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Blood presentation

This document discusses red blood cell and component therapy. It covers three pillars of patient blood management: preoperative detection of anemia, intraoperative hemostasis and cell salvage, and postoperative optimization. It then describes the components that make up component therapy, including packed red blood cells (PRBC), platelets, fresh frozen plasma, cryoprecipitate, and leukoreduced and irradiated PRBCs. Indications for transfusion and potential complications are also summarized.

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RED BLOOD CELL AND COMPONENT THERAPY NIKHIL BANSAL
PATIENT BLOOD MANAGEMENT THREE PILLARS OF CARE • Preoperative: detect anemia • Intra-operative: hemostais and cell salvage • Post operative: optimization
WHY ? One donated unit can help multiple patients • Conserves resources • Optimal method for transfusing large amounts of a specific component
COMPONENTS A blood component is a constituent of blood, separated from whole blood, such as: • Red cell concentrate Plasma Platelet concentrate Cryoprecipitate, prepared from fresh frozen plasma; rich in Factor VIII and fibrinogen
WHOLE BLOOD • 450 mL whole blood in 63 mL anticoagulant‐preservative solution CONTENT • Hb=1.2 g/dL, haematocrit (Hct)= 35‐45% • No functional platelets or labile coagulation factors (V and VIII ) STORED +2°C to +6°C
WHOLE BLOOD cont.. Administration: • NOT PREFFERED NOW
PRBC (PACKED RED BLOOD CELL) • Red blood cells from which most of the plasma has been removed CONTENT • Hb =20 g/100 mL (not <45 g per unit), Hct 55‐75% STORED • Stored at +2°C to +6°C
PRBC cont.. IN BAG 200ml of RBC+100ml optisol+30ml of plasma DOSING • Hb should be measured before and after every unit of RBCs transfused • Increase by 1g/dl, Hct by 3% PAEDS 10ml/kg increase by 2g/dl Satellite bags:50ml 5ml/kg bolus->1mg/kg furosemide->5ml/kg/hr
ADMINISTRATION DISCUSSED LATER
INDICATIONS Clinical signs and biochemical markers of inadequate oxygen delivery CLINICAL • Tachycardia • Hypotension • Tachypnea or dyspnea LAB • Elevated blood lactate concentration (>2mmol/lt) • Low pH (<7.2) • Low central or mixed venous oxygen saturation (<60/50%)
INDICATIONS cont.. Signs of end-organ dysfunction • Electrocardiographic (ST changes, onset of arrhythmias) or echocardiographic indications of myocardial ischemia • Electroencephalographic indications of cerebral hypoperfusion • New onset oliguria (less than 0.5 mL/kg/h for >6 h)
TRANSFUSION TRIGGERS • Hct <26%, no indication of transfusion if Hct >30% • Contains no clotting factors,so if >4-5units required give FFPs also Perioperative transfusion • 8g/dL for patient undergoing cardiovascular surgery Chronic anaemia • 7g/dL in adults
Processing Residual Circuit Whole Blood Three re-infusion methods – Direct Ann Thorac Surg. 1993;56(4):938-43. – Cell-Wash JECT. 1996;28(3):134-9. – Ultrafiltration Perfusion. 2005;20(6):343-9. Final Infusion Volume Contents Technique Volume cc % HCT Plt Cnt 109/L [Fib] mg/dL % Clot Factors Direct 700-1800+ 17-25 50-140 80-135 15-40 Cell-wash 225-450 40-58 5-25 10-30 2-10 Ultrafiltration 450-1000 45-55 125-325 225-385 85-259
Ultrafiltration Versus Cell Washing Residual CPB Circuit Whole Blood Issue Ultrafiltration Cell-Washing Clotting factor preservation Concentrates remaining factors Discards clotting factors Protein (fibrinogen) preservation Concentrates Albumin and Fibrinogen Discard albumin and fibrinogen Allogeneic transfusion avoidance Helps to avoid use of PRBCs and component therapy Helps to avoid use of PRBCs; May increase the use of component therapy Heparin / drug removal Concentrates some drugs Removes many drugs Platelet / RBC / WBC preservation Concentrates Functional Blood Cells May waste or activate Platelets, WBCs and RBCs Interleukin / complement removal Removes some ILs complements Removes some ILs or complements Contamination Should not introduce bacteria CW product contains bacteria Fat removal May remove some fat Removes some fat Cost-savings Cost savings with decreased allogeneic component therapy Some cost savings with reduced allogeneic PRBC use 1 Roeder. J Extra Corpor Technol. 2004;36(2):162-5. 2 Samolyk. Perfusion. 2005;20(6):343-9. 3 Jackson. J Extra Corpor Technol. 2006;38(1);A86. 4 Beckmann. J Extra Corpor Technol. 2007;39(2):103-8. 5 Riley. J Extra Corpor Technol. 2007;39(1)A3.
Platelet concentrates (PC) • From pooled buffy coat-derived platelets from four whole blood donations, suspended in platelet additive solution and the plasma of one of the four donors • As an adult therapeutic dose obtained from a single donor by apheresis donation CONTENT • 50‐60 mL plasma that should contain ≥55 x 109 platelets • Pooled unit, i.e. platelets prepared from 4‐6 donor units containing at least 240 x 109 platelets STORED • Up to 5 days at +20°C to +24°C (with agitation)
PC cont.. IN BAG 250-350 ml DOSING • 1 unit of platelet concentrate/10 kg (6bags); for an adult of 60‐70 kg • single donor units containing 8 x 109 platelets should raise the platelet count by 7000-10,000 • Increment will be less if there is splenomegaly, disseminated intravascular coagulation (DIC) or septicaemia PAEDS 10-20ml/kg
PC cont.. Administration: • After pooling should be infused as soon as possible because of the risk of bacterial proliferation • Over a period of not more than 30 minutes • Do not give platelet concentrates prepared from RhD positive donors to an RhD negative female with childbearing potential • ABO compatible, whenever possible (NOT OBLIGATORY)
INDICATIONS • Platelet function defects and thrombocytopenia often occur after cardiac bypass surgery/antiplatelet medication • Platelet transfusion is recommended for patients with bleeding not due to surgically correctable causes (closure time provides global indication of platelet function) • Prophylactic platelet transfusions are not required for all bypass procedures NON BLEEDING: <20,000 BLEEDING: <100,000 Platelet function is impaired in hypofibrinigenemia and Hct <30%. So use PRBC and cryo to bring Hct >30% Should not be transfused within 6hrs of loading dose and within 4hrs of maintainance dose of clopidogrel
Complications • Febrile non‐haemolytic and allergic urticarial reactions, especially in multiple transfusions
Fresh Frozen Plasma (FFP) • FFP is plasma prepared from whole blood, either from the primary centrifugation of whole blood into red cells and plasma or from a secondary centrifugation of platelet rich plasma CONTENT • Normal plasma levels of stable clotting factors, albumin, immunoglobulin and Factor VIII at a level of at least 70% of normal fresh plasma except factor V (66%), VIII (41%) STORAGE • Rapidly frozen to –25°C or colder within 8 hours of collection, can be stored for upto 1yr
FFP cont.. IN BAG 200‐300 mL Dosage: 2-4units (increase clotting factors by 10%) PAEDS: 15 mL/kg Administration: • Should be ABO compatible • Infuse as soon as possible after thawing • Labile coagulation factors rapidly degrade; use within 6 hours of thawing
FFP cont.. • Before use, it should be thawed in the blood transfusion centre between +30°C and +37°C • FFP can be thawed Dry oven (10 minutes) Microwave (2-3 minutes) Water bath (20 minutes) Thawed FFP can be used for up to 24 hours as long as it is stored at 4ºC Once out of the fridge, it must be used within 30 min Once thawed should never be refrozen
INDICATIONS • Dilutional effect of CPB and progressive loss of clotting factors in bleeding-can be given evn if INR is high normal • Patients with antithrombin III deficiency-heparin resistance • Replacement of a single coagulation factor deficiency, where a specific or combined factor concentrate is unavailable or contraindicated • Immediate reversal of warfarin effect where prothrombin complex concentrate is unavailable • In patients who are actively bleeding and whose INR is >1.5 (or POC equivalent) • Massive blood transfusion • Acute DIC if there are coagulation abnormalities and patient is bleeding • Severe sepsis, particularly in neonates (independent of DIC)
COMPLICATIONS • Acute allergic reactions are not uncommon, especially with rapid infusions • Severe life‐threatening anaphylactic reactions occasionally occur FFP for volume expansion can be avoided by using crystalloid or colloid solutions
Cryoprecipitated anti‐haemophilic factor (Cryo‐AHF) • Cryo‐AHF is prepared from FFP by collecting the precipitate formed during controlled thawing at +4°C and re‐suspending in 10‐20 mL plasma CONTENT • Contains about half the Factor VIII and fibrinogen as a pack of fresh whole blood: e.g. Factor VIII: 80‐100 iu; fibrinogen: 150‐300 mg, 40-70% von Willebrand factor, 50-1000 units of factor XIII and 50-60mg fibronectin STORED • At –25°C or colder for up to 1 year
CRYO cont.. IN BAG • One unit of 20 to 40 ml • 5-6 units,100 to 200 ml DOSE 1unit/10kg body wt 10units=fibrinogen increase by 70mg in 70kg man PAEDS 10ml/kg
FORMULAE • Blood volume=70ml/kg*wt in kg • Plasma volume=BV *(1-Hct) • Fibrinogen required(mg)=0.01*PV*(desired- current) • Bags of Cryo required=mg of fibrinogen req/250mg
Administration • ABO compatible product should be used (not essential) • After thawing, infuse as soon as possible • Must be transfused within 6 hours of thawing
INDICATIONS • Hypofibrinogenaemia due to major haemorrhage and massive transfusion, vWD • During major haemorrhage, fibrinogen should be maintained > 1.5 g.l-1 • Combined liver and renal failure with bleeding • Bleeding associated with thrombolytic therapy • Disseminated intravascular coagulation with fibrinogen < 1.0 g.l-1.
Leukoreduced PRBC • Removing a proportion of the plasma from leucocyte depleted whole blood or by leuco-depleting plasma reduced red cells • Non-LR RBC contain 1-3 x 109 WBC • LR contain < 5 x 106 WBC and retains 85% of the original cells • HLA alloimmunization against class I antigens, febrile reactions, and CMV infections
Indications • Chronically transfused patients • Patients with previous febrile nonhemolytic transfusion reactions
Irradiated PRBC • PRBC units are exposed to gamma irradiation (2,500 cGy) to damage donor WBC DNA • Prevent a cellular immune proliferative response to the recipient’s tissues • Cesium-137 blood irradiators • Irradiated within 14 days of donation and it then has a shelf life of 14 days
Indications • Transplant Recipients • Intrauterine transfusion • Immunosuppressed patients at risk for this complication(GVHD) • Neonates/Infants undergoing exchange transfusion or ECMO
Trigger Values 1.PRBC Premature Normal: <7gm/dl Preop: <10gm/dl Cyanotic: <12gm/dl Term(<4m) Normal: <7gm/dl Preop: <10gm/dl Ecmo: <12gm/dl Cyanotic: <13gm/dl
Triggers cont.. 2.PC Premature: <30,000 Term (<4m): <20,000 Term (>4m): <10,000 Preop: <50,000 Ecmo: <100,000 3.FFP INR: >1.5 PT> 1.5 times 4.Cryoppt Fibrinogen: <100gm
Massive Blood Transfusion • Replacement of a blood volume equivalent within 24 hours • >10 units within 24 hours • Transfusion >4 units in 1 hour • Replacement of 50% of blood volume in 3‐4 hours • A rate of loss >150 ml/hour
MANAGEMENT • Prolongation PT – FFP in a dose of 15 mL/kg • APTT is also prolonged- Factor VIII/fibrinogen concentrate in addition to FFP/ 10‐15 units of cryoprecipitate • PCs only when Clinical signs of microvascular bleeding The patient’s platelet count falls below 50 x 109/L Below 20 x 109/L, even if there is no clinical evidence of bleeding The prophylactic use of platelet concentrates in patients receiving large volume blood transfusions is not recommended.
AVOID • Hypothermia • Acidosis • Hypocalcaemia (aim for ionised calcium > 1.0 mmol.l-1) • Hyperkalaemia
AIM • Temperature: >35 celsius • pH: >7.2 • Base exces: <-6 • Lactate: <4mmol/lt • Calcium: >1.1mmol/lt • Platelets: >50,000 • PT/APTT: <1.5 times normal • INR: <1.5 • Fibrinogen: >1gm/dl
Preservative solutions CPD -21days • Citrate is an anticoagulant, • Phosphate serves as a buffer, • Dextrose is a red cell energy source CPDA -35 days • Adenine allows RBCs to resynthesize adenosine triphosphate (ATP), which extends the storage time from 21 to 35 days
CHANGES DURING STORAGE • RBCs metabolize glucose to lactate, hydrogen ions accumulate, and plasma pH decreases • 1° to 6° C stimulate the sodium potassium pump, and RBCs lose K+ and gain Na • The osmotic fragility of RBCs increases, and some cells undergo lysis, resulting in increased plasma Hb levels • Decreases in RBC concentrations of ATP and 2,3- diphosphoglycerate (2,3- DPG)->leftward shift->decreased offloading of oxygen
ADMINISTRATION OF BLOOD PRODUCTS When blood is transfused, it is important to keep detailed records including the following in the patient’s notes: Type and volume of each unit transfused Unique donation number of each unit transfused Blood group of each unit transfused Time at which the transfusion of each unit commenced Signature of the individual responsible for administration of the blood Monitor the patient before, during and on completion of the transfusion Record the time of completion of the transfusion Identify and respond immediately to any adverse effect, by stopping the transfusion Record the details of any transfusion reaction
COMPATIBILITY TESTING The laboratory performs COMPATIBILITY testing: ABO and RhD grouping on patient and donors Antibody screening on patient Cross matching between serum of patient and red cells of donor
CHECK POINTS Blood bag should be checked for: Haemolysis Haemolysis on the line between the red cells and plasma Contamination, such as a change of colour in the red cells, which often look darker/purple/ black when contaminated • Clot • Leak
DISCARDED The blood unit must be discarded if: • It has been out of the refrigerator for longer than 30 minutes • The seal is broken • There is any sign of haemolysis, clotting or contamination
Once issued by the blood centre, the transfusion of whole blood, red cells, platelet concentrate and thawed fresh frozen plasma should be commenced within 30 minutes of removal from the optimal storage conditions
IDENTIFY • The patient must be positively identified-first name, last name, date of birth and patient identification number • Check that the compatibility label attached to the blood component has the same blood group and 14-digit component donation number (or batch number for coagulation factors or SD FFP) as the sticker on the blood component • Check the expiry date and time
Suggested rates of transfusion Adult Rate Paediatric Rate • Whole blood 150‐200 mL/hour 2‐5 mL/kg/hour • PRBC 100‐150 mL/hour 2‐5 mL/kg/hour • Platelets / plasma 150‐300 mL/hour 1‐2 mL/minute
Time limits for transfusion • There is a risk of bacterial proliferation or loss of function in blood products once they have been removed from the correct storage conditions • Transfusion of a unit of blood should be completed within a maximum period of four hours after removal from the blood fridge: discard the unit if this period is exceeded • If blood has been out of the blood bank refrigerator for more than 30 minutes and is not transfused, then the unit must be returned to the laboratory, where it will be disposed of
Duration times for transfusion Start transfusion Complete transfusion • PRBC Within 30 minutes ≤ 4 hours • PC Immediately Within 30 minutes • FFP As soon as possible Within 30 minutes • Cryoprecipitate As soon as possible Within 30 minutes
Blood administration set • Use a new, sterile blood administration set containing an integral 170‐200μ filter • Change the set at least 12‐hourly during blood transfusion • In a very warm climate, change the set more frequently and usually after every four units of blood, if given within a 12‐hour period • Priming with saline,D5 is hypotonic, RL contains calcium
Monitoring the transfusion • Before commencing the transfusion, it is essential to encourage the patient to notify a nurse or doctor immediately if he or she becomes aware of any discomfort such as shivering, flushing, pain or shortness of breath or begins to feel anxious • Ensure that the patient is in a setting where he or she can be directly observed For each unit of blood transfused, monitor the patient: - Before starting the transfusion (baseline observation). - 15 minutes after starting the transfusion. - At least every hour during transfusion. - Carry out a final set of observations 15 minutes after each unit has been transfused
Warming blood • There is no evidence that warming blood is beneficial to the patient when transfusion is slow Warmed blood is most commonly required in: Large volume rapid transfusions: - Adults: more than 50 mL/kg/hour - Children: more than 15 mL/kg/hour Exchange transfusion in infants Patients with clinically significant cold agglutinins
Use of medication at time of transfusion • Not recommended to routinely use pre‐medication like anti‐histamines, steroids,mask or delay the signs and symptoms of an acute transfusion reaction and therefore delay recognition and action to stop the transfusion • Use a separate IV line if an intravenous fluid has to be given at the same time as blood transfusion
Use of fresh blood Stored blood less than 7 days old is termed “fresh blood” Uses ( to avoid biochemical overload) to raise Hb: - Renal and liver dysfunction - Massive blood transfusion - Raised plasma potassium - Neonate requiring exchange transfusion
TRANSFUSION REACTIONS Acute TR (<24 hours) - Wrong blood, primed immunological recipient - Poor quality blood, faulty assessment Delayed TR (>24 hours) - Diseases, other delayed immunologic reactions, metabolic effect (5‐10 days)
TRANSFUSION REACTION cont.. • With the exception of urticarial allergic and febrile non‐haemolytic reactions, all are potentially fatal and require urgent treatment • The severity of the reaction and the degree of morbidity is usually related to the volume of blood transfused The only sign in an unconscious or anesthetized patient may be hypotension and uncontrolled bleeding or oozing. In a conscious patient this may occur within minutes of transfusion of as little as 5‐10 mL blood
ACUTE COMPLICATIONS
Haemolytic transfusion reaction • An acute haemolytic transfusion reaction is the result of a mismatched blood transfusion, and causes acute intravascular haemolysis • Antibodies in the patient’s plasma haemolyse the incompatible red cells • Small volume (5‐10 mL) of incompatible blood can cause a severe reaction • Appear within minutes
Bacterial contamination and septic shock • Affects up to 0.4% of red cells and 1‐2% of platelet concentrates • Pseudomonas species, grow at +2°C to +6°C and can survive or multiply in refrigerated red cell unit • Staphylococci grow in warmer conditions and are able to proliferate in PCs which are stored at+20°C to +24°C • Signs usually appear rapidly after starting infusion, but may be delayed for a few hours • Sudden onset of high fever, rigors and hypotension • Urgent supportive care and high‐dose intravenous antibiotics are required
Transfusion Associated Circulatory Overload • Can result in heart failure and pulmonary edema • May occur when: - Too much fluid is transfused. - The transfusion is given too rapidly. - Renal function is impaired.
Anaphylactic reaction • Rare, risk is increased by rapid infusion, typically when fresh frozen plasma is used • IgA deficiency in the recipient is a rare cause of very severe anaphylaxis • This can be caused by any blood product since most contain traces of IgA Occurs within minutes of starting the transfusion and is characterized by: - Cardiovascular collapse. - Respiratory distress. - No fever Anaphylaxis is likely to be fatal if it is not managed rapidly and aggressively.
Transfusion Related Acute Lung Injury • Caused by donor plasma that contains antibodies against the patient’s leucocytes • Rapid failure of pulmonary function usually presents within 1‐4 hours of starting transfusion, with diffuse opacity on the chest X‐ray • No specific therapy • Intensive respiratory and general support in an intensive care unit is required
DELAYED COMPLICATIONS
Delayed haemolytic transfusion reaction Signs appear 5‐10 days after transfusion: Fever. Anaemia. Jaundice. Occasionally haemoglobinuria. Severe, life‐threatening delayed haemolytic transfusion reactions with shock, renal failure and DIC are rare
Post‐transfusion purpura • This is a rare but potentially fatal complication of transfusion of red cells or platelet concentrates, caused by antibodies directed against platelet‐specific antigens in the recipient • Multigravida female patients Signs and symptoms: – Signs of bleeding. – Acute, severe thrombocytopenia 5‐10 days after transfusion, defined as a platelet count of <100 x 109/L.
MANAGEMENT Management becomes clinically important at a platelet count of 50 x 109/L, with a danger of hidden (occult) bleeding at 20 x 109/L. • High dose corticosteroids • High dose IV immunoglobulin, 2 g/kg or 0.4 g/kg for 5 days • Plasma exchange • Monitor the patient’s platelet count • Platelet concentrates that are negative for the platelet‐specific antigen against which the antibodies are directed • Recovery of platelet count after 2‐4 weeks is usual
Transfusion associated graft‐versus‐host disease (TA‐GVHD) • Fatal condition Occurs in patients such as: – Immuno‐deficient recipients of bone marrow transplants – Immuno‐competent patients transfused with blood from individuals with whom they have a compatible HLA tissue type, usually blood relatives particularly 1st degree Signs and symptoms typically occur 10‐12 days after transfusion and are characterized by: – Fever – Skin rash and desquamation – Diarrhoea – Hepatitis – Pancytopenia
TA-GVHD cont.. Management • Treatment is supportive; there is no specific therapy. Prevention • Do not use 1st degree relatives as donors, unless gamma irradiation of cellular blood components is carried out to prevent the proliferation of transfused lymphocytes
Delayed complications: transfusion transmitted infections • HIV, Hepatitis B and C, syphilis (Treponema pallidum), malaria Cytomegalovirus (CMV) Other TTIs include human parvovirus B19, brucellosis, Epstein‐Barr virus, toxoplasmosis, Chagas disease, infectious mononucleosis and Lyme’s disease.
Duration of red-cell storage and complications after cardiac surgery. N England J Med 2008 Mar 20;358(12):1229-39. Koch CG, et al. In patients undergoing cardiac surgery, transfusion of red cells that had been stored for more than 2 weeks was associated with a significantly increased risk of postoperative complications as well as reduced short-term and long-term survival.
Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007 Nov 12 Murphy GJ, Reeves BC, Rogers CA, Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.
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Blood presentation

  • 1.
    RED BLOOD CELLAND COMPONENT THERAPY NIKHIL BANSAL
  • 2.
    PATIENT BLOOD MANAGEMENT THREEPILLARS OF CARE • Preoperative: detect anemia • Intra-operative: hemostais and cell salvage • Post operative: optimization
  • 3.
    WHY ? One donatedunit can help multiple patients • Conserves resources • Optimal method for transfusing large amounts of a specific component
  • 4.
    COMPONENTS A blood componentis a constituent of blood, separated from whole blood, such as: • Red cell concentrate Plasma Platelet concentrate Cryoprecipitate, prepared from fresh frozen plasma; rich in Factor VIII and fibrinogen
  • 5.
    WHOLE BLOOD • 450mL whole blood in 63 mL anticoagulant‐preservative solution CONTENT • Hb=1.2 g/dL, haematocrit (Hct)= 35‐45% • No functional platelets or labile coagulation factors (V and VIII ) STORED +2°C to +6°C
  • 6.
  • 7.
    PRBC (PACKED REDBLOOD CELL) • Red blood cells from which most of the plasma has been removed CONTENT • Hb =20 g/100 mL (not <45 g per unit), Hct 55‐75% STORED • Stored at +2°C to +6°C
  • 8.
    PRBC cont.. IN BAG 200mlof RBC+100ml optisol+30ml of plasma DOSING • Hb should be measured before and after every unit of RBCs transfused • Increase by 1g/dl, Hct by 3% PAEDS 10ml/kg increase by 2g/dl Satellite bags:50ml 5ml/kg bolus->1mg/kg furosemide->5ml/kg/hr
  • 9.
  • 10.
    INDICATIONS Clinical signs andbiochemical markers of inadequate oxygen delivery CLINICAL • Tachycardia • Hypotension • Tachypnea or dyspnea LAB • Elevated blood lactate concentration (>2mmol/lt) • Low pH (<7.2) • Low central or mixed venous oxygen saturation (<60/50%)
  • 11.
    INDICATIONS cont.. Signs ofend-organ dysfunction • Electrocardiographic (ST changes, onset of arrhythmias) or echocardiographic indications of myocardial ischemia • Electroencephalographic indications of cerebral hypoperfusion • New onset oliguria (less than 0.5 mL/kg/h for >6 h)
  • 12.
    TRANSFUSION TRIGGERS • Hct<26%, no indication of transfusion if Hct >30% • Contains no clotting factors,so if >4-5units required give FFPs also Perioperative transfusion • 8g/dL for patient undergoing cardiovascular surgery Chronic anaemia • 7g/dL in adults
  • 13.
    Processing Residual CircuitWhole Blood Three re-infusion methods – Direct Ann Thorac Surg. 1993;56(4):938-43. – Cell-Wash JECT. 1996;28(3):134-9. – Ultrafiltration Perfusion. 2005;20(6):343-9. Final Infusion Volume Contents Technique Volume cc % HCT Plt Cnt 109/L [Fib] mg/dL % Clot Factors Direct 700-1800+ 17-25 50-140 80-135 15-40 Cell-wash 225-450 40-58 5-25 10-30 2-10 Ultrafiltration 450-1000 45-55 125-325 225-385 85-259
  • 14.
    Ultrafiltration Versus Cell Washing ResidualCPB Circuit Whole Blood Issue Ultrafiltration Cell-Washing Clotting factor preservation Concentrates remaining factors Discards clotting factors Protein (fibrinogen) preservation Concentrates Albumin and Fibrinogen Discard albumin and fibrinogen Allogeneic transfusion avoidance Helps to avoid use of PRBCs and component therapy Helps to avoid use of PRBCs; May increase the use of component therapy Heparin / drug removal Concentrates some drugs Removes many drugs Platelet / RBC / WBC preservation Concentrates Functional Blood Cells May waste or activate Platelets, WBCs and RBCs Interleukin / complement removal Removes some ILs complements Removes some ILs or complements Contamination Should not introduce bacteria CW product contains bacteria Fat removal May remove some fat Removes some fat Cost-savings Cost savings with decreased allogeneic component therapy Some cost savings with reduced allogeneic PRBC use 1 Roeder. J Extra Corpor Technol. 2004;36(2):162-5. 2 Samolyk. Perfusion. 2005;20(6):343-9. 3 Jackson. J Extra Corpor Technol. 2006;38(1);A86. 4 Beckmann. J Extra Corpor Technol. 2007;39(2):103-8. 5 Riley. J Extra Corpor Technol. 2007;39(1)A3.
  • 15.
    Platelet concentrates (PC) •From pooled buffy coat-derived platelets from four whole blood donations, suspended in platelet additive solution and the plasma of one of the four donors • As an adult therapeutic dose obtained from a single donor by apheresis donation CONTENT • 50‐60 mL plasma that should contain ≥55 x 109 platelets • Pooled unit, i.e. platelets prepared from 4‐6 donor units containing at least 240 x 109 platelets STORED • Up to 5 days at +20°C to +24°C (with agitation)
  • 16.
    PC cont.. IN BAG 250-350ml DOSING • 1 unit of platelet concentrate/10 kg (6bags); for an adult of 60‐70 kg • single donor units containing 8 x 109 platelets should raise the platelet count by 7000-10,000 • Increment will be less if there is splenomegaly, disseminated intravascular coagulation (DIC) or septicaemia PAEDS 10-20ml/kg
  • 17.
    PC cont.. Administration: • Afterpooling should be infused as soon as possible because of the risk of bacterial proliferation • Over a period of not more than 30 minutes • Do not give platelet concentrates prepared from RhD positive donors to an RhD negative female with childbearing potential • ABO compatible, whenever possible (NOT OBLIGATORY)
  • 18.
    INDICATIONS • Platelet functiondefects and thrombocytopenia often occur after cardiac bypass surgery/antiplatelet medication • Platelet transfusion is recommended for patients with bleeding not due to surgically correctable causes (closure time provides global indication of platelet function) • Prophylactic platelet transfusions are not required for all bypass procedures NON BLEEDING: <20,000 BLEEDING: <100,000 Platelet function is impaired in hypofibrinigenemia and Hct <30%. So use PRBC and cryo to bring Hct >30% Should not be transfused within 6hrs of loading dose and within 4hrs of maintainance dose of clopidogrel
  • 19.
    Complications • Febrile non‐haemolyticand allergic urticarial reactions, especially in multiple transfusions
  • 20.
    Fresh Frozen Plasma(FFP) • FFP is plasma prepared from whole blood, either from the primary centrifugation of whole blood into red cells and plasma or from a secondary centrifugation of platelet rich plasma CONTENT • Normal plasma levels of stable clotting factors, albumin, immunoglobulin and Factor VIII at a level of at least 70% of normal fresh plasma except factor V (66%), VIII (41%) STORAGE • Rapidly frozen to –25°C or colder within 8 hours of collection, can be stored for upto 1yr
  • 21.
    FFP cont.. IN BAG200‐300 mL Dosage: 2-4units (increase clotting factors by 10%) PAEDS: 15 mL/kg Administration: • Should be ABO compatible • Infuse as soon as possible after thawing • Labile coagulation factors rapidly degrade; use within 6 hours of thawing
  • 22.
    FFP cont.. • Beforeuse, it should be thawed in the blood transfusion centre between +30°C and +37°C • FFP can be thawed Dry oven (10 minutes) Microwave (2-3 minutes) Water bath (20 minutes) Thawed FFP can be used for up to 24 hours as long as it is stored at 4ºC Once out of the fridge, it must be used within 30 min Once thawed should never be refrozen
  • 23.
    INDICATIONS • Dilutional effectof CPB and progressive loss of clotting factors in bleeding-can be given evn if INR is high normal • Patients with antithrombin III deficiency-heparin resistance • Replacement of a single coagulation factor deficiency, where a specific or combined factor concentrate is unavailable or contraindicated • Immediate reversal of warfarin effect where prothrombin complex concentrate is unavailable • In patients who are actively bleeding and whose INR is >1.5 (or POC equivalent) • Massive blood transfusion • Acute DIC if there are coagulation abnormalities and patient is bleeding • Severe sepsis, particularly in neonates (independent of DIC)
  • 24.
    COMPLICATIONS • Acute allergicreactions are not uncommon, especially with rapid infusions • Severe life‐threatening anaphylactic reactions occasionally occur FFP for volume expansion can be avoided by using crystalloid or colloid solutions
  • 25.
    Cryoprecipitated anti‐haemophilic factor (Cryo‐AHF) •Cryo‐AHF is prepared from FFP by collecting the precipitate formed during controlled thawing at +4°C and re‐suspending in 10‐20 mL plasma CONTENT • Contains about half the Factor VIII and fibrinogen as a pack of fresh whole blood: e.g. Factor VIII: 80‐100 iu; fibrinogen: 150‐300 mg, 40-70% von Willebrand factor, 50-1000 units of factor XIII and 50-60mg fibronectin STORED • At –25°C or colder for up to 1 year
  • 26.
    CRYO cont.. IN BAG •One unit of 20 to 40 ml • 5-6 units,100 to 200 ml DOSE 1unit/10kg body wt 10units=fibrinogen increase by 70mg in 70kg man PAEDS 10ml/kg
  • 27.
    FORMULAE • Blood volume=70ml/kg*wtin kg • Plasma volume=BV *(1-Hct) • Fibrinogen required(mg)=0.01*PV*(desired- current) • Bags of Cryo required=mg of fibrinogen req/250mg
  • 28.
    Administration • ABO compatibleproduct should be used (not essential) • After thawing, infuse as soon as possible • Must be transfused within 6 hours of thawing
  • 29.
    INDICATIONS • Hypofibrinogenaemia dueto major haemorrhage and massive transfusion, vWD • During major haemorrhage, fibrinogen should be maintained > 1.5 g.l-1 • Combined liver and renal failure with bleeding • Bleeding associated with thrombolytic therapy • Disseminated intravascular coagulation with fibrinogen < 1.0 g.l-1.
  • 30.
    Leukoreduced PRBC • Removinga proportion of the plasma from leucocyte depleted whole blood or by leuco-depleting plasma reduced red cells • Non-LR RBC contain 1-3 x 109 WBC • LR contain < 5 x 106 WBC and retains 85% of the original cells • HLA alloimmunization against class I antigens, febrile reactions, and CMV infections
  • 31.
    Indications • Chronically transfusedpatients • Patients with previous febrile nonhemolytic transfusion reactions
  • 32.
    Irradiated PRBC • PRBCunits are exposed to gamma irradiation (2,500 cGy) to damage donor WBC DNA • Prevent a cellular immune proliferative response to the recipient’s tissues • Cesium-137 blood irradiators • Irradiated within 14 days of donation and it then has a shelf life of 14 days
  • 33.
    Indications • Transplant Recipients •Intrauterine transfusion • Immunosuppressed patients at risk for this complication(GVHD) • Neonates/Infants undergoing exchange transfusion or ECMO
  • 34.
    Trigger Values 1.PRBC Premature Normal: <7gm/dl Preop:<10gm/dl Cyanotic: <12gm/dl Term(<4m) Normal: <7gm/dl Preop: <10gm/dl Ecmo: <12gm/dl Cyanotic: <13gm/dl
  • 35.
    Triggers cont.. 2.PC Premature: <30,000 Term(<4m): <20,000 Term (>4m): <10,000 Preop: <50,000 Ecmo: <100,000 3.FFP INR: >1.5 PT> 1.5 times 4.Cryoppt Fibrinogen: <100gm
  • 36.
    Massive Blood Transfusion •Replacement of a blood volume equivalent within 24 hours • >10 units within 24 hours • Transfusion >4 units in 1 hour • Replacement of 50% of blood volume in 3‐4 hours • A rate of loss >150 ml/hour
  • 37.
    MANAGEMENT • Prolongation PT– FFP in a dose of 15 mL/kg • APTT is also prolonged- Factor VIII/fibrinogen concentrate in addition to FFP/ 10‐15 units of cryoprecipitate • PCs only when Clinical signs of microvascular bleeding The patient’s platelet count falls below 50 x 109/L Below 20 x 109/L, even if there is no clinical evidence of bleeding The prophylactic use of platelet concentrates in patients receiving large volume blood transfusions is not recommended.
  • 38.
    AVOID • Hypothermia • Acidosis •Hypocalcaemia (aim for ionised calcium > 1.0 mmol.l-1) • Hyperkalaemia
  • 39.
    AIM • Temperature: >35celsius • pH: >7.2 • Base exces: <-6 • Lactate: <4mmol/lt • Calcium: >1.1mmol/lt • Platelets: >50,000 • PT/APTT: <1.5 times normal • INR: <1.5 • Fibrinogen: >1gm/dl
  • 40.
    Preservative solutions CPD -21days •Citrate is an anticoagulant, • Phosphate serves as a buffer, • Dextrose is a red cell energy source CPDA -35 days • Adenine allows RBCs to resynthesize adenosine triphosphate (ATP), which extends the storage time from 21 to 35 days
  • 41.
    CHANGES DURING STORAGE •RBCs metabolize glucose to lactate, hydrogen ions accumulate, and plasma pH decreases • 1° to 6° C stimulate the sodium potassium pump, and RBCs lose K+ and gain Na • The osmotic fragility of RBCs increases, and some cells undergo lysis, resulting in increased plasma Hb levels • Decreases in RBC concentrations of ATP and 2,3- diphosphoglycerate (2,3- DPG)->leftward shift->decreased offloading of oxygen
  • 42.
    ADMINISTRATION OF BLOOD PRODUCTS Whenblood is transfused, it is important to keep detailed records including the following in the patient’s notes: Type and volume of each unit transfused Unique donation number of each unit transfused Blood group of each unit transfused Time at which the transfusion of each unit commenced Signature of the individual responsible for administration of the blood Monitor the patient before, during and on completion of the transfusion Record the time of completion of the transfusion Identify and respond immediately to any adverse effect, by stopping the transfusion Record the details of any transfusion reaction
  • 43.
    COMPATIBILITY TESTING The laboratoryperforms COMPATIBILITY testing: ABO and RhD grouping on patient and donors Antibody screening on patient Cross matching between serum of patient and red cells of donor
  • 44.
    CHECK POINTS Blood bagshould be checked for: Haemolysis Haemolysis on the line between the red cells and plasma Contamination, such as a change of colour in the red cells, which often look darker/purple/ black when contaminated • Clot • Leak
  • 46.
    DISCARDED The blood unitmust be discarded if: • It has been out of the refrigerator for longer than 30 minutes • The seal is broken • There is any sign of haemolysis, clotting or contamination
  • 47.
    Once issued bythe blood centre, the transfusion of whole blood, red cells, platelet concentrate and thawed fresh frozen plasma should be commenced within 30 minutes of removal from the optimal storage conditions
  • 48.
    IDENTIFY • The patientmust be positively identified-first name, last name, date of birth and patient identification number • Check that the compatibility label attached to the blood component has the same blood group and 14-digit component donation number (or batch number for coagulation factors or SD FFP) as the sticker on the blood component • Check the expiry date and time
  • 49.
    Suggested rates oftransfusion Adult Rate Paediatric Rate • Whole blood 150‐200 mL/hour 2‐5 mL/kg/hour • PRBC 100‐150 mL/hour 2‐5 mL/kg/hour • Platelets / plasma 150‐300 mL/hour 1‐2 mL/minute
  • 50.
    Time limits fortransfusion • There is a risk of bacterial proliferation or loss of function in blood products once they have been removed from the correct storage conditions • Transfusion of a unit of blood should be completed within a maximum period of four hours after removal from the blood fridge: discard the unit if this period is exceeded • If blood has been out of the blood bank refrigerator for more than 30 minutes and is not transfused, then the unit must be returned to the laboratory, where it will be disposed of
  • 51.
    Duration times fortransfusion Start transfusion Complete transfusion • PRBC Within 30 minutes ≤ 4 hours • PC Immediately Within 30 minutes • FFP As soon as possible Within 30 minutes • Cryoprecipitate As soon as possible Within 30 minutes
  • 52.
    Blood administration set •Use a new, sterile blood administration set containing an integral 170‐200μ filter • Change the set at least 12‐hourly during blood transfusion • In a very warm climate, change the set more frequently and usually after every four units of blood, if given within a 12‐hour period • Priming with saline,D5 is hypotonic, RL contains calcium
  • 53.
    Monitoring the transfusion •Before commencing the transfusion, it is essential to encourage the patient to notify a nurse or doctor immediately if he or she becomes aware of any discomfort such as shivering, flushing, pain or shortness of breath or begins to feel anxious • Ensure that the patient is in a setting where he or she can be directly observed For each unit of blood transfused, monitor the patient: - Before starting the transfusion (baseline observation). - 15 minutes after starting the transfusion. - At least every hour during transfusion. - Carry out a final set of observations 15 minutes after each unit has been transfused
  • 54.
    Warming blood • Thereis no evidence that warming blood is beneficial to the patient when transfusion is slow Warmed blood is most commonly required in: Large volume rapid transfusions: - Adults: more than 50 mL/kg/hour - Children: more than 15 mL/kg/hour Exchange transfusion in infants Patients with clinically significant cold agglutinins
  • 55.
    Use of medicationat time of transfusion • Not recommended to routinely use pre‐medication like anti‐histamines, steroids,mask or delay the signs and symptoms of an acute transfusion reaction and therefore delay recognition and action to stop the transfusion • Use a separate IV line if an intravenous fluid has to be given at the same time as blood transfusion
  • 56.
    Use of freshblood Stored blood less than 7 days old is termed “fresh blood” Uses ( to avoid biochemical overload) to raise Hb: - Renal and liver dysfunction - Massive blood transfusion - Raised plasma potassium - Neonate requiring exchange transfusion
  • 57.
    TRANSFUSION REACTIONS Acute TR(<24 hours) - Wrong blood, primed immunological recipient - Poor quality blood, faulty assessment Delayed TR (>24 hours) - Diseases, other delayed immunologic reactions, metabolic effect (5‐10 days)
  • 58.
    TRANSFUSION REACTION cont.. •With the exception of urticarial allergic and febrile non‐haemolytic reactions, all are potentially fatal and require urgent treatment • The severity of the reaction and the degree of morbidity is usually related to the volume of blood transfused The only sign in an unconscious or anesthetized patient may be hypotension and uncontrolled bleeding or oozing. In a conscious patient this may occur within minutes of transfusion of as little as 5‐10 mL blood
  • 59.
  • 60.
    Haemolytic transfusion reaction •An acute haemolytic transfusion reaction is the result of a mismatched blood transfusion, and causes acute intravascular haemolysis • Antibodies in the patient’s plasma haemolyse the incompatible red cells • Small volume (5‐10 mL) of incompatible blood can cause a severe reaction • Appear within minutes
  • 61.
    Bacterial contamination andseptic shock • Affects up to 0.4% of red cells and 1‐2% of platelet concentrates • Pseudomonas species, grow at +2°C to +6°C and can survive or multiply in refrigerated red cell unit • Staphylococci grow in warmer conditions and are able to proliferate in PCs which are stored at+20°C to +24°C • Signs usually appear rapidly after starting infusion, but may be delayed for a few hours • Sudden onset of high fever, rigors and hypotension • Urgent supportive care and high‐dose intravenous antibiotics are required
  • 62.
    Transfusion Associated Circulatory Overload •Can result in heart failure and pulmonary edema • May occur when: - Too much fluid is transfused. - The transfusion is given too rapidly. - Renal function is impaired.
  • 63.
    Anaphylactic reaction • Rare,risk is increased by rapid infusion, typically when fresh frozen plasma is used • IgA deficiency in the recipient is a rare cause of very severe anaphylaxis • This can be caused by any blood product since most contain traces of IgA Occurs within minutes of starting the transfusion and is characterized by: - Cardiovascular collapse. - Respiratory distress. - No fever Anaphylaxis is likely to be fatal if it is not managed rapidly and aggressively.
  • 64.
    Transfusion Related AcuteLung Injury • Caused by donor plasma that contains antibodies against the patient’s leucocytes • Rapid failure of pulmonary function usually presents within 1‐4 hours of starting transfusion, with diffuse opacity on the chest X‐ray • No specific therapy • Intensive respiratory and general support in an intensive care unit is required
  • 65.
  • 66.
    Delayed haemolytic transfusion reaction Signsappear 5‐10 days after transfusion: Fever. Anaemia. Jaundice. Occasionally haemoglobinuria. Severe, life‐threatening delayed haemolytic transfusion reactions with shock, renal failure and DIC are rare
  • 67.
    Post‐transfusion purpura • Thisis a rare but potentially fatal complication of transfusion of red cells or platelet concentrates, caused by antibodies directed against platelet‐specific antigens in the recipient • Multigravida female patients Signs and symptoms: – Signs of bleeding. – Acute, severe thrombocytopenia 5‐10 days after transfusion, defined as a platelet count of <100 x 109/L.
  • 68.
    MANAGEMENT Management becomes clinicallyimportant at a platelet count of 50 x 109/L, with a danger of hidden (occult) bleeding at 20 x 109/L. • High dose corticosteroids • High dose IV immunoglobulin, 2 g/kg or 0.4 g/kg for 5 days • Plasma exchange • Monitor the patient’s platelet count • Platelet concentrates that are negative for the platelet‐specific antigen against which the antibodies are directed • Recovery of platelet count after 2‐4 weeks is usual
  • 69.
    Transfusion associated graft‐versus‐host disease(TA‐GVHD) • Fatal condition Occurs in patients such as: – Immuno‐deficient recipients of bone marrow transplants – Immuno‐competent patients transfused with blood from individuals with whom they have a compatible HLA tissue type, usually blood relatives particularly 1st degree Signs and symptoms typically occur 10‐12 days after transfusion and are characterized by: – Fever – Skin rash and desquamation – Diarrhoea – Hepatitis – Pancytopenia
  • 70.
    TA-GVHD cont.. Management • Treatmentis supportive; there is no specific therapy. Prevention • Do not use 1st degree relatives as donors, unless gamma irradiation of cellular blood components is carried out to prevent the proliferation of transfused lymphocytes
  • 71.
    Delayed complications: transfusion transmittedinfections • HIV, Hepatitis B and C, syphilis (Treponema pallidum), malaria Cytomegalovirus (CMV) Other TTIs include human parvovirus B19, brucellosis, Epstein‐Barr virus, toxoplasmosis, Chagas disease, infectious mononucleosis and Lyme’s disease.
  • 72.
    Duration of red-cellstorage and complications after cardiac surgery. N England J Med 2008 Mar 20;358(12):1229-39. Koch CG, et al. In patients undergoing cardiac surgery, transfusion of red cells that had been stored for more than 2 weeks was associated with a significantly increased risk of postoperative complications as well as reduced short-term and long-term survival.
  • 73.
    Increased mortality, postoperativemorbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007 Nov 12 Murphy GJ, Reeves BC, Rogers CA, Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.
  • 74.