detailed blood transfusion knowledge

1. BLOOD TRANSFUSION
PRESENTED BY-
DR. ANKITA RAJ (PROFESSOR)
DEPTT. OF ORAL AND MAXILLOFACIAL
SURGERY

2. outline
 INTRODUCTION
 INDICATIONS FOR BLOOD TRANSFUSION
 MEASUREMENT OF BLOOD LOSS
 TYPES OF BLOOD TRANSFUSION
 DONATION AND COLLECTION
 ADMINISTRATION OF BLOOD

3. INTRODUCTION
Blood is a familiar red fluid in the body that contain white blood cells,
Red blood cells, platelet, proteins, and other elements.
Each part of the blood has special function and can be separated
From each other.
Blood component
1. Whole blood
2. Packed cell
3. Platelet
4. Fresh frozen plasma
5. Cryoprecipitate
6. Protein solution
7. Factor concentrate
8. granulocyte concentration

4. BLOOD TRANSFUSION
Process of receiving blood or blood products into one’s circulation
intravenously.
Used to replace lost components of blood
Donated blood is usually subjected to processing after it is collected,
and is separated into blood component by centrifugation

5. INDICATION FOR BLOOD TRANSFUSION
INDICATIONS FOR WHOLE BLOOD
1. Hemorrhage (sudden loss of 25 % or more of the blood
volume).
2. Patients undergoing exchange transfusion.
3. Patients who continue to bleed after receiving 4 units of
packed red blood cells.
.

6. • INDICATIONS FOR PACKED CELL
TRANSFUSION
• The blood is centrifuged at 3000 rev/min and the
supernatant plasma removed. 1unit of packed cell increases
the level of hemoglobin by 1g/dl and hematocrit by 3%.
• Packed red cells are used when whole blood may overload
the circulation,
• It is used in chronic anaemia, in old age, in children.
• It minimizes the cardiac overload due to transfusion.
• It can be stored for 35 days at 1°-6°C

7. INDICATIONS FOR PLATELET RICH
PLASMA
Platelet-rich plasma is the supernatant plasma after whole
blood is centrifuged at 1000 rev/min.
1. patients with thrombocytopenia or platelet function defect.
2. Prophylactic transfusion, e.g. in,
• Major surgery or invasive procedures
• Ocular surgery or neurosurgery
• Surgery with active bleeding
Contraindication to platelet include;
• Thrombotic thrombocytopenic purpura
• Heparin-induced thrombocytopenia

8. INDICATIONS FOR FRESH FROZEN PLASMA
TRANSFUSION
It is the supernatant Liquid portion when fresh blood is
centrifuged at 3000 revs/min. is rapidly frozen and stored at
–40°C.
It contains all coagulant factors. 1 unit of FFP increases the
clotting factors levels by 3%.
It can be stored for 2 year
Uses:
-- Severe liver disease with abnormal coagulation function
.-- Congenital clotting factor deficiency.
-- Deficiency following warfarin therapy, DIC, massive transfusion.
-- To maintain prothrombin time at normal level.
Dose of FFP is 15 ml/kg.

9. INDICATIONS FOR TRANSFUSION OF
CRYOPRECIPITATE
It is the precipitate when fresh frozen plasma is allowed to thaw at 4
degree cent. and the supernatant plasma removed. It is rich in Factors
VIII and XIII, fibrinogen and Von Willebrand's factor.
It is indicated in the following conditions;
1. hemophilia..
2. von Willebrand's disease.
3. Disseminated intravascular coagulation
4. hepatic failure
5. surgical bleeding
6. congenital fibrinogen deficiency

10. INDICATIONS FOR TRANSFUSION OF
PROTEIN SOLUTION
Human plasma protein fraction, e.g. albumin concentrate,
immunoglobulins, anti-thrombin III and protein concentrate.
•It is indicated in the following conditions;
1. Hypoalbuminemia
2. Patient undergoing plasmapheresis
3. Patient with nephrotic syndrome
4. Liver failure

11. • INDICATION FOR TRANSFUSION OF FACTOR
CONCENTRATE
• e.g. Factor VIII, Factor IX- prothrombin complex, protein c,
fibrinogen concentrates and Recombinant factor.
• Indications include;
1. hemophilia A and von willebrand disease (factor VIII
concentrate)
2. Christmas disease, liver disease (Factor IX- prothrombin
complex concentrate)
3. Severe sepsis with DIC (protein C concentrate)

12. MEASUREMENT OF BLOOD
LOSS
Methods-
1)Weighing the swab
2)Measurement of blood clot
3)Measurement of swelling in closed fracture

13. Maximum capacity of Swab
Small (10x10cm): 60ml
Medium (30x30 cm): 140ml
Large (45x45 cm): 350ml
Floor spill
50 cm diameter: 500ml
75 cm diameter: 1000ml
100cm diameter: 1500ml

14. • Clot size of a clenched fist is 500 ml.
• Blood loss in a closed tibial fracture is 500-1500 ml;
in a fracture femur is 500-2000 ml.
• Weighing the swab before and after use is an
important method of on-table assessment of blood
loss.

15. Mops used during major surgery should be kept in a rack so that quantity of
bleeding during surgery can be assessed approximately.

16. Various Blood groups
• ABO
• MNS
• P
• Rh
• Lutheran
• Kell
• Lewis
• Duffy
• Kidd
• Diego
• Yt or Cartwright
• XG
• Scianna
• Dombrock
• Colton
• Landsteiner-Wiener
• Chido/Rodgers
• Hh/Bombay
• Kx
• Gerbich
• Cromer
• Knops
• Indian
• Ok
• Raph
• JMH
• Ii
• Globoside
• GIL
• Rh-associated glycoprotein

17. ABO system-by LANDSTEINER(1900)
• Most important blood group antigen system-
ABO system- 3 allelic genes A ,B ,O
• Red cells contain AGGLUTINOGENS named – A and B
• These agglutinogens actually causes blood cell agglutination
• For transfusion -red cells of the donor is matched against
serum of recipient
• As well as CROSS MATCHING is done of the donor and the
recipient bloods

19. RHESUS(Rh)blood group
• Discovered by Landsteiner & Weiner(1940)
• Rbc of rhesus monkey when injected into rabbit The
rabbit responds to the present antigen in these cells by
forming an antibody which agglutinates the rhesus’s RBCs
• If the immunised rabbit’s serum is tested against human
RBC, agglutination occurs in 85% people (having rh
antigen –D) called Rh +(positive) and no agglutination
occurs in 15% (do not have rh antigen-D) these are called
Rh –(negative)

20. ERYTHROBLASTOSIS
FOETALIS
• Rh - Mother having Rh+ foetus ,then foetal RBC
having D-antigen can pass the placenta to reach
mother’s circulation .
• Mother responds by forming Anti-D which returns
to foetal circulation and tends to destroy foetal
RBCs

21. • First child is usually normal as sensitization of Rh negative
mother occurs but in later pregnancies the results are very
unpleasant .
• Prevention-administering a single dose of Anti-Rh antibodies
soon after child birth prevents active antibodies formation by
mother

22. Erythroblastosis foetalis

23. Blood collection-procedure
• Donor lies down on a bed
• Sphygmomanometer cuff is applied to the upper arm and
inflated to a pressure of 80 mm hg
• 0.5 ml local anaesthetic solution is injected subcutaneously in
the ante cubital fossa through which 15 gauge needle is
introduced into median cubital vein
• Needle is connected to a plastic tube which is attached to a
plastic bag which forms a sterile unit
• Blood from the donor is allowed to come out and run into the
sterile bag which already contains75 ml of anticoagulant
solution

24. • During collection blood is constantly mixed with the
anticoagulant solution to prevent clotting
• A specimen of blood is sent to for GROUPING and CROSS
MATCHING
• About 410 ml of blood is taken in a single bag

25. Blood storage
• Collected blood is stored in special refrigerator at controlled
temperature of 4ᵒc (range 2ᵒc to 6ᵒc)
• During storage ,erythrocytes lose ability to release oxygen to tissues
of recipient within 7 days
• So in case of massive transfusion ,it is advisable to use 1-2 units of
blood which are less than 7 days old
• Leucocytes are rapidly destroyed in stored blood
• Platelets are also destroyed considerably at 4ᵒc.but a few are still
functionally useful after 24 hours
• Clotting factors like factors V,VIII and platelets also destroy quickly

26. Amount of blood transfusion
• Approximately 70% of amount of blood
loss should be replaced by transfusion of blood
• One unit of stored blood will raise the Hb by 1%

27. Blood donation and collection
Administration of the blood

28. Blood donation and donor selection
Blood donation
• Voluntary activity
• Whole blood
• Specific components
Donor selection
• Donors should be between 18-65 years and over 50 kg in weight
• Hb not less than 12g/dL
• No major operation in the last 6 months
• No blood donation in past 6 months
• No blood transfusion within the last 12 months
• No pregnancy within the last 12months
• No clinical malaria in the past 1 month
• Free from severe hypertension, splenomegaly, hepatomegaly, bleeding
disorders and allergic conditions such as asthma

29. • Free of history or clinical evidence and not a carrier of the
• Viral hepatitis
• HIV infection
• Syphilis
• Trypanosomiasis
• Brucellosis
• Unvaccinated within the last 3 weeks
• Must not belong to any of the risk groups for HIV infections

30. COLLECTION OF BLOOD
• Collection of blood should be done under strict
asepsis into a sterile plastic bag containing 60ml of
citrate-phosphate dextrose(CPD) as anticoagulant
and preservative
• CPD keeps the red cell viable for 21 days in vitro
• Use of CPDA-1,adenine enriched CPD extends the
shelf life to 35 days

31. • Glass bottle and ACD (acid citrate dextrose) are seldom used
now
• The plastic bag is labelled stored as early as possible in a
special bank refrigerator at 2-6°C
• Afterward the tests are done on donors blood collected into
separate container
• ABO and Rh grouping
• Serological test for syphilis, HBsAg, HTLV1 and HIV1
and HIV2,hepatitis B core antibody
• Thick and thin film for malaria parasite

32. Administration and rate of transfusion
• Blood to be transfused should be identified and checked against the
recipient’s name , group, hospital number and ward
• The drip is set up under strict asepsis using 15 gauge or large needle
• The rate should initially be 20-30 drops/min i.e.2-3ml/min.
• It is increase after half an hour to 60-80 drops /min

33. • If there is blood loss the rate of infusion should be rapid,
squeezing the bag containing the blood if necessary
• In the elderly and very young, the rate should be slow-
about 40 drops or less /min
• The patients general condition, pulse and BP should be
monitored throughout

34. COMPLICATIONS OF
BLOOD TRANSFUSION

35. A. IMMEDIATE REACTIONS
1. Febrile non-hemolytic reaction
2. Allergic reaction
3. Hemolytic reaction
4. Bacterial contamination
5. circulation overload
6 Cardiac arrest
7. Air embolism
B. DELAYED REACTIONS
1. Thrombophlebitis
2. Delayed hemolytic reaction
3. post-transfusional thrombocytopaenic purpura

36. Febrile non-haemolytic transfusion reaction
• Definition: incompatibility between antigens on the WBCs and
antibodies in the recipient’s plasma.
• causes: endotoxins or pyogens in the transfusion set or blood.
• Features: Rigors and fever, nausea and vomiting.
• Management:
• Temporary stoppage of transfusion.
• If severe it is investigated to exclude a hemolytic reaction,

37. Allergic Reaction
due to allergens, usually plasma proteins in the donor
plasma.
Symptoms: urticaria, myalgia and arthalgia, bronchospasm,
edema of the face,
in severe cases with anaphlaxis, chest pain, hypotension,
abdominal cramps, diarrhea and shock, pyrexia.
the reactions are mediated by histamine and leukotrienes.
Management: transfusion interrupted, antihistamine and
corticosteroid given, IV adrenaline

38. Hemolytic reactions
Hemolysis of donor cells if there are antibodies to them in the recipient's
plasma.
Clinical features:
• Sensation of heat and pain along the vein being used for transfusion.
• Headache
• Rigors and fever
• Dyspnea
• Pain in loins
• Shock
• Haemoglobinuria
• Jaundice
• Hypotention
• Oliguria to anuria

39. Hemolytic reactions
management:
The blood should be stopped and the reminder pt’s blood taken
for further grouping and cross matching.
Laboratory confirmation:
haemoglobinaemia
methaelbumin
bilirubin
saline suspension
Diuresis
Alkaline urine

40. Bacterial contamination
• About 2% of bank blood is contaminated usually at
the time of collection, and septicemia or endotoxic
shock may ensue when it is transfused.
• Contaminates include: cryophilic bacteria,
pseudomonas, G-ve bacteria.

41. Bacterial contamination
• Clinical features: chills, high fever, dry skin,
hypotension, DIC.
• Management: drip stopped, donor and recipient
blood taken for culture, IV broad-spectrum
antibiotics, IV fluids, steroids

42. Circulatory overload
• It leads to pulmonary edema and CCF
• Symptoms: dyspnea , orthopnea, cough, cyanosis,
frothy sputum, raised JVP, rapid and weak pulse
• Treatment: transfusion stopped and pt proped up,
IV furasemide, phlebotomy, digitalization

43. Cardiac arrest
• Its more likely to occur in massive transfusion
• Cold blood transfused rapidly may cool the heart and
precipitate cardiac arrhythmias

44. Air embolism
• It is uncommon with collapsible plastic bags.
• occurs Rarely,
• Symptoms: gasping respiration, cyanosis, venous
congestion, hypotension, splashing noises over the
heart.
• Treatment: oxygen administration,

45. B. DELAYED
REACTIONS

46. 1. Thrombophlebitis
• Its more common in lower limb veins because of
immobility of legs, it follows
• Clinical features: pain, redness, tenderness and later
thickening of the vein, pyrexia.
• Treatment: analgesics, culture and sensitivity.

47. 2. Delayed haemolytic reaction
• Mild jaundice
• Production of antibodies
• Hemolysis of red cells

48. 3. Post-transfusion
thrombocytopaenic purpura
• Anamnestic production of platelet alloantibody
• Treatment: prednisolone, IV immunoglobulin, plasmapheresis.
• .

49. TECHNIQUES/METHODS IN
ALTERNATIVES TO BLOOD
TRANSFUSION
1. Autologous blood transfusion
2. Blood substitutes
i. Plasma substitutes
ii. RBC substitutes

50. AUTOLOGOUS BLOOD
TRANSFUSION
• It is the collection and subsequent re-infusion of
patient's own blood.
• It prevent both transmission of infectious diseases as
well as immunological complication of homologous
transfusion.

51. TYPES OF AUTOLOGOUS
TRANSFUSION
I. preoperative autologous blood donation(PABD)
II. Acute isovolumic hemodilution (AIVH)
III. Intra operative blood salvage
IV. Post operative blood salvage

52. preoperative autologous blood donation(PABD)
I
 It is an effective method for patients going for ellective
surgery.
 The patient donates preoperatively 1-5 units of his blood
which can be use to replace blood loss if necessary.
 Criteria for PABD
 Patient’s Hb should be >10g/dl & a PCV over 30%.
 Precautions
 Donation should be 3-7days apart and last one should not
be within 72h of surgery.
 The patient is given ferrous sulphate to elevate his Hb
levels.

53. Acute isovolumic hemodilution
II. AIVH
 Here,1-4 units of patient’s own blood is removed immediately prior
to commencement of an operation, and replaced simultaneously
with a crystalloid (3ml for every 1ml of blood collected) and/or
colloid(1ml /ml of blood collected)
 Blood is subsequently re-infused during or after the operation
 Criteria
 Patient’s initial Hb and PCV should be >12g/dl and 36%
respectively and must not fall below 9g/dl and 27% respectively
after the homodilution.
 Precaution
 Blood should be collected from one venous line while
simultaneously replacement with crystalloid or colloid via a second
venous line.
 Blood collected should be transferred into a standard plastic bag
containing SDA/CPDA and transfusion sets with filters are
required.

54. Intra operative blood salvage
 Blood that has been shed from wound/body cavity during
surgery is collected and reinfused into the same patient.
 This method of autologous transfusion is important in/useful
in ectopic pregnancy,hemothorax, ruptured spleen, penetrating
injuries, cardiovascular surgery, orthopaedic surgery.
 Collection
 The shed blood in a body is collected with a galipot into a
kidney dish or large bowl containg an anticoagulant.
 Blood is filtered into a bottle through 4-6 layers of sterile gauge
placed in a funnel.
 Bottle is sealed and blood is reinfuse it
 Now special machine are available which aspirates the blood,
adds heparin,filters and washes it and uses a roller pump to
reinfused it.

55. Precaution
 Hemolysed blood or infected blood should not be
used
 It is contraindicated in patients undergoing tumour
resection because of concern of reinfusing tumour
cells

56. Post operative blood salvage
 This method is considers in patient that have the likelihood of
postoperative blood loss likely to cause hemodynamic instability.
 Example in chest injuries, cardiac surgery, orthopadic Surgery etc
Blood is salvaged from joint spaces & body cavities.

57. What is massive blood transfusion?
There are various definitions such as
 Replacement of one entire blood volume within 24
hr
 Transfusion of >10 units of packed red blood cells
in 24 hr
 Replacement of 50% of total blood volume with in 3
hr

58. Indications for massive blood
transfusion
Patients undergoing exchange transfusions
In order to restore blood volume in cases of sudden loss
of more than 25% of the total blood volume
Trauma
Cardiovascular injury such as cardiac bypass and valve
replacement
Spinal surgery
Hepatic surgery including transplants
Obstetrics emergencies

59. Problems associated with MBT
 when many units of blood are required urgently, thus hemolytic
reactions are more common
Circulatory overload:-In elderly and debilitated patients , rapid and
excessive blood transfusion may overload the circulation and result
in pulmonary oedema and/or congestive cardiac failure
 Arrhythmias and cardiac arrest which can include
• Hyperkalaemia
• Hypocalcemia
• Hypothermia
• Acidosis

60. BLOOD SUBSTITUTES

61. Perfluorocarbon (Fluosoleda)— abiotic substitute as
synthetic oxygen carrier. Its half life is 7 days. RBC substitute,
high affinity for O2.
It is inert, colourless, odourless, dense, poorly soluble
biocompatible liquid.
It is emulsified with albumin or lipids before infusion, emulsion
alone injection can cause pulmonary embolism.
It can bind and release oxygen. But as it reduces the pO2 quickly,
it is a disadvantage. Patient ideally to be kept in hyperbaric place.
2. Stroma free haemoglobin— biomimetic haemoglobin based
substitute.
3. Chelates which reverse bound O2.
Intraoperative--salvage of blood: On table blood is
collected, washed, filtered and transfused. Used in
trauma.

62. Human albumin 4.5%
• Plasma fractionation is done using organic liquids and heat to
extract albumin which is stored at 4°C for many months.
• It can be used in patients with cirrhosis, burns, nephrotic
syndrome, ovarian hyperstimulation syndrome (occurring
after ovarian stimulation with gonadotrophin injections
during in vitro fertilization (IVF) therapy).
• One gram of albumin binds with 14 ml of water so it
increases the blood volume also. Albumin is infused daily as
needed until good response is observed.

63. Dextrans
are useful to improve plasma volume. They are polysaccharides
of varying molecular weights.
This is derived from leuconostoc mesenteroides bacteria after
adding yeast.
One gram of dextran binds with 20 ml of water to raise the
plasma volume.
a. Low molecular weight dextran (40,000 mol wt) (Dextran
40, Rheomacrodex).
Dextran 40 is very effective in restoring blood volume
immediately. But small molecules are readily excreted in
kidney and so effect is transitory.
b. High molecular weight dextran (Dextran 110 and Dextran70).
Less effective but long acting and so useful to have prolonged
effect.

64. Gelatin: in a degraded form of mol. wt. 30,000S, is used
as a plasma expander. Up to 1000 ml of 3.4-4% solution
containing anions and cations is given intravenously—
But it is less effective than dextran and after 4 hours of its infusion,
only 30% remains intravascular.
Hydroxyethystarch: It contains starch, sodium hydroxide,
ethylene oxide. It is a good plasma volume expander but
lasts only for 6 hours.

65. SAG – M BLOOD
• A proportion of donations will have plasma removed and
will be replaced by crystalloid solution of SAG-M.
• S — Sodium chloride.
• A — Adenine.
• G — Glucose anhydrate.
• M — Mannitol
ADVANTAGES.
• ™
. This allows good viability of cells
• ™
. But it is devoid of any protein
• ™
. It is very useful in anaemias

66. Precautions
• For every four units of SAG-M blood, one whole blood has to
be given.
• Later for every two units of SAG-M blood, one unit (400ml) of
4.5% human albumin has to be given.
• Coagulation status and platelet count should be checked
regularly.
• One litre of blood contains 350 mg of iron. Normal excretion
of iron is 1 mg/day. Iron overload can occur after many
transfusions.
• Iron excretion can be increased by desferrioxamine infusion.

67. Summary.
• Blood transfusion or its products is an invaluable
therapeutic measure which should be with good
reasons because of its potential hazards.
• Blood loss in during a surgical procedure should be
minimized
• RBC booster should be given pre & postoperatively
to patients
67

68. THANK YOU