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Blood component therapy part I
- 1. BLOOD TRANSFUSION AND COMPONENT THERAPY Dr.Indubala Maurya Assistant professor Department of Anaesthesia & critical care MGMCRI
- 2. Lecture Part 1 ( blood products and its uses ) Part 2 ( Complication of blood transfusion )
- 4. What Is The Need For Transfusion INADEQUATE O2 CARRYING CAPACITY - Anemia - Blood loss INADEQUATE COAGULATION PROTEINS -To provide adequate homeostasis
- 5. General Rules For Transfusion Should not be the first choice Should have a policy regarding typing, cross matching for those surgeries where it is not required Autologous transfusion should be promoted
- 6. Whole Blood Transfusion or Component Therapy Can give individual component for specific illness Patient does not require all the components This policy can benefit more than one individual
- 7. One Unit Of Whole Blood One unit of RBC’S One unit of Platelets One unit of Cryoprecipitate One unit of Plasma (minus above 2 ) 1 unit of whole blood = 450 ml blood 63 ml anticoagulant preservative
- 8. Blood Components Cellular components Plasma components Plasma derivatives Red cell concentrate Fresh frozen plasma Albumin 5% and 25% Leucocytes-reduced red cells Single donor plasma Plasma protein fractions Platelet concentrate Cryoprecipitate Factor VIII concentrate Leucocytes-reduced platelet concentrate Cryo-poor plasma Other coagulation factors Platelet apheresis Immunoglobulins Granulocyte apheresis
- 10. Changes In RBC’s During Storage Decrease in ATP (can be improved with glucose, phosphate & adenine) Decrease in 2,3 DPG Hyperkalaemia , Acidosis in storage RBC lysis & decrease in Hb (6 weeks storage- RBC recovery 85%) Membrane damage making it difficult to penetrate microcirculation ( can be improved with Mannitol / Citrate) Decrease in viability ( shelf life of stored RBC’s is 35 – 42 days)
- 11. Anticoagulants AIM – To increase the RBC life, safety & overall effectiveness 1. CPDA (35 Days) 2. SAGM- Saline ,Adenine , Glucose, Mannitol 3. AS-1, AS-3 ,AS -5 ( Additive solution) (42 Days) 4. Extended storage preservative solution containing - Dextrose - NaCl - Citric acid - Sodium citrate - Adenine and Mannitol
- 12. Status Of Heparin Though an anticoagulant ,but maintains viability only upto 24 – 48 hrs MAIN USE - ECMO - Exchange transfusion
- 13. LIGHT SPIN at 2000 rpm for 3 minutes at 22º RESULT - Packed RBC - PRP WHY LIGHT SPIN? To avoid damage to Platelets Process required to be done within 6 hrs of whole blood collection Packed RBC’s are suspended in a hematocrit of 70% (CPDA-1) or 60 % ( AS -1 or AS- 3,5)
- 14. HEAVY SPIN at 5000 rpm ,5 minutes & 4ºC RESULT- PPP Heavy spin → Damage to platelets Volume → 200 – 400 ml per whole blood transfusion bag
- 15. Platelet Poor Plasma (PPP) FRESH PLASMA Prepared & infused within 6 hrs of preparation FRESH FROZEN PLASMA Fresh plasma stored at -20ºC in a freezer Is stable for 1 year Both forms of PPP have all the Coagulation factors & proteins
- 16. High spin at 4 ºC to PPP RESULT - Cryoprecipitate - Cryosupernant Cryoprecipitate Concentrated source of Von- Willebrand factor, fibrinogen, Factor VIII and fibronectin Stable for 1 year Cryosupernant Remaining plasma after removal of cryoprecipitate
- 17. Fresh Whole Blood Packed Red Cells Light spin, 22o C Platelet Rich Plasma Platelet Concentrate Fresh Plasma Store at 22o C Freeze(FFP) Heavy spin, 4o C
- 18. Thaw at 4o C & heavy spin Fresh Frozen Plasma Cryoprecipitate -Refrozen within 1 hr -Store at < - 18 o C Cryoremoved Plasma Freeze -80o C immediately Stored at < -18o C
- 19. VOLUME WHOLE BLOOD → PPP → CRYOPRECIPITATE 450ml 250ml 10-20 ml
- 20. Packed RBC’s Most frequently required and used Benefit – Will increase amount of O2 delivery to tissues 1 unit PRBCs = 200 ml RBCs 100 ml additive solution 30 ml plasma Storage - 1ºC to 6 ºC Normally, 20 days viability in CPDA solution Post transfusion viability - 75 %
- 21. Indications Broadly Anaemia Haemorrhage Other Indications Critically ill patients of sepsis and trauma Acutely bleeding patients - Rapid loss of > 15 % if preexisting Hb is < 10 gm / dl
- 22. Indications contd…. Perioperative period - < 8 gm / dl without significant Heart, Lung, Vascular, Renal or Neural disease - < 10 gm / dl with significant underlying diseases Patients of chronic Anemia - Hb < 8 gm / dl with evidence of CHF, Angina or Hypovolemia Patients of marrow failure - Hb < 10 gm / dl with Leukemia, Lymphoma , Aplastic anemia
- 23. Clinical Indications Of PRBCs Transfusion SBP < 90 mm Hg Fall in SBP > 40 mm Hg within 4 hrs DBP < 40 mm Hg within 4 hrs Fall in DBP > 40 mm Hg within 4 hrs Heart rate > 100 bpm SpO2 < 90 mm Hg & PaO2 < 70 mm Hg
- 24. Leucocyte Reduced Blood Components WHY REQUIRED? Average unit of RBC’S contain 1 – 2 million WBC’s Average unit of platelets contain 50 million WBC’s Febrile and inflammatory reactions largely due to WBC’s METHODS FOR REDUCTION Washing of RBC’s( Average life 24 hrs ) Leucocytes reduction filters
- 25. Fresh Frozen Plasma (FFP) Primary source of coagulation factors Most common blood component to be used irrationally in today’s practice 1 unit of FFP = 200 – 250 ml plasma Expiry date 365 days Use – Thaw at 37 ºC for about 20 – 30 mins Once thawed , can be again stored for upto 24 hrs at 1- 6 ºC SHOULD BE ABO COMPATIBLE OR IDENTICAL CROSS MATCHING NOT REQUIRED
- 26. Indications Congenital coagulation factor deficiencies except VII ,VIII, IX or Von Willebrand disease Acquired coagulation problems like liver disease, Vit. K deficiency In massive blood transfusion to provide clotting factors Treatment of TTP Dose = 10 – 20 ml / kg 1 unit of FFP = ↑ in factor levels by 3 -5 %
- 27. Cryoprecipitate 1 bag of cryoprecipitate = 250 mg of fibrinogen 15 – 20 ml plasma Von Willebrand factor (IX) 80 – 130 units of factor VIII Fibronectin Factor XIII 20 -30 % Expiry date= 365 days Once thawed , use in 4 hrs
- 28. Indications Congenital / Acquired Hypofibrinogenemia Congenital / Acquired Factor VIII deficiency Secondary choice in Uraemia
- 29. Platelets CERTAIN FACTS Aphretic platelets collected from a single donor contains platelets equivalent to 6 - 8 whole blood derived platelet concentrates Storage – 20 – 24 ºC ( Never refrigerate) Expiry – 5 - 7 days Use Platelet filters and not routine blood filters
- 30. Indications Blood platelet count < 50,000 /μl and evidence of significant active bleeding Thrombocytopenia DIC Dengue Platelet count <10,000 /μlt without evidence of bleeding Bone marrow failure Functional platelet defect & bleeding Dose – 1 unit = ↑ 5000 – 10000 platelets in patient 5 -6 unit = 1 aphretic unit NO CROSS MATCHING REQUIRED
- 31. Transfusion Triggers The RBC , transfusion triggers is a term used to describe, the set of circumstances under which transfusion is reasonable and for which no further justification is needed. WHY the word TRIGGER ?
- 32. Transfusion Triggers contd… Two type of Physiological Triggers 1) Invasive Triggers 1) Non invasive Triggers
- 33. Invasive Triggers 1. Mixed venous O2 (PVO2) The rate of a fall is more important 2. Mixed venous O2 saturation ( SVO2) Declines rapidly when haematocrit falls below 20 % 3. Oxygen uptake VO2 In sepsis and low perfusion not a true indicator as DO2 is normal but due to low pressure VO2 is reduced. Will transfusion benefit here? 4. Oxygen extraction ratio O2 ER If it is > 50% , decompensation is imminent . Usually happens at H’crit of 10%
- 34. Non invasive Triggers DO remember 1. Minimum Hb reqd to have adequate DO2 for isolated tissue is 3-5 gm/dl. 2. In healthy people, acute normovoluemic hemodilution can be safely tolerated upto 5 gm /dl. 3. Transfusion is reqd usually at Hb < 7 gm/dl. 4. Transfusion is unjustified at Hb >10 gm /dl. 5. Duration of Anemia.
- 35. ASA Guidelines for Blood Component Therapy RBC’s-Rarely for Hb>10 g/dl Usually for Hb<6g/dl Decision based on risk for complications related to inadequate oxygenation Platelets-Rarely for PLT>100,000 Usually for PLT<50,000 For PLT between 50,000 and 100,000 decision based on assessment of risk FFP-Microvascular bleeding present and PT or PTT is 1.5 times normal .Condemns use for volume replacement Cryoprecipitate- Consider for fibrinogen levels < 80 mg/dL orwhen levels can not be rapidly obtained
- 36. Maximum Surgical Blood Ordering Schedule (MSBOS) List of procedures performed in a hospital together with recommended quantity of RBC units to cross match , based upon the utilization data specific to that hospital CROSS MATCH : TRANSFUSION ( C:T) ratio Should not exceed 2 :1 GROUP AND SAVE Procedure where transfusion is not reqd
- 37. Blood Sparing Strategies Transfusion is either Autologous or Homologous ( Allogenic )
- 38. Sparing Strategies in Preoperative Period Diagnosing and effective treatment of preexisting ailments like Iron deficiency anemia, bleeding disorders. Review of Anticoagulant therapy Adoption of MSBOS Utilizing Cell salvage.
- 39. Sparing Strategies in Intraoperative Period Careful positing to reduce venous congestion To maintain Normothermia If possible controlled Hypotension Appropriate use of Diathermy , laser Utilizing cell salvage Following Transfusion Triggers
- 40. Autologous Blood Harvesting A) Predeposit Autologous Blood Donation( PABD) A) Acute Normovoluemic Hemodilution (ANH)
- 41. PABD Patients visit 6 weeks in advance to donate blood Blood donation 1 per week Blood donation stops 3 weeks before surgery Iron therapy is integral to PABD No PABD 72 hrs before surgery Usually 2 units sufficient
- 42. Contraindications to PABD 1) If HB < 11 gm /dl 2) More than 6 units reqd 3) Comorbidity e.g cardiac disease 4) Patient having infectious disease markers Since maximum allowed storage interval for RBC is 6 weeks , hence PABD is executed 6 weeks in advance.
- 43. ANH Removal of whole blood , replacement with acellular fluid shortly before anticipated blood loss Done after Induction of Anesthesia and before start of surgery
- 44. Advantages of ANH 1) Reduced Absolute RBC loss 2) Unit with patient ; no wrong transfusion 3) No microbiological testing reqd 4) No risk of hemolytic reaction Caution: Should be restricted to patients with sufficiently high Hb, who can withstand 1 lt of whole blood to be taken out and in whom low target Hb is deemed appropriate
- 45. Cell Salvage INTRAOPERATIVE / POSTOPERATIVE Shed surgical blood is suctioned under low pressure into a reservoir filled with saline Then washed & filtered & returned to patient Can be given upto 6 hrs at room temperature Cost effective if loss is > 1000 ml CONTRAINDICATIONS Malignancy Leakage of bowel contents in surgical field
- 46. Pharmacological Blood Sparing Strategies ERYTHROPOIETIN- 300 U /kg x14 days or 600 U / kg thrice a week APROTININ ( Serine protease inhibitor) – 2 million loading 0.5 million units / hr High risk of Anaphylaxis to reexposure TRANEXAMIC ACID – 10 – 15 mg / kg prior to release of tourniquet DESMOPRESSIN – Mainly for Haemophilia, Von Willebrand disease FIBRINOGEN – ( Combination of bovine thrombin & human fibrinogen)
- 48. Immediate Further divided into A – Immunological 1) Haemolytic transfusion reaction 2) Febrile nonhemolytic transfusion reaction 3) Allergic reactions 4) Anaphylaxis 5) TRALI
- 49. Immediate B - Non Immunological 1) Bacterial contamination 2) Circulatory overload 3) Metabolic complications 4) Non immune haemolysis
- 50. Delayed A – Immunological 1) Delayed haemolytic tranfusion reaction 2) TAGVHD 3) Post transfusion Purpura (PTP) 4) Alloimmunization B - Non Immunological 1) Iron overload 2) Transfusion transmitted diseases
- 51. Acute Haemolytic Transfusion Reactions 1) Intravascular Haemolysis 2) Extravascular Haemolysis 3) DIC 4) Renal failure
- 52. Intravascular Haemolysis (IVH) Mediated by classical pathway of Complement system Signs Sudden drop in B.P Haemoglobinuria Haemoglobinaemia No rise in haematocrit
- 53. Extravascular Haemolysis (EVH) Antibody mediated or Complement mediated cell destruction in RE system Generally life threatening Signs Falling Haematocrit Increased unconjugated bilirubin Abnormal peripheral smear a ) Polychromasis b) Spherocytes May lead to I/V heamolysis
- 54. Extravascular Haemolysis (EVH) CAUSE Exposure to patient through previous - Pregnancy - Transplant - Transfusion Generation of antibodies in response to incompatible Antigens
- 55. Febrile Nonhemolytic Transfusion Reaction Most common Adverse effects Increase in temperature of > 10c over base line during transfusion Cause 1) Formation of Antibodies in recipients against donor WBCs and Platelets 2) Release of bioactive substances like Interleukins, Cytokines in the blood
- 56. Transfusion Related Acute Lung Injury ( TRALI) Rapid onset of respiratory distress, noncardiogenic pulmonary edema and hypoxia occuring during or soon after transfusion CAUSE Due to the presence of A) Anti HLA antibody in the plasma of donor B) Antigranulocyte antibody in the plasma of donor leads to complement activation and increased pulmonary vascular permeability Agent - Any plasma containing blood product
- 57. TRALI Definition New acute lung injury occurring during or within 6 hours post transfusion with a clear temporal relationship to the transfusion North American European Consensus Conference Criteria Acute Hypoxemia PaO2/ fiO2 ≤ 300 mm Hg B/L infilterates in the absence of circulatory overload Edema fluid to plasma protein ratio > 0.6
- 58. Limitations 1) Not possible to differentiate between ALI and TRALI 2) No specific lab tests 3) Limit of 6 hrs may exclude cases developing later Treatment On the lines of ARDS
- 59. Anaphylactic Reactions More commonly observed in Patients of hereditary IgA deficiency Patients having IgG antibodies to infused allergens Remedy Saline washed RBCs for future transfusions
- 60. Immediate Immunological Reactions CLINICAL PRESENTATION Chills with fever, nausea, chest tightness Pain at I/V site, abdomen, joints Tachycardia, tachypnea Hypotension, diffuse bleeding Shock, renal failure CLINICAL PRESENTATION UNDER ANAESTEHSIA Hypotension Dark urine Generalized ooze
- 61. Immediate Immunological Reactions Lab Diagnosis Send blood back for repeat typing and cross match Rising serum bilirubin Urine for heamoglobinuria Chest X ray if TRALI is suspected
- 62. Immediate Immunological Reactions Management Oxygen by face mask/ Intubation (TRALI) Catheterization Continuous vital monitoring Furosemide (if BP normal) Epinepherine/ corticoids if anaphylaxis suspected Maintain urine output between 30-100ml/hr
- 63. Aquired Diseases Incidence getting less due to effective screening HIV 1 & 2 Hepatitis B & C Syphilis CMV Lyme Malaria Filaria
- 64. TA GVHD Due to transfused immunocompetent lymphocytes against immunocompromised host Rapid course Average mortality- 90 % Treatment – Gamma irradiated blood products by exposing WBC’s to 1500 rad to 5000 rad Not much effect on RBC’s Platelet survival decreases by 30 % at higher doses
- 65. Metabolic Complications Clinically significant depletion of coagulation proteins & platelets occur in stored blood leading on to - Hypothermia - Hyperkalaemia - Hypocalcemia - DIC 8 – 10 units of red cells infused in a patient may lead to fall in the level of coagulation proteins to 25 % of normal
- 66. Delayed Hemolytic Transfusion Reactions Occuring > than 24 hrs post transfusion Previous transfusion primes the patient Signs & Symptoms Within 4 – 14 days of transfusion Progressive unexplained fall in hemoglobin Low grade fever Unconjugated hyperbilirubinemia Treatment Self limiting till clearing of all RBC’s
- 67. Post Transfusion Purpura More in females 5 – 9 days post transfusion Due to platelet specific alloantibodies Treatment High dose IV IgG( 2 gm/ kg over 5 days) Platelet transfusion though not effective may be required for bleeding Steroids ? Plasma exchange?
- 68. Massive Blood Transfusion(MBT) Replacement of one blood mass in a period of 24 hrs Transfusion of 4 or more red cell concenterates with in 1 hr Replacement of 50% of total blood volume with in 3 hrs Rate of infusion > 1 unit in 10 minutes Indication Hypovolemic shock secondary to blood loss
- 69. Complications Of MBT Physical Hypothermia Hemodilution Metabolic - Hyperkalemia –Plasma K+ levels in the stored blood increased by 1 mEq/ l /day - Citrate toxicity(3 gm / unit) - Acidosis - Alkalosis( 1 ml citrate = 3 mEq HCO3)
- 70. Complications Of MBT Physiological Left shift of ODC Decrease of labile coagulation factors Dilutional Thromocytopenia
- 71. Citrate Toxicity May lead to Hypocalcaemia Look for total calcium : ionized calcium ratio (Normal 2:1) If low give 10 – 20 ml 10 % calcium gluconate
- 72. Thank you