Blood & Blood Products Transfusion


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SALSO Series - Blood & Blood Products Transfusion

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Blood & Blood Products Transfusion

  2. 2. Pregnancy and blood loss <ul><li>Pregnant women has an increased blood volume of about 20-30% </li></ul><ul><ul><li>Blood volume estimation - about 100ml/kg </li></ul></ul><ul><ul><li>60kg = 6 litres of blood </li></ul></ul><ul><li>As such </li></ul><ul><ul><li>1.0L of blood loss in a pregnant woman is not the same as 1.0L of blood loss in a non-pregnant woman </li></ul></ul><ul><ul><li>1.0L of blood loss in a 80kg woman is different from a 40kg woman </li></ul></ul>
  3. 3. Lost of circulating volume in obstetrics Referring to a normal healthy pregnant woman i.e. not anaemic, etc Circulating volume lost Signs Up to 0.5L-1.0L Mild increase in PR - 1.0-1.5L Increase PR Increase breathing Slight fall in BP (80-100 mmHg SBP) Use crystalloids to replace fluid loss 1.5-2.0L Use colloids to replace 30-40% (Over 2 L) BP drops Need a blood transfusion in addition to crystalloids >40% Immediate life threatening Blood transfusion is required immediately Need rapid transfusion
  4. 4. Vital signs <ul><li>When abnormal in the context of haemorrhage, they are useful in assessing the severity of the hypovolemic shock </li></ul><ul><li>When normal however, they are not reliable in assessing the severity of the hypovolemic shock </li></ul><ul><ul><li>Remember that a drop in BP is a late sign of hypovolaemia! Patient has lost at least 30% of her blood volume!!! </li></ul></ul><ul><li>Should not rely on BP to assess volume loss!!! </li></ul>
  5. 5. <ul><li><30% blood loss - Red cell transfusion not necessary unless: </li></ul><ul><ul><ul><li>Pre-existing anaemia </li></ul></ul></ul><ul><ul><ul><li>Reduced cardiorespiratory reserve </li></ul></ul></ul><ul><ul><ul><li>Ongoing blood loss </li></ul></ul></ul>
  6. 6. Loss of circulating volume <ul><li>Replacement with crystalloids - every ml blood loss, 3ml crystalloids needed </li></ul><ul><ul><li>3 to 1 ratio </li></ul></ul><ul><li>Replacement with colloids – every ml blood loss, 1.5 ml colloids needed </li></ul><ul><ul><li>3 to 2 ratio </li></ul></ul>
  7. 7. Blood transfusion <ul><li>Whole blood vs Packed cells </li></ul><ul><ul><li>No data to suggest that the use of whole blood, even “fresh” is associated with better outcome in acute blood loss </li></ul></ul><ul><ul><li>Usually used in exchange transfusion </li></ul></ul><ul><ul><li>For acute blood loss, </li></ul></ul><ul><li>Give specific blood components as required: </li></ul><ul><ul><li>Packed cells </li></ul></ul><ul><ul><li>Platelet concentrate </li></ul></ul><ul><ul><li>FFP </li></ul></ul><ul><ul><ul><li>Cryoprecipitate - Factor I, VIII, vWF (+ XIII, fibronectin) </li></ul></ul></ul><ul><ul><ul><li>Cryosupernatant </li></ul></ul></ul>
  8. 8. Rapid blood transfusion in life-threatening condition <ul><li>BP cuff (high-pressure infusion devices) </li></ul><ul><li>No blood filters </li></ul><ul><li>With warmers </li></ul><ul><li>O-ve blood </li></ul>
  9. 9. DIVC in obstetrics <ul><li>Consumption coagulopathy (depletion of platelets and coagulation factors) that leads to further haemorrhage </li></ul><ul><li>Can be due to: </li></ul><ul><ul><li>Massive bleeding (e.g. APH, PPH, abruption) </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Amniotic fluid embolism </li></ul></ul><ul><ul><li>Eclampsia </li></ul></ul><ul><ul><li>IUD </li></ul></ul>
  10. 10. DIVC <ul><li>Treat the underlying cause (sepsis, massive blood loss, severe vessel injury, toxins) </li></ul><ul><li>Transfuse platelet if bleeding associated with thrombocytopaenia. Aim for > 50 x 10 9 /L (C, IV) </li></ul><ul><ul><li>Platelets should not be allowed to fall <50 x 10 9 in acutely bleeding patient </li></ul></ul>
  11. 11. DIVC <ul><li>If bleeding continues after large volumes red cell and platelets have been transfused, FFP and cryoprecipitate may be given (depending on protocol e.g. after 10 units of RBCs, abnormal coagulation profile, etc) </li></ul><ul><li>Transfuse FFP and cryoprecipitate so that the PT and APTT ratios are within 1.5 and a fibrinogen level of > 1.0 g/ L </li></ul>
  12. 12. <ul><li>Adequate resuscitation from shock - most important in preventing coagulopathy </li></ul><ul><li>No evidence that prophylactic regimes prevents or reduce transfusion requirements </li></ul>
  13. 13. Hgb = hemoglobin; Hct = hematocrit; PLT = platelets; PT = prothrombin time; PTT = partial thromboplastin time; FFP = fresh frozen plasma; RBCs = red blood cells; Cryo = cryoprecipitate. Table 1. Transfusion Trigger RBC Infusion Platelet Infusion FFP Infusion Cyro Infusion American Society of Anesthesiologists Guidelines for Blood Component Therapy 13 Rarely for Hgb>10g/dL Usually for Hgb <6g/dL Decision based on risk for complications related to inadequate oxygenation Rarely for PLT>100,000 Usually for PLT<50,000 For PLT between 50,000 and 100,000 decision based on assessment of risk Microvascular bleeding present and PT or PTT is 1.5 times normal In the absence of lab results: After transfusion of 1 total blood volume Condemns use for volume replacement Consider for fibrinogen levels<80 mg/dL to 100 mg/dL or when levels can not be rapidly obtained Coffland & Shelton1 8 Symptoms, not Hgb and Hct, should dictate transfusion Symptomatic anemia PLT < 50,000 Condemns use for volume replacement Minimum therapeutic fibrinogen 50-100 mg/dL Crosson 5 - PLT < 100,000 Only if PT and PTT >1.5 times normal After 10u of RBCs Fibrinogen < 150mg/dL Dennis (1992) 3 - Condemns prophylactic use Bleeding times usu abnormal after 5u RBCs; little value in determination PLT < 100,000 After 10u of RBCs - Faringer et al (1993) 7 HCT < 30% Penetrating trauma with low PLT: delayed until microvascular bleeding is identified Blunt trauma with low PLT: replace promptly Only monitor PT For PT > 1.5 times normal Fibrinogen < 100 mg/dL Hurley Medical Center 6 - Oozing and PLT < 50,000 Initial: 2u FFP after10u RBCs Followed by: 1u FFP after each additional 5u RBC Consider coagulation - Spence 14 Hgb alone should not dictate transfusion Must understand physiologic anemia - - -
  14. 14. Massive Blood Loss <ul><li>Replacement of total blood volume (5 L) within 24 hours </li></ul><ul><li>Loss of 50% blood volume in less than or equal to 3 hours </li></ul><ul><li>150ml/ min blood loss (Loss of half the blood volume in 20 minutes) </li></ul><ul><li>Transfusion of more than 20 units of erythrocytes </li></ul>
  15. 15. Complications of massive transfusion <ul><li>Hypothermia </li></ul><ul><li>Acid-base disturbance – metabolic alkalosis > acidosis </li></ul><ul><li>Thrombocytopenia & reduced factor I,V,VIII </li></ul><ul><li>Electrolyte imbalance </li></ul><ul><ul><li>Hypokalemia > Hyperkalemia </li></ul></ul><ul><ul><li>Hypocalcemia & citrate intoxication </li></ul></ul>