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Guidelines for rational use of blood


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Guidelines for rational use of blood

  1. 1. GUIDELINES FOR RATIONAL USE OF BLOOD Dr. Guvera Vasireddy Department of Pathology Osmania Medical College departmentofpathology,osmanamedical college,Hyderabad 1
  2. 2. THEFIRSTBLOODBANKINMOSCOW The first academic institution devoted to the science of blood transfusion was founded by Alexander Bogdanov in Moscow in 1925. 2 departmentofpathology,osmanamedical college,Hyderabad
  3. 3. ―WARS WERE MOTIVATED BY PROFITS, NOT PRINCIPLES‖ departmentofpathology,osmanamedical college,Hyderabad 3  Henry Norman Bethune (March 4, 1890 – November 12, 1939;) was a Canadian physician and medical innovator.  Known for his service in war time medical units during the Spanish Civil War and with the Communist Eighth Route Army (Ba Lu Jun) during the Second Sino- Japanese War.  He developed the first mobile blood-transfusion service in Spain in 1936
  4. 4. MAJOR MILESTONES IN BLOOD TRANSFUSION  Soviet experience travels to America, in 1937 Bernard Fantus, director of therapeutics at the Cook County Hospital in Chicago, established the first hospital blood bank in the United States.  In 1947, the American Association of Blood Banks, now known as the AABB, was formed.  In 1953, the plastic blood bag was invented by the Fenwal Co.,  By 1962, America's Blood Centres network was established with the help of hospitals, doctors, local civic groups and community-based blood centres.  By 1970, blood banks were using a volunteer donating system; approximately 5 to 6 million units of blood per year were being collected. 4 departmentofpathology,osmanamedical college,Hyderabad
  5. 5. AIDS: A NEW DEADLY DISEASE ARRIVES  Young gay men in the United States started dying from a mysterious disease in the late 70s and 80s.  1981 January, Michael S. Gottlieb, MD, a young assistant professor of medicine at the University of California at Los Angeles School of Medicine, met Michael — the man who would become the AIDS index case.  1982, July 27, The term AIDS (acquired immune deficiency syndrome) is proposed at a meeting in Washington of gay- community leaders, federal bureaucrats and the CDC to replace GRID (gay-related immune deficiency) as evidence showed it was not gay specific. 5 departmentofpathology,osmanamedical college,Hyderabad
  6. 6. THE DEADLY VIRUS GETS A NAME  1983, January, Françoise Barré-Sinoussi, at the Pasteur Institute in Paris, isolates a retrovirus that kills T-cells from the lymph system of a gay AIDS patient.  1984, March 4 edition of the MMWR, CDC notes that most cases of AIDS have been reported among homosexual men with multiple sexual partners, injection drug users, Haitians, and hemophiliacs.  The report suggests that AIDS may be caused by an infectious agent that is transmitted sexually or through exposure to blood or blood products and issues recommendations for preventing transmission.  This retrovirus would be called by several names, including LAV and HTLV-III before being named HIV in 1986. 6 departmentofpathology,osmanamedical college,Hyderabad
  7. 7. departmentofpathology,osmanamedical college,Hyderabad 7
  8. 8. SCREENING FOR HIV MADE MANDATORY o 1985, March 2, FDA approves the first AIDS antibody screening tests for use on all donated blood and plasma intended for transfusion and product manufacture. o In addition to HIV several other pathogens have been made part of routine screening programs in blood banks world wide. 8 departmentofpathology,osmanamedical college,Hyderabad
  9. 9. WHY DO WE NEED TO BE WARY OF TRANSFUSING BLOOD AND BLOOD PRODUCTS? 9 departmentofpathology,osmanamedical college,Hyderabad
  10. 10. BLOOD TRANSFUSION RISKS  Despite rigorous screening blood components continue to pose a small risk of transmission of pathogens, including viruses, bacteria, and parasites.  Currently unrecognized pathogens may also emerge in time.  Some studies have suggested that allogeneic blood may have an immunomodulatory effect. 10 departmentofpathology,osmanamedical college,Hyderabad
  11. 11. INFECTIOUS DISEASE RISKS Primary Risks  Bacteria  Hepatitis B virus  Hepatitis C virus  HIV-1  HIV-2  Malaria (primarily Plasmodium malariae and P. falciparum)  Syphilis (Treponema pallidum) Additional Risks in Immunocompromised Recipients  Cytomegalovirus  Parvovirus B19  Epstein-Barr virus  Babesiosis (Babesia microti) 11 departmentofpathology,osmanamedical college,Hyderabad
  12. 12. RARE RISKS  Chagas disease (Trypanosoma cruzi)  West Nile virus  Hepatitis A  Variant Creutzfeldt- Jakob disease  Human T-cell lymphotropic viruses  Leishmaniasis (visceral Leishmania tropica and possibly L. donovani)  Human anaplasmosis (formerly human granulocytic anaplasmosis and human granulocytic ehrlichiosis)  Dengue fever 12 departmentofpathology,osmanamedical college,Hyderabad
  13. 13. THEORETICAL, BUT UNREPORTED RISKS  Creutzfeldt-Jakob disease  Human ehrlichiosis (formerly human monocytic ehrlichiosis)  Lyme disease (Borrelia burgdorferi)  Toxoplasmosis (Toxoplasma gondii) 13 departmentofpathology,osmanamedical college,Hyderabad
  14. 14. ESTIMATED RESIDUAL RISKS OF SOME TRANSFUSION-TRANSMISSIBLE VIRUSES Virus Recent Risk Estimate Ranges HIV-1 1/1,467,000 units HCV 1/1,149,000 units HBV 1/280,000 – 1/357,000 units HTLV 1/1,208,000 units 14 departmentofpathology,osmanamedical college,Hyderabad
  15. 15. NON-INFECTIOUS COMPLICATIONS OF TRANSFUSION 15 departmentofpathology,osmanamedical college,Hyderabad
  16. 16. IMMUNOLOGIC COMPLICATIONS, IMMEDIATE  Hemolytic transfusion reaction  Immune-mediated platelet destruction.  Febrile nonhemolytic reaction.  Allergic reactions as mild or self-limiting urticaria or wheezing.  Anaphylactoid/anaphylactic reactions.  Transfusion-related acute lung injury (TRALI). 16 departmentofpathology,osmanamedical college,Hyderabad
  17. 17. IMMUNOLOGIC COMPLICATIONS, DELAYED  Delayed hemolytic reactions occur in previously red-cell- alloimmunized patients in whom antigens on transfused red cells provoke anamnestic production of antibody.  Alloimmunization to antigens of red cells, white cells, platelets, or plasma proteins may occur unpredictably after transfusion.  Post transfusion purpura (PTP) is characterized by the development of dramatic, sudden, and self limited thrombocytopenia.  Transfusion-associated graft-vs.-host disease (TA-GVHD). 17 departmentofpathology,osmanamedical college,Hyderabad
  18. 18. METABOLIC AND PHYSIOLOGIC COMPLICATIONS  Citrate ―toxicity‖ reflects a depression of ionized calcium caused by the large quantities of citrate anticoagulant.  Because citrate is promptly metabolized by the liver, this complication is rare.  Acidosis or alkalosis and hyper- or hypokalemia  Transfusion Associated Circulatory Overload can accompany transfusion of any component at a rate more rapid than the recipient‘s cardiac output can accommodate.  Iron overload is a long-term complication of repeated RBC transfusions 18 departmentofpathology,osmanamedical college,Hyderabad
  19. 19. HOW TO PREVENT TRANSFUSION RELATED INFECTIONS AND ADVERSE REACTIONS? 19 departmentofpathology,osmanamedical college,Hyderabad
  20. 20. HAEMOVIGILANCE  "Haemovigilance is required to identify and prevent occurrence or recurrence of transfusion related unwanted events, to increase the safety, efficacy and efficiency of blood transfusion, covering all activities of the transfusion chain from donor to recipient." otherwise  '… A set of surveillance procedures covering the whole transfusion chain (from the collection of blood and its components to the follow-up of recipients), intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence or recurrence …' 20 departmentofpathology,osmanamedical college,Hyderabad
  21. 21. TRANSFUSON RELATED ISSUES IN SURGICAL PATIENTS 21 departmentofpathology,osmanamedical college,Hyderabad
  22. 22. ENSURE APPROPRIATENESS OF BLOOD TRANSFUSION  Risk should be outweighed by the potential benefits.  Alternative strategies to reduce the use of allogeneic blood should be considered.  Patients should be informed that transfusion is part of the planned intervention  The patient‘s consent should be obtained for the planned transfusion and recorded in the patient‘s medical chart. 22 departmentofpathology,osmanamedical college,Hyderabad
  23. 23. 23 departmentofpathology,osmanamedical college,Hyderabad
  24. 24. REDUCE EXPOSURE TO ALLOGENEIC TRANSFUSION  Autologous transfusion  Surgical, anaesthetic and pharmacological approaches to reduce blood loss.  Strategies for management of transfusion requirements in surgical patients: 1. Pre-operative 2. Intra-operative 3. Post-operative 24 departmentofpathology,osmanamedical college,Hyderabad
  25. 25. PRE-OPERATIVE MANAGEMENT  Treatment of Pre-existing Anaemia  Predeposit Autologous Donation  Avoidance of Drugs that Increase Surgical Blood loss. 25 departmentofpathology,osmanamedical college,Hyderabad
  26. 26. PATIENTS ANTICOAGULATED WITH WARFARIN 1 ELECTIVE SURGERY  Stop warfarin 3 days pre-operatively and monitor INR daily  Give heparin by infusion or subcutaneously, if required.  Stop heparin 6 hours pre-operatively.  Check INR and APTT ratio immediately prior to surgery.  Commence surgery if INR and APTT ratio are < 2.0.  Restart warfarin as soon as possible post-operatively.  Restart heparin at the same time and continue until INR is in the therapeutic range. 26 departmentofpathology,osmanamedical college,Hyderabad
  27. 27. PATIENTS ANTICOAGULATED WITH WARFARIN 2  EMERGENCY SURGERY  Give vitamin K, 0.5-2.0 mg by slow IV infusion.  Give fresh frozen plasma, 15 ml/kg. This dose may need to be repeated to bring coagulation factors to an acceptable range.  Check INR immediately prior to surgery.  Commence surgery if INR and APTT ratio are < 2.0. 27 departmentofpathology,osmanamedical college,Hyderabad
  28. 28. PATIENTS ANTICOAGULATED WITH HEPARIN ELECTIVE SURGERY  Stop heparin 6 hours pre-operatively.  Commence surgery if INR and APTT ratio are < 2.0.  Check APTT ratio immediately prior to surgery.  Restart heparin as soon as appropriate post-operatively. EMERGENCY SURGERY  Consider reversal with IV protamine sulphate. 1 mg of protamine neutralizes 100 iu heparin. PATIENTS RECEIVING LOW-DOSE HEPARIN  It is rarely necessary to stop low-dose heparin injections, used in the prevention of deep vein thrombosis and pulmonary embolism, prior to surgery. 28 departmentofpathology,osmanamedical college,Hyderabad
  29. 29. INTRA-OPERATIVE MANAGEMENT  Management of Blood Loss  Management of Volume Replacement  Reduction of Oxygen Demand  Intra-operative Blood Salvage (IBS)  Antifibrinolytic Agents 29 departmentofpathology,osmanamedical college,Hyderabad
  30. 30. POST-OPERATIVE MANAGEMENT  Post-operative Blood Salvage (PBS)  Management of Volume Replacement & On-going Blood Loss  Post-operative patients in ICU/HDU require close monitoring of haemodynamic status, oxygenation, pain relief, biochemical and haematological indices and on going blood loss.  Red Cell Transfusion 30 departmentofpathology,osmanamedical college,Hyderabad
  31. 31. THRESHOLDS FOR SPECIFIC SITUATIONS  Hb <7-10g/dL during surgery associated with major blood loss or if evidence of impaired oxygen transport  Hb <8g/dL; patients on a chronic transfusion regimen or during marrow suppressive therapy (for symptom control and appropriate growth)  Hb <10g/dL; only for very select populations (eg. neonates) 31 departmentofpathology,osmanamedical college,Hyderabad
  32. 32. RECOMMENDATIONS BY AAAB 32 departmentofpathology,osmanamedical college,Hyderabad
  33. 33. departmentofpathology,osmanamedical college,Hyderabad 33  In hospitalized, hemodynamically stable patients, at what hemoglobin concentration should a decision to transfuse RBCs be considered?  The AABB recommends adhering to a restrictive transfusion strategy.  In adult and pediatric intensive care unit patients, transfusion should be considered at hemoglobin concentrations of 7 g/dL or less.  In postoperative surgical patients, transfusion should be considered at a hemoglobin concentration of 8 g/dL or less or for symptoms  Quality of evidence: high; strength of recommendation: strong.
  34. 34.  In hospitalized, hemodynamically stable patients with preexisting cardiovascular disease, at what hemoglobin concentration should a decision to transfuse RBCs be considered?  The AABB suggests adhering to a restrictive transfusion strategy. Transfusion should be considered at a hemoglobin concentration of 8 g/dL or less or for symptoms.  Quality of evidence: moderate; strength of recommendation: weak. 34 departmentofpathology,osmanamedical college,Hyderabad
  35. 35.  In hospitalized, hemodynamically stable patients with the acute coronary syndrome, at what hemoglobin concentration should an RBC transfusion be considered?  The AABB cannot recommend for or against a liberal or restrictive RBC transfusion threshold.  Further research is needed to determine the optimal threshold.  Quality of evidence: very low; strength of recommendation: uncertain. 35 departmentofpathology,osmanamedical college,Hyderabad
  36. 36.  In hospitalized, hemodynamically stable patients, should transfusion be guided by symptoms rather than hemoglobin concentration?  The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration.  Quality of evidence: low; strength of recommendation: weak. 36 departmentofpathology,osmanamedical college,Hyderabad
  37. 37. departmentofpathology,osmanamedical college,Hyderabad 37
  38. 38. BLOOD MANAGEMENT – GETTING THE RIGHT BLOOD TO THE RIGHT PATIENT AT THE RIGHT TIME 38 departmentofpathology,osmanamedical college,Hyderabad
  39. 39. HOSPITAL TRANSFUSION COMMITTEE  Every hospital should establish a hospital transfusion committee to monitor clinical blood use and investigate any acute and delayed transfusion reactions.  Committee should include medical and surgical departments along with blood bank director.  The committee should ensure that National guidelines on the clinical use of blood are followed.  If no national guidelines exist, each hospital should develop local guidelines 39 departmentofpathology,osmanamedical college,Hyderabad
  40. 40. COMMITTEE SHOULD ENSURE THAT THE FOLLOWING ARE IN PLACE 1. A blood request form. 2. A blood ordering schedule for common surgical procedures. 3. Guidelines on clinical and laboratory indications for the use of blood, blood products and simple alternatives to transfusion 4. Medical devices to minimize the need for transfusion. 5. Standard operating procedures for each stage in the clinical transfusion process. 6. The training of all staff involved in the transfusion process to follow standard operating procedures. 40 departmentofpathology,osmanamedical college,Hyderabad
  41. 41. STANDARD OPERATING PROCEDURES FOR TRANSFUSION PROCESS 1. Ordering blood and blood products for elective/planned surgery 2. Ordering blood and blood products in an emergency 3. Completing the blood request form 4. Taking and labelling the pre-transfusion blood sample 5. Collecting blood and blood products from the blood bank 6. Storing and transporting blood and blood products, including storage in the clinical area 7. Administering blood and blood products, including the final patient identity check 8. Recording transfusions in patient records 9. Monitoring the patient before, during and after transfusion 10. Managing, investigating and recording transfusion reactions. 41 departmentofpathology,osmanamedical college,Hyderabad
  42. 42. 42 departmentofpathology,osmanamedical college,Hyderabad
  43. 43. ESTABLISHING MAXIMUM SURGICAL BLOOD ORDERING SCHEDULE  A table of surgical procedures which lists the number of units of blood routinely requested, and cross-matched for them pre-operatively.  The schedule is based on retrospective analysis of actual blood usage associated with the individual surgical procedure.  However when antibody screen is positive, compatible blood must be made available in all cases before surgery. 43 departmentofpathology,osmanamedical college,Hyderabad
  44. 44. 44 departmentofpathology,osmanamedical college,Hyderabad
  45. 45. DEVELOPING MSBOS  Data on blood request for all procedures for 6 months is analysed.  For each procedure, indicate the number of units cross- matched and the number of units transfused.  Calculate the percentage of blood usage:  In procedures where blood usage is less than 30%, GSH are performed.  Other procedures are allotted based on the average number of blood transfused. 45 departmentofpathology,osmanamedical college,Hyderabad
  46. 46. IMPLEMENTATION OF MSBOS  MSBOS should be explained to all doctors in the hospitals and the best way is through the Transfusion Committee.  When all heads of department have agreed on a schedule, it should be circulated and implemented.  Regular monitoring is necessary to detect any problems and for ‗fine tuning‘ of the schedule if necessary.  Confidence in the operation of MSBOS and compliance by users depend on the laboratory being able to provide compatible blood whenever it is required, including urgent requests. 46 departmentofpathology,osmanamedical college,Hyderabad
  47. 47. PROTOCOL FOR GSH GROUP 1. Serum saved for cross-matching must be accurately labelled and readily accessible. 2. Procedures must be clearly defined to enable blood transfusion staff to provide compatible blood safely should an emergency occur during a GSH operation. 3. Communication between the operating theatre and the blood transfusion laboratory must be clearly defined. 4. Transporting blood between the laboratory and the operating theatre must have an established priority. 5. For GSH category, the serum is kept for 48 hours. 47 departmentofpathology,osmanamedical college,Hyderabad
  48. 48. PROCEDURE FOR EMERGENCIES  Blood samples from all patients must have a full ABO and RhD grouping and antibody screening done.  If required urgently, blood of the same ABO and RhD can be given after an appropriate ‗quick blood method‘.  After been issued, the laboratory would continue to do a full cross-match.  If any incompatibility is detected, the patient‘s doctor must be informed immediately. 48 departmentofpathology,osmanamedical college,Hyderabad
  49. 49. RECOMMENDATIONS IN RH D NEGATIVE PATIENTS  All Rh D negative patients must receive D negative whole blood or packed red cells except in certain situations.  All blood banks should have a few RhD negative units in their stock based on their requirement.  Blood banks to keep a list of their RhD negative donors who can be contacted in an emergency.  When D negative blood is not available, the treating clinicians may decide to allow RhD positive blood to be given instead. 49 departmentofpathology,osmanamedical college,Hyderabad
  50. 50. INSTRUCTIONS FOR USE  All blood and blood components must be stored under appropriate conditions as described in the AABB Standards.  The intended recipient and the blood container must be properly identified before the transfusion is started.  Aseptic technique must be employed during preparation and administration.  All blood components must be transfused through a filter designed to remove clots and aggregates (generally a standard 170- to 260-micron filter).  Blood and blood components should be mixed thoroughly before use. 50 departmentofpathology,osmanamedical college,Hyderabad
  51. 51. 51 departmentofpathology,osmanamedical college,Hyderabad
  52. 52. PRECAUTIONS DURING TRANSFUSION  No medications should be added to or infused through the same tubing with blood.  Lactated Ringer‘s, Injection (USP) or other solutions containing calcium should never be added.  Blood components should be warmed if clinically indicated.  Unless otherwise indicated by the patient‘s clinical condition, the rate of infusion should initially be slow. 52 departmentofpathology,osmanamedical college,Hyderabad
  53. 53. SPECIAL SITUATIONS 53 departmentofpathology,osmanamedical college,Hyderabad
  54. 54. MANAGEMENT OF ANEMIA IN CANCER PATIENTS  Cancer-related anemia adversely affects quality of life and is associated with reduced overall survival.  Thecorrection of anemia in cancer patients has the potential to improve treatment efficacy and increase survival.  Treatment of anemia in cancer patients using erythropoiesis-stimulating agents (ESAs) significantly increases hemoglobin levels.  Decreases transfusion requirements and improves quality of life, predominantly by reducing fatigue. 54 departmentofpathology,osmanamedical college,Hyderabad
  55. 55. GRADING OF ANEMIA ACCORDING TO THE NATIONAL CANCER INSTITUTE 55 departmentofpathology,osmanamedical college,Hyderabad
  56. 56. ERYTHROPOIESIS-STIMULATING AGENTS  ESAs are capable of increasing hemoglobin levels in most anemic patients with cancer.  ESAs increase the risk of thromboembolic events.  During chemotherapy, ESA treatment should be initiated when hemoglobin values are lower than 10 g/dl.  ESAs should not be used in patients with cancer who are not receiving chemotherapy. 56 departmentofpathology,osmanamedical college,Hyderabad
  57. 57. IRON  Chemotherapy is associated with abnormal iron metabolism.  Another mechanism contributing to iron deficiency in cancer patients is the low bioavailability of orally administered iron.  The use of intravenous iron (and not oral iron) during treatment with ESAs may improve hemoglobin levels even in the absence of depleted iron stores (or absolute iron deficiency).  Recommendations for the optimal supplementation with ESA treatment in cancer-related anemia need to be established. 57 departmentofpathology,osmanamedical college,Hyderabad
  58. 58. BLOOD TRANSFUSION  Blood transfusion is capable of immediately correcting the signs or symptoms resulting from anemia.  There is wide variation in the levels of hemoglobin that are used to justify blood transfusions among the various studies and among different types of cancers.  There are several acute hazards related to blood transfusion, and long-term side effects have not been properly studied. 58 departmentofpathology,osmanamedical college,Hyderabad
  59. 59. SHELF LIFE OF IRRADIATED RED CELLS  Irradiation of blood products is undertaken using a dedicated blood irradiator with a long half-life gamma emitting source.  Irradiation of red blood cells and whole blood results in reduced post transfusion red cell recovery and increases the rate of efflux of intracellular potassium.  Packs irradiated within 14 days of collection expire 28 days after collection.  Packs irradiated more than 14 days after collection expire either 5 days after irradiation OR at original expiry of pack, whichever comes first. 59 departmentofpathology,osmanamedical college,Hyderabad
  60. 60. SHELF LIFE OF IRRADIATED COMPONENTS  In patients where hyperkalaemia is a concern, red cells should be transfused within 24 hours of irradiation.  Irradiation of platelets has not been shown to cause any clinically significant change in platelet function.  Platelets may be irradiated at any stage during their 5 day storage life.  Granulocytes should be transfused as soon as possible after collection and irradiation. 60 departmentofpathology,osmanamedical college,Hyderabad
  61. 61. IRRADIATED BLOOD COMPONENTS IN INFANTS  Irradiation of cellular blood components with a minimum of 2,500 rad (25 Gy) is recommended for the following:  infants < 1500 g birth weight  infants with known or suspected congenital immunodeficiency syndromes involving T-cells, eg: DiGeorge syndrome  infants receiving granulocyte transfusions  infants receiving directed donor blood components from blood relatives  infants undergoing immunosuppressive therapy or chemotherapy  Infants receiving exchange transfusions 61 departmentofpathology,osmanamedical college,Hyderabad
  62. 62. 62 departmentofpathology,osmanamedical college,Hyderabad
  63. 63. CYTOMEGALOVIRUS (CMV)  Blood components from CMV-seropositive donors may contain residual leucocytes which are potentially infectious to seronegative infants.  CMV-seronegative or leucoreduced cellular components (RBCs, platelets, granulocytes) should be provided for infants who weigh <1,200 g at birth or who are immunocompromised, 63 departmentofpathology,osmanamedical college,Hyderabad
  64. 64. ALTERNATIVES TO TRANSFUSION 64 departmentofpathology,osmanamedical college,Hyderabad
  65. 65. AUTOLOGOUS BLOOD COLLECTION AND TRANSFUSION  Preoperative collection.  Frozen autologous blood  Perioperative acute haemodilution.  Intraoperative blood salvage. 65 departmentofpathology,osmanamedical college,Hyderabad
  66. 66. PLASMA EXPANDERS  Crystalloid Solutions (Plasmalyte®)  Gelatin Solutions (Gelofusin®)  Dextran Solutions (Dextran 40, Dextran 70)  Hydroxyethyl Starch (HES; HESPAN®; PENTASPAN®:) 66 departmentofpathology,osmanamedical college,Hyderabad
  67. 67. OXYGEN CARRYING COMPOUNDS  Although artificial blood in the form of perfluoro compounds and modified haemoglobin solutions have been under investigation for many years there is no indication that these compounds will be widely available for routine use in the near future.  Products based on polymerised haemoglobin Hemopure® (Biopure Corporation), a bovine-derived product which despite safety concerns is currently approved for human use in South Africa;  PolyHeme® (Northfield Laboratories), which uses human haemoglobin, has been taken to phase III clinical trials in the US,  Second-generation products Hemospan® (Sangart) uses humanhaemoglobin conjugated with polyethylene glycol (PEG) and is currently in a phase II trial in the US and entering phase III trials in Europe. 67 departmentofpathology,osmanamedical college,Hyderabad
  68. 68. HAEMOPOIETIC GROWTH FACTORS  Recombinant Human Erythropoietin (rEPO; Epoetin beta, EPRE X™, Recormon®)  Granulocyte Stimulating Factor (G-CSF; Neupogen®)  Thrombopoietin (TPO)  Recombinant Coagulation Factors  on-transfusion Therapy using Desmopressin (DDAVP; Minirin®;Octostim®) 68 departmentofpathology,osmanamedical college,Hyderabad