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Blood transfusion and its reactions in obstetrics


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blood transfusion is one of the key aspects of obstetrics, and its knowledge is a must to every clinician.

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Blood transfusion and its reactions in obstetrics

  1. 1. By DR. Momina Zulfeen SMC,DRNTRUHS,VJA
  2. 2.  The transfer of blood or blood components from one person (the donor) into the bloodstream of another person (the recipient) DR.MOMINA ZULFEEN
  3. 3.  Maternal mortality due to obstetric haemorrhage is 25-30 percent and anaemia is 15percent, both these conditions require blood transfusion.  Studies show that there is inappropriate transfusion in 15-45% , either transfusion done in non indicated cases or too late or too little done in indicated cases.  Rising cost and non availability of blood, risk of transfusion reaction and transmission of infections have made us to limit transfusion only in indicated cases. DR.MOMINA ZULFEEN
  4. 4.  Anemia in antenatal period  Pregnancy < 36 weeks:  Hb – 5gm % or below  Hb – 5- 7 gm % in presence of established or incipient cardiac failure or clinical evidence of hyooxia, pneumonia or any other serious bacterial infection and malaria.  Pregnancy > 36 weeks:  Hb <7gm%  Hb < 7 – 9 gm % or below in presence of clinical evidence of hypoxia , pneumonia or any other serious bacterial infection and malaria. DR.MOMINA ZULFEEN
  5. 5.  Anemia in intranatal or postnatal period  If hb<7gm/dl  Patient needing major surgery and Hb < 8 gm/dl  Ongoing bleeding or risk of further bleeding with Hb < 8 gm/dl  Hypovolemic shock  When hb is <7g/dl in immediate postpartum period, blood transfusion depends on the medical history, age and symptoms. Fit and healthy women require no blood transfusion even with Hb of <7g/dl.  In sickle cell anemia repeated transfusions are indicated, thus partial exchange transfusion done. DR.MOMINA ZULFEEN
  6. 6.  All women should have their blood group and Rh antibody status checked at booking.  Patient blood samples used for cross matching should be no more than 7 days old  In pregnancy, pre autologous deposit is not recommended. DR.MOMINA ZULFEEN
  7. 7.  Compatibility testing is done in two steps  1. ABO-Rh typing  2.cross-match  ABO-Rh typing is done by testing RBC for A and B antigens and the serum for A and B antibodies. Rh typing follows.  Cross match is essentially a trial transfusion in which donor cells are mixed with recipient serum. It takes about 45-60 minutes. DR.MOMINA ZULFEEN
  8. 8.  Screening for infectious agents  Every unit of donated blood should be screened for transfusion- transmissible infections using the most appropriate and effective tests, in accordance with both national policies and the prevalence of infectious agents in the potential blood donor population.  No blood or blood product should be released for transfusion until all nationally required tests are shown to be negative.  All donated blood should be screened for  HIV 1 AND HIV 2  HBsAg  Treponema pallidum antibody  Hepatitis C  Malaria DR.MOMINA ZULFEEN
  9. 9.  WHO prescribes a checklist before prescribing blood 1. What improvement in the patient’s condition am I to achieve following blood transfusion? 2. Can I minimize the blood loss to reduce the transfusion? 3. Are there any other treatment like IV replacement fluid and oxygen? 4. What are the specific clinical and lab indications for transfusion? 5. What are the risks of transmitting infectious agent? 6. Do the benefits of transfusion outweigh the risks? 7. What other options are there if no blood is available in time? 8. Will the trained person monitor and respond immediately if any acute transfusion reaction occur? 9. Have I recorded my decision and reasons for transfusion on patients chart and the blood request form? DR.MOMINA ZULFEEN
  10. 10.  RCOG Recommends reduction of blood transfusion by 1. Treatment of anemia a must. 2. Hb% of 10.5 gm/dl indicates hematinic deficiency , excludes hemoglobinopathies. 3. Oral iron preferred in the treatment of anemia. Parenteral iron only in intolerance to oral, absorption defects, doubtful compliance of patient. 4. Recombinant human erythropoietin used only in end stage renal disease. 5. Hemoglobinopathies and bone marrow failure syndrome treated by blood transfusion in close conjunction with hematologist. 6. Active management of 3rd stage of labour proved to decrease incidence of blood transfusion. 7. Optimal management of women on anticoagulants. DR.MOMINA ZULFEEN
  11. 11.  Blood grouping at Rh typing at booking.  Patients blood sample should ideally be fresh and save sample in high risk cases, not more than 7 days.  Only Kell negative blood should be used in women of child bearing age.  seronegative red cells and platelets for seronegative women.  Autologous transfusion in ruptured ectopic cases  Normal blood volume is 7 % of ideal body weight and it increases to 8- 9% in pregnancy. Massive blood loss is loss of one blood volume in 24 hours or 50 percent blood volume in three hours or loss at a rate of 150ml /minute. DR.MOMINA ZULFEEN
  12. 12.  Whole blood  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  Contraindications  Chronic anemia  Incipient cardiac failure DR.MOMINA ZULFEEN
  13. 13.  Quantity- 350ml.  No functional platelets, no labile coagulation factors V and VIII.  Components prepared are PRBC, platelet concentrates, FFP and Cryoprecipitate.  Collected into a sterile disposable plastic pack containing anticoagulant CPDA(Citrate Phosphate Dextrose Adenine).  Storage- 2-6*C.  Shelf life – 35 days DR.MOMINA ZULFEEN
  14. 14.  One unit of whole blood increases Hb by 0.75 to 1 g/dl and hematocrit by 3-5%.  Transfusion should be started within 30mins of issue  Complete transfusion ideally within 2 hours not more than 4 hours.  Obst indications- postpartum hemorrhage, ectopic pregnancy, antepartum hemorrhage, DIC. DR.MOMINA ZULFEEN
  15. 15.  Packed red cells  Platelet concentrate  Fresh frozen plasma  Cryoprecipitate  Human plasma proteins such as albumin, coagulation factor concentrates, immunoglobulins.  Specialized products : leukoreduced blood and HLA matched plateletes. DR.MOMINA ZULFEEN
  16. 16.  Quantity – 150 – 200 ml  Hemoglobin approximately 20g/dl  Hematocrit 55-70 percent  Prepared from single blood donor, collected in plastic bags  Plasma separated by either centrifugation or sedimentation  Preparation time : 20 mins  Single unit of PRBC raises the hb by 1g and hematocrit by 3 percent DR.MOMINA ZULFEEN
  17. 17.  Contains stable clotting factors, albumin, immunoglobulin and no platelet.  CBC and coagulation screening advised.  FFP takes 30mins to thaw, once thawed, used within 6 hours.  Should ideally be of same group, different group is acceptable.  No anti-d prophylaxis required  Fibrinogen levels should be maintained above 1.0g/l DR.MOMINA ZULFEEN
  18. 18.  Quantity – 100ml  Contains all the coagulation factors specially fibrinogen  Factor VIII level at least 70% of normal fresh plasma level.  Plasma separated form one whole blood donation within 6 hours  Stored at <25*C  Shelflife-12 months  1unit raises the fibrinogen level by 5-10mg%  Indications- DIC,TTP,INR>2timesnormal, massive transfusion. DR.MOMINA ZULFEEN
  19. 19.  Infusion of FFP ideally before 1 blood volume is lost.  In DIC a combination of FFP, platelets and cryoprecipitate indicated.  FFP indicated when fibrinogen is <100mg/dl and maintain fibrinogen >1g/dl.  FFP and cryoprecipitate should ideally be of same group. No need for anti-D prophylaxis. DR.MOMINA ZULFEEN
  20. 20.  Quantity- 15ml  From FFP by collecting the precipitate during controlled thawing  Frozen within 1hr at <1*C.  Shelf life – 12 months.  Transfuse within 20 mins. Infuse with 6 hours of thawing.  Each unit increases fibrinogen by 5-10 units  Indicated in DIC, vWD deficiency, factor VIII deficiency. DR.MOMINA ZULFEEN
  21. 21.  The platelet count should not be allowed to fall below 50,000/dl in acutely bleeding patient.  Should be ideally group compatible  Anti D required.  Indicated in thrombocytopenia due to ITP,TTP,DIC,HELLP syndrome and massive transfusion.  1 unit of plt concentrate per 10kg bwt.  Increments will be less if there is spleenomegaly,DIC or septicemia. DR.MOMINA ZULFEEN
  22. 22.  RDP-  Quantity 50-100ml.  One unit increases the plt count by 6,000 to 8,000 cells  Preparation time – 1 hour  Storage- 20-24*C.  Continuous gentle agitation maintained  Shelf life – 72 hours.  4-6 units infused over 30 minutes.  SDP- quantity- 300-350ml.  One unit increases plt by 30,000-60,000. DR.MOMINA ZULFEEN
  23. 23.  Is recombinant factor VII.  Dose- 50-100ug/kg IV  Mechanism of action- binds tissue factor at site of injury. Activates factors X and IX.  Response time- within 20-30 min  Potential complications- thrombosis inculding CVA, MI.  Works best in presence of normothermia  Indicated in treatment of coagulopathy in massive hemorrhage. DR.MOMINA ZULFEEN
  24. 24.  Check the blood unit details against issue slip  Check patient details against blood unit  Attach unit of blood and remove air column before connecting, under aseptic precautions.  Ensure blood is flowing at correct rate.  Start transfusion rate at the rate of 6drops/minute  Increase the rate half an hourly upto 20drops/minute  Complete transfusion with in 4-5 hours.  No recommendations for warming of blood/ routine use of diuretics. DR.MOMINA ZULFEEN
  25. 25.  Monitor before starting, at once and 15 minutes after transfusion and then half hourly.  Record all the details  Check for  General appearance  Temperature  Pulse  Respiration  Blood pressure  Fluid balance DR.MOMINA ZULFEEN
  27. 27.  Any adverse event attributed to the introduction of whole blood or blood components into the blood stream of the recipient.  Can occur in any transfusion recipient, but is more common with hematologic and oncologic disease DR.MOMINA ZULFEEN
  28. 28. *based on time of appearance *based on cause  Acute  Delayed  Immunologic  Chemical  Physical  Infectious DR.MOMINA ZULFEEN
  29. 29. Acute rxns  Volume overload  Acute lung injury  Fluid overload  Sepsis  Hemolytic reaction  Febrile nonhemolytic reaction  Urticaria  anaphylaxis Delayed rxns  Delayed hemolysis  Thrombocytopenia  Graft versus host disease DR.MOMINA ZULFEEN
  30. 30.  Common reactions: •Urticaria – 1 to 3 percent. •Febrile nonhemolytic transfusion reaction (FNHTR) – 0.1 to 1 percent  Relatively common reactions: •Transfusion-associated circulatory overload (TACO) – <1 percent •Transfusion-related acute lung injury (TRALI) – <0.01 percent.  Relatively rare reactions: •Anaphylaxis – 1:20,000 to 1:50,000. •Acute hemolytic transfusion reaction (AHTR) – 1:76,000, virtually all occurring with RBC transfusion. •Sepsis – 1:50,000 for platelets; 1:5,000,000 RBCs. DR.MOMINA ZULFEEN
  31. 31.  Febrile non-hemolytic transfusion reactions  Acute hemolytic transfusion reactions  Delayed hemolytic transfusion reactions  Anaphylactic transfusion reactions  Urticarial transfusion reactions  Post-transfusion purpura  Transfusion-related acute lung injury (TRALI)  Post-transfusion GVHD DR.MOMINA ZULFEEN
  32. 32.  The most common transfusion reaction  Occurs towards end of transfusion  Occurs in 1/20 platelet and 1/300 RBC transfusions  Clinical manifestations: Fever, chills and sometimes mild dyspnea within one to six hours after transfusion of red cells or platelets DR.MOMINA ZULFEEN
  33. 33.  Cytokines, such as interleukin (IL)-1, IL-6, IL- 8, and tumor necrosis factor-alpha (TNFa), which are generated and accumulate during the storage of blood components.  Interaction between donor leukocytes and recipient antibody leads to interleukin-1 release from donor leukocytes or recipient monocytes, which stimulates PG-E2 production in the hypothalamus. DR.MOMINA ZULFEEN
  34. 34.  Stopping the transfusion  Antipyretics and meperidine  Ruling out hemolytic reaction Prevention:  Leukoreduction of transfused blood DR.MOMINA ZULFEEN
  35. 35.  A medical emergency that results from the rapid destruction of donor erythrocytes by preformed recipient antibodies  Usually due to ABO incompatibility  Some acquired alloantibodies like anti-Rh and anti- Jka are also implicated  Can occur with as low as 20-30 RBC.  Most fatal complication, followed by TRALI and TACO respectively. DR.MOMINA ZULFEEN
  36. 36.  Typical triad: Fever, flank pain, and red or brown urine (ie, hemoglobinuria)  Fever and chills may be the only manifestations  DIC may be the presenting mode, with oozing of blood from puncture sites and hemoglobinuria  Pink plasma and direct Coomb’s positive DR.MOMINA ZULFEEN
  37. 37.  Stop the transfusion, but leave the intravenous line attached.  The bag containing transfused cells, along with all attached labels should not be discarded to repeat typing and cross-matching of this unit, if required.  Maintain airway, blood pressure, and heart rate  Initiate IV normal saline (100-200 mL/hr)  From the other arm, obtain a sample for a direct antiglobulin test, plasma free hemoglobin, and repeat type and cross-match.  Urine sample for hemoglobin testing. DR.MOMINA ZULFEEN
  38. 38.  Alert blood bank immediately and search for clerical errors.  Follow hospital protocol for evaluating transfusion reactions.  In massive hemolysis or DIC  Early heparinization (10 units/kg/hour) for 12 to 24 hours may be of value  low-dose dopamine as vasopressor  Look for hyperkalemia, cardiac and renal function monitoring, coagulation profile monitoring and hemodialysis DR.MOMINA ZULFEEN
  39. 39.  Seen generally within 3 to 30 days after transfusion  Anamnestic antibody response occurring after re- exposure to a foreign red cell antigen previously encountered by transfusion, transplantation, or pregnancy.  The antibody, often of the Kidd or Rh system, is undetectable on pre-transfusion testing but increases rapidly in titer following the transfusion.  Hemolysis is usually extravascular, gradual, and less severe than with acute reactions DR.MOMINA ZULFEEN
  40. 40.  Falling hematocrit, slight fever, mild increase in serum unconjugated bilirubin, and spherocytosis on the blood smear.  A new positive direct antiglobulin test and a new positive antibody screen are found when more blood is ordered.  No treatment is required in the absence of brisk hemolysis. However, future transfusions containing the implicated red cell antigen need to be avoided. DR.MOMINA ZULFEEN
  41. 41.  May occur within a few seconds to a few minutes following the initiation of a transfusion that contains plasma, red cells, platelets, granulocytes, cryoprecipitate, or gamma globulin.  Not generally seen following the administration of normal serum albumin, plasma protein fraction, or coagulation factors.  Manifested by shock, hypotension, angioedema, and respiratory distress DR.MOMINA ZULFEEN
  42. 42.  Patients with prior history of anaphylaxis/allergy, IgA deficiency are more prone  Treatment:  Immediate cessation of the transfusion  Epinephrine, 0.3 mL of a 1:1000 solution intramuscularly  Resuscitation of hypotensive patients with intravenous fluids  Airway maintenance, oxygenation  Vasopressors (eg, dopamine), if necessary DR.MOMINA ZULFEEN
  43. 43.  Occur when soluble allergenic substances in the plasma of the donated blood product react with preexisting IgE antibodies in the recipient causing mast cells to release histamine.  The transfusion should first be stopped and if the urticaria is extensive, 25 to 50 mg of diphenhydramine can be given orally or intravenously.  If the urticaria wanes and dyspnea, hypotension, and anaphylaxis are absent, the transfusion may be resumed. DR.MOMINA ZULFEEN
  44. 44.  Characterized by drop in blood pressure (SBP, DBP, or both) of </= 30 mmHg, within minutes of onset of transfusion and returning to baseline once the transfusion is stopped.  Other types of transfusion reactions like transfusion- related acute lung injury [TRALI], sepsis, severe allergic reactions must be excluded.  Mediated by two vasoactive kinins (bradykinin and one of its derivatives) generated by activation of the contact system  Generally not serious, and rapidly reversible with cessation of the transfusion, no specific preventative or treatment recommendations. DR.MOMINA ZULFEEN
  45. 45.  Rare transfusion reaction that can occur after transfusion of any platelet-containing product (eg, red cells, platelets, or granulocyte concentrates), commonly in women (M:F- 1:26).  Caused in Human Platelet Antigen-1a (HPA- 1a) deficient women being sensitized by previous HPA-1a positive transfusion or pregnancy DR.MOMINA ZULFEEN
  46. 46.  Present with severe thrombocytopenia (eg, platelet count ≤20,000/microL) that develops approximately 5 to 10 days following transfusion, which often lasts for days to weeks.  Mimics idiopathic thrombocytopenic purpura/ drug-induced thrombocytic purpura  Specific tests to determine the platelet antigenic composition and/or the presence of anti-platelet antibodies may not be readily available. Hence clinical history has to be relied upon.  Preferred therapy is intravenous immune globulin (IVIG) in high doses (400 to 500 mg/kg per day, usually for five days); 1 g/kg per day for two days can be given for severe thrombocytopenia DR.MOMINA ZULFEEN
  47. 47.  Rare complication that develops 4 to 30 days after a blood transfusion  GVHD results from an attack by viable immunocompetent donor lymphocytes on the recipient's antigen presenting tissues. This immunologic assault is manifested clinically by dysfunction of the skin, liver, gastrointestinal tract and bone marrow  Occurs in two settings: when the recipient is immunodeficient; and when there is a specific type of partial HLA matching between the donor and recipient. DR.MOMINA ZULFEEN
  48. 48.  ta-GVHD has been reported after the administration of non-irradiated transfusions.  Not induced by frozen, deglycerolized red cells, fresh frozen plasma, or cryoprecipitate.  Typically fever and rash. Other symptoms include anorexia, vomiting, abdominal pain, profuse diarrhea, and cough.  Pancytopenia due to a strikingly hypocellular marrow, abnormal liver function tests, and electrolyte abnormalities induced by diarrhea. DR.MOMINA ZULFEEN
  49. 49.  Diagnosis is suggested from biopsy of affected skin, which classically reveals vacuolization of the basal layer and a histiocytic infiltrate, which is also seen in the aplastic bone marrow.  Definitive diagnosis is established if the circulating lymphocytes are shown to have a different HLA phenotype from host tissue cells.  Differential diagnosis: Certain infections (HIV, HBV,HCV), drug reactions, other causes of liver failure, the patient's underlying illness, and hemophagocytic syndromes. DR.MOMINA ZULFEEN
  50. 50.  Ta-GVHD is almost universally fatal; there is no effective treatment.  Prevention: gamma irradiation DR.MOMINA ZULFEEN
  51. 51.  Defined as new acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) occurring during or within six hours after blood product administration  Can be seen following transfusion of any type of blood component in any patient, especially those with a high concentration of donor plasma (due to antibodies to human leukocyte and human neutrophil antigens). DR.MOMINA ZULFEEN
  52. 52.  A "two-hit" hypothesis for the pathogenesis of TRALI holds that recipient neutrophils are primed for activation by virtue of the patient's underlying clinical condition.  The second hit involves activation of these neutrophils by pre-formed anti-leukocyte antibodies or biological response modifiers contained in the transfused product.  Characteristic clinical presentation of TRALI is the sudden onset of hypoxemic respiratory insufficiency during or shortly after the transfusion of a blood product.  Often have frothy airway secretions (if intubated), fever, cyanosis, and hypotension. DR.MOMINA ZULFEEN
  53. 53.  Immediate discontinuation of the transfusion  Evaluate the recipient’s vital signs  Assess the extent of hypoxemia,  Obtain a chest radiograph.  Pulse oximetry is often sufficient, but arterial blood gas analysis may be warranted in more severe cases.  Report to the blood bank that TRALI is suspected  Therapy is supportive, with oxygen supplementation. DR.MOMINA ZULFEEN
  54. 54.  Non-invasive respiratory support with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) ,endotracheal intubation with invasive mechanical ventilation  Fluid resuscitation and/or vasoactive support to counter hypotension.  Although the risk for mortality is significant, patients who survive a TRALI episode are expected to recover completely.  Prevention of TRALI involves deferring donors implicated in a case of TRALI, donations from multiparous women DR.MOMINA ZULFEEN
  55. 55.  Transfusion associated circulatory overload (TACO)  Addition of drugs and diluents to blood products  Thermal hemolysis  Coagulation defects  Citrate toxicity  Hyperkalemia, hypokalemia, and metabolic alkalosis  Hypothermia  Iron overload  Air embolism DR.MOMINA ZULFEEN
  56. 56.  Common especially in elderly patients, small children, and/or those with compromised cardiac function  Where large fluid volumes and some blood are administered  Symptoms include dyspnea, orthopnea, tachycardia and a wide pulse pressure, often with hypertension and hypoxemia  Symptoms may begin near the end of the transfusion, or within six hours DR.MOMINA ZULFEEN
  57. 57.  May be difficult to differentiate TACO and TRALI  TACO is characterized by elevated N terminal Pro-BNP (NT Pro-BNP), central venous pressure, and pulmonary artery wedge pressure.  In TACO, the ratio of protein in the edema fluid to plasma is low, reflecting a transudate rather than an exudate DR.MOMINA ZULFEEN
  58. 58.  Similar to cardiogenic pulmonary edema  Non-invasive ventilation for respiratory distress  Phlebotomy (250ml increments) with/without reinfusion of the removed red cells. Prevention:  A transfusion rate of approximately 2.0 to 2.5 mL/kg per hour is acceptable for routine transfusions of blood components  Patients deemed to be at risk of TACO (eg, small stature or low body weight, elderly, known or suspected poor cardiac function) can be safely transfused at a rate of 1 mL/kg per hour and should also be monitored more closely during the transfusion for signs and symptoms of TACO. DR.MOMINA ZULFEEN
  59. 59.  Limiting transfusion of red cells to two units per day in patients who are not actively bleeding.  Administering packed cells instead of whole blood  Administering a small dose of diuretic between transfusions.  Isovolemic exchange: One unit of the patient's blood (with a low hematocrit) is removed at the same time as a unit of packed cells (with a hematocrit of 60 to 80 percent) is infused. DR.MOMINA ZULFEEN
  60. 60.  No drugs should ever be added to a blood component or given through an intravenous line through which blood is flowing, as osmotic hemolysis can result.  Only 0.9 percent saline is acceptable as an additive or diluent for a blood transfusion. DR.MOMINA ZULFEEN
  61. 61.  Transported, as well as stored, blood products must be carefully maintained (and monitored) at temperatures appropriate to the products: 4°C for packed red cells, 22°C for platelets, -30°C for frozen plasma.  If red cells are frozen without cryoprotectant or are too rapidly thawed after appropriate freezing, they will hemolyze  Blood warmers — carefully calibrated and continuously monitored to avoid heating of the blood cells above 40ºC, with resultant hemolysis DR.MOMINA ZULFEEN
  62. 62.  Balanced citrate solution is used to chelate calcium and prevent the blood from clotting  Citrate toxicity is rare.  Symptoms: Sense of heightened anxiety, carpopedal spasm, tetanic contractions, and arrhythmias.  Mild symptoms are more common: Chilliness, anxiousness, circumoral paresthesias and tightness of jaw and/or other muscles. DR.MOMINA ZULFEEN
  63. 63.  Hyperkalemia and potassium leakage: Leakage of potassium from red cell products (eg, prolonged storage, irradiation) may be a problem in some settings (eg, infants and patients with renal impairment).  Red cells that have been irradiated to prevent graft-versus-host disease leak more potassium than non-irradiated products. As a result, their shelf life is reduced to 28 days DR.MOMINA ZULFEEN
  64. 64.  Hypothermia is occasionally seen in recipients of large volumes of refrigerated (1 to 6ºC) blood products.  Slowing the infusion, warming the patient, or warming the blood with properly functioning blood warmers is helpful DR.MOMINA ZULFEEN
  65. 65.  May occur in chronically transfused patients, such as those with sickle cell disease, thalassemia major, aplastic anemia, myelodysplastic syndrome or other illnesses requiring many red cell transfusions over long periods of time.  Each unit of red cells contains approximately 250 mg of iron.  Under normal circumstances, total body iron burdens are 2-4grams, most of which is circulating as hemoglobin DR.MOMINA ZULFEEN
  66. 66.  Free iron is toxic to tissues.  When reticuloendothelial storage sites are saturated, iron begins to be deposited in organs such as the liver, heart, endocrine organs, and pancreas, leading to hepatic fibrosis, cardiomyopathy, arrhythmias, endocrine dysfunction (including hypogonadism), and pancreatic dysfunction.  Since phlebotomy is not an option in anemic patients with iron toxicity, iron-chelation is used as treatment for such patients. DR.MOMINA ZULFEEN
  67. 67.  With the advent of plastic equipment and closed blood delivery systems, entry of large volumes of air into the venous system is no longer a problem with routine transfusions.  However, significant amounts of air may be inadvertently transfused following the use of more complex transfusion systems, such as apheresis and blood salvage equipments. DR.MOMINA ZULFEEN
  68. 68.  Defined as bacterial infection following transfusion (in the absence of infection prior to transfusion), with evidence of blood product contamination or infection in the donor  The organisms causing TTBI can come from donor blood, donor skin, the phlebotomist's skin, or environmental contamination during production or packaging (eg, contaminated water baths used to thaw blood products) DR.MOMINA ZULFEEN
  69. 69. Gram-positive Bacillus cereus Coagulase-negative staphylococci Enterococcus faecalis Streptococcus spp Staphylococcus aureus Propionibacterium acnes Bacillus cereus Gram-negative Klebsiella spp Serratia spp Escherichia coli Acinetobacter spp Enterobacter spp Proteus mirabilis Providencia rettgeri Pseudomonas spp Yersinia enterocolitica DR.MOMINA ZULFEEN
  70. 70.  Cryophilic organisms especially Yersinia enterocolitica and Pseudomonas fluorescens, Enterobacter, and Serratia can survive and multiply in cold-stored bank blood.  Infection with gram-negative organisms has been associated with the greatest risk of death  Tickborne infections can also be transmitted by transfusion of blood products.  Transfusion is associated with risk for transmission of parasitic infection in endemic countries. DR.MOMINA ZULFEEN
  71. 71.  Clinical manifestations: Fever >39ºC (or an increase of >2ºC following transfusion), rigors, tachycardia (>120 beats per minute or increase of 40 beats per minute following transfusion), and rise or fall in systolic blood pressure (>30 mmHg).  Median interval between completion of transfusion and appearance of symptoms is 30 minutes (range 0 to 5 hours).  Significant overlap with clinical manifestations of non-hemolytic transfusion reactions, acute hemolytic reactions, allergic reactions, and other causes. DR.MOMINA ZULFEEN
  72. 72.  Stop the transfusion immediately.  Resuscitate the patient.  Collect blood from the opposite arm from that used for the transfusion and send for culture, direct antiglobulin (Coombs) test, plasma-free hemoglobin, and repeat crossmatch and typing. Urine should be analyzed for free hemoglobin.  Check for clerical error. If an error is found, investigate the status of the unit intended for the recipient (so that it is not administered to another patient unintentionally).  If there is high suspicion for TTBI (eg, in the setting of fever together with hypotension, shock, or respiratory failure), begin empiric broad-spectrum antibiotics. The choice of antibiotics should be determined by local resistance patterns; the combination of vancomycin and a broad-spectrum beta- lactam or an aminoglycoside should provide coverage for the most likely pathogens.  Alert the hospital blood bank and microbiology laboratory.  Seal the blood product bag and send to the microbiology laboratory for Gram stain and culture. A sample from the bag should be obtained using aseptic technique with a needle and syringe. If there is no residual blood product in the bag, then culture broth should be added to the bag and an aspirate of the broth be used for culture.  Co-components from the same donation should be quarantined. DR.MOMINA ZULFEEN
  73. 73.  Donor screening – Exclusion of donors with identifiable infectious diseases and deferral of donors for 24 hours after dental extraction  Skin preparation – Careful donor arm disinfection; the preferred skin disinfection solution is a product combining 2 percent chlorhexidine in 70 percent isopropyl alcohol.  Sample diversion – Discarding the first aliquot of donor blood has been proposed in order to prevent infection due to skin contaminants.  Increasing culture volume – In one study, doubling the volume of blood cultured resulted in a 54 percent relative increase in culture sensitivity.  Preferential use of apheresis – A single donor product (apheresis platelets) carries a lower risk of TTBI than whole-blood–derived platelet concentrates, since bacterial contamination may result from a contaminated venipuncture.  Reduced storage time – The risk of TTBI increases with storage time between blood donation and blood product administration.  Leukodepletion  Bactericidal treatments (eg, ultraviolet light exposure after psoralen sterilization) DR.MOMINA ZULFEEN
  76. 76.  Fever/chills — Fever (ie, increase in temperature of >1°C), with or without a chill, is a critical sign of an acute transfusion reaction. Suggest :  acute hemolytic transfusion reaction (AHTR), a septic transfusion reaction, transfusion-related acute lung injury (TRALI), or a febrile nonhemolytic transfusion reaction (FNHTR)  Significant ATRs not accompanied by fever include: urticaria, anaphylaxis, primary hypotensive reactions and transfusion-associated circulatory overload (TACO) DR.MOMINA ZULFEEN
  77. 77.  Respiratory distress — Respiratory symptomatology characterizes TACO, TRALI, and anaphylaxis.  TACO and TRALI may be difficult to differentiate because they both present with pulmonary edema. ●TACO is more often characterized by hypertension, while TRALI is often associated with hypotension. ●The pulmonary artery wedge pressure is usually elevated in TACO but not in TRALI. ●TRALI is more often accompanied by fever. DR.MOMINA ZULFEEN
  79. 79.  Hypotension — A significant drop in blood pressure (eg, by >20 mmHg) is characteristic of AHTR, TRALI, and sepsis. Importantly, hypotension may also be due to bleeding rather than a transfusion reaction.  AHTR may be accompanied by fever, chills, back pain, pain along the infusion vein, and disseminated oozing from intravenous catheters. Dark urine and/or oliguria. Evidence of intravascular immune hemolysis.  TRALI is accompanied by fever/chills, respiratory distress, rales on lung exam, and hypoxemia; chest radiography shows bilateral pulmonary edema.  Sepsis may be accompanied by fever/chills, and other findings of shock. Laboratory evaluation will reveal the infectious organism. DR.MOMINA ZULFEEN
  80. 80.  Rash- can be isolated reaction or associated with serious anaphylaxis or anaphylactoid rxn.  Anaphylaxis occurs with in three hours, associated with hypotension, abdominal pain etc. DR.MOMINA ZULFEEN
  81. 81.  The massive transfusion protocol is used to identify and manage patients at risk of bleeding by standardizing blood orders for component replacement during the bleeding episode.  Criteria for activation of massive transfusion protocol:  Actual or anticipated 4 units of RBC in <4 hours + hemodynamically stable+/- ongoing blood loss  In adults > 50ml per kg per hour  Major obstetric hemorrhage DR.MOMINA ZULFEEN
  82. 82.  Investigations- CBC, Coagulation profile – PT,Aptt, INR, fibrinogen ,Ionized calcium,Arterial blood gas  Aim-  Temperature >35*c  pH >7.2  Base excess < -6  Lactate <4 mmol  Calcium > 1.1mmol/l  Plateletes >50,000  PT/Aptt <1.5 x normal  INR </= 1.5  Fibrinogen >1g/l DR.MOMINA ZULFEEN
  83. 83.  RBC:FFP:Platelets=1:1:1(damage control)  Resuscitation with FFP, platelets, and RBCs at 1:1:1 unit ratios means that the actual blood being given has a coagulation factor concentration of 65 percent of normal, a platelet count of 88 x 109/L, and a hematocrit of 29 percent. Because 30 percent of the platelets and 10 percent of the RBC administered will not circulate, the effective concentrations are a plasma coagulation factor concentration of 65 percent, platelet count of 55 x 109/L, and a hematocrit of 26 percent.  Tranexemic acid- loading dose 1gm over 10 min, then infusion of 1gm over 8 hours.  Cryoprecipitate if fibrinogen <1g/l  Monitor CBC, coagulation profile, ionized calcium ,ABG every ½ hour. DR.MOMINA ZULFEEN
  84. 84.  Acidosis  Hyperkalemia  Citrate toxicity and hypocalcemia  Depletion of fibrinogen and coagulation factors  Depletion of platelets  Disseminated intravascular coagulation  Hypothermia  Reduced 2,3 diphosphoglycerate  Microaggregate DR.MOMINA ZULFEEN
  85. 85.  Acidosis- under normal circumstances body can easily neutralize this acid load. Routine use of bicarbonate is unnecessary.  hyperkalemia-small increase is rarely of significance.  Inj calcium gluconate 10% , 10 ml over 10 minutes slow IV;  salbutamol nebulization 15mg every 30 min for first 2 hours and then 4th hourly.  25% dextrose 100ml with 10 units rapid acting insulin over half hour  Potassium binder  Last resort – dialysis.  Prevention- using fresh blood. DR.MOMINA ZULFEEN
  86. 86.  Citrate toxicity- citrate is usually rapidly metabolized, may cause hypocalcemia. Prophylactic calcium is not recommended  Dilutional coagulopathy by depletion of fibrinogen and coagulation factors- FFP and cryoprecipitate used.  DIC- abnormal activation of coagulation and fibrinolytic systems- correct underlying cause and replace coagulation factors.  Hypothermia- warm blood and warm IV fluids  Microaggregates- filters can be used,little evidence on their efficacy. DR.MOMINA ZULFEEN
  87. 87.  Cell free purified hemoglobin solution  Perfluorocarbon emulsions- an inert liquid with high oxygen solubility , oxygen delivered by simple diffusion.  Liposome-encapsulated hemoglobin.  Blood cell subsititutes such as flusol, oxigant. DR.MOMINA ZULFEEN