat causes of anaemia before surgery
 Identify bleeding disorders and stop medications that impair hemostasis

44. THE BEST PATIENT BLOOD MANAGEMENT
RECOMMENDATION
Blood Transfusion is like marriage:
It should not be entered upon lightly,
Unadvisedly or wantonly, or
More often than is absolutely necessary

45. THANK YOU

46. DEVELOP TRANSFUSION TARGETS: INCORPORATE LABORATORY
TRIGGER NUMBERS WITH CLINICAL JUDGMENT

47. MONITORING OF TRANSFUSED PATIENTS
 Before & till 15 min of transfusion
 Hourly
 On completion
 After 4 hours
 Only NS & 5% albumin should be used to dilute blood

48.  Change IV set 12 hourly (filter clogs with risk of bacterial infection)
 Leucocyte depletion filters to be used especially in multi-transfused ( WBC < 5 x 10 6/
bag)
 Blood warming commonly required for:
 Large volume rapid transfusions:
 Adults: > 50 ml/kg/hour
 Children: > 15 ml/kg/hr
 Exchange transfusion in infants
 Pts with clinically significant cold agglutinins

49. MASSIVE BLOOD TRANSFUSION
 Replacement of one or more blood volumes within 24 hours (Widmann)
 Transfusion of about 10 units of whole blood or 20 units of red cells within 24 hours
 Replacement of more than 50% of the blood volume in 3 hours in an adult

50. MASSIVE BLOOD TRANSFUSION
 Surgical or Medical emergencies
 Cardiac or vascular surgeries
 Exchange transfusion in infants
 Obstetric cases
 In multiple trauma
 Liver transplantation

51. MASSIVE BLOOD TRANSFUSION
 Acidosis
 Due to Red cell metabolism
 Hyperkalemia
 Due to increased extra cellular K+
 Hypocalcemia
 Citrate binds serum calcium
 Depletion of coagulation factors & platelets

52. TRANSFUSION REACTIONS
 Immune mediated reactions
 Preformed donor or recipient antibody
 Non immunogenic reactions
 Chemical & physical properties of blood
 Additives

53. TRANSFUSION REACTIONS
 Immune/Immediate
 Immediate hemolytic transfusion reaction
(IHTR)
 NHFTR (Febrile reaction)
 Allergic (Urticarial)
 Anaphylaxis
 Noncardiogenic pulmonary edema

54. TRANSFUSION REACTIONS
 Immune/Delayed
 Delayed hemolytic transfusion reaction (DHTR) – same as IHTR
 Alloimmunization
 Posttransfusion purpura
 Graft versus host disease (GVHD)
 Immunosuppression

55. TRANSFUSION REACTIONS
 Nonimmune / Immediate
 Bacterial contamination (Fever & shock)
 Transfusion associated circulatory overload (TACO)
 Physical RBC damage – hemolysis
 Dilution of coagulation factors and platelets
 Emboli
 Hyperkalemia & hypocalcemia
 Patients underlying condition

56. TRANSFUSION REACTIONS
 Mild reaction
 Moderately severe reactions
 Life threatening

57. MILD
Slow the transfusion
Administer antihistamine IM
If no clinical improvement within 30 min treat as Moderately severe

58. MODERATELY SEVERE REACTIONS

59. MODERATELY SEVERE REACTIONS
 Stop the transfusion
 Replace the giving set and maintain IV line with NS
 Notify blood bank immediately
 Send blood sample to blood bank
 Antihistamine IV and oral PCM
 IV steroids and bronchodilators if anaphylactoid features
 Urine sample for hemolysis
 In clinical improvement, restart transfusion slowly

60. LIFE THREATENING

61. LIFE THREATENING
 Stop transfusion
 Infuse NS to maintain BP
 Highflow oxygen
 Inj Adrenaline(1:1000) 0.01mg/kg IM
 IV steroids & bronchodilators
 Lasix 1mg/kg/IV upto 250 mg over 4 hours
 Inform blood bank immediately and send sample

62. LIFE THREATENING
 Urine for hemoglobinuria
 Assess for bleeding → send for platelets , FFP, cryoprecipitate
 Inotropes if hypotension persists
 ARF → may need dialysis
 If septic shock suspected → IV antibiotics to cover Pseudomonas & gram +ve
organisms