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blood products.pptx
- 1. The use ofblood and blood products in surgery Dr PJ Shindang
- 2. Outline • Introduction • Indicationand use of the blood products • Principles of blood transfusion • Massive blood transfusion. • Autologous blood transfusion. • Complications of blood transfusion • Alternatives to blood transfusion • Challenges • Conclusion • References
- 3. Introduction • Blood transfusionrefers to the intravenous transfer of compatible blood or blood products from one individual to the same (autologous) or to another individual (homologous/allogenic) • WHOLE BLOOD: un-separated blood collected into an approved container containing an anticoagulant-preservative solution. • BLOOD PRODUCT: Any therapeutic substance prepared from human blood. • Cellular derivatives: Packed red cell, Leucocytes depleted red cell, Platelet concentrate, granulocyte concentrate • Plasma derivatives: Fresh frozen plasma, Cryoprecipitate • Coagulation factor concentrates: Factor VIII, Factor IX, X, XII, VII • Oncotic Agents: Human albumin solution • Immunoglobulins (Immune Serum Globulin): Immune serum globulin (IgG), Hepatitis B immune globulin..ETC
- 4. Historical perspective • 1665– First recorded blood transfusion in England , R Lower revived a dog by transfusing blood from another dog via a tied artery • 1900 Karl Landsteiner discovers the first three human blood groups, A, B and O. • 1914 Adolf Hustin discovers that sodium citrate can anticoagulate blood for transfusion, allowing it to be stored and later transfused safely to patients on the battlefield • 1940 The Rh blood group is discovered when RBCs of monkeys were injected into rabbits . • 1985 The first HIV blood-screening test is licensed and implemented by blood banks.
- 5. Blood collection andStorage • Collection of blood should be done under strict asepsis form suitable donors • Standard blood bag contains 450 +/- 45mls blood, with 60mls of anticoagulant preservative • Stored at 2-6oC • Anticoagulants include • Heparin: 24 hours • Acid-citrate-dextrose (ACD) : 21 days (obsolete) • Citrate-phosphate-dextrose (CPD): 28 days • Citrate-phosphate-dextrose-adenine(CPDA): 35days • SAGM: 42days • Storage • Whole blood & packed cells: 2-60C • Platelet concentrate: 20-240C (room temperature) • FFP & cryoprecipitate (frozen): -18 to -400C. • Shelf-life: • Platelets- 5days • FFP/Cryoppt-1yr • Factor concentrates- 2yrs • Albumin- 4yrs
- 6. Effects of bloodstorage • CELLS • RBC: • Swell, lose K+ to plasma. • 1% is lost for each day of storage • 2,3-DPG levels fall after 1 week • WBC: Survives for 30-90 min in the recipient's blood. WBC’s are not viable after 24h of storage. • Platelets: there are no viable platelets after 24h. However, non-viable platelets remain for 2 weeks.
- 7. Effect of storage •Electrolytes • The plasma potassium rises at the rate of 1mmol/day. • The sodium concentration of the plasma is increased because of the sodium citrate in the CPD anticoagulant. • Calcium: There is no ionized calcium. Ionized calcium displaces sodium in disodium citrate, forming unionized calcium citrate. • pH:- falls from about 7.2 at the time of collection to about 6.8 at 20 days. • Plasma Hb levels rise during storage due to leakage of Hb from cells. At 20 days the level is about 0.2 g/L. • The ammonia concentration also rises.
- 8. Effect of storage •Clotting factors • Factor Vlll (AHF) declines rapidly and activity falls by 40% after 24h of storage, There is little activity after 7 days. • Factor V declines rapidly after 24h and there is very little activity after 7 days. • Factor IX declines rapidly after 7 days and there is no activity after 14 days. • Factor X loses its activity after 7 days. • Factor Vll declines only after 14 days. • Fibrinogen and factor II are stable for 21 days.
- 9. Whole blood • Itcontains all the blood components • It’s use is now limited except in hospitals and areas where facilities for producing blood fractions are unavailable. • Indications • To restore blood volume after acute loss of > 25% blood volume • Exchange blood transfusion: hyperbilirubinemia, priapism. • Extracorporeal circulation: haemo-dialysis, heart-lung machine • Autologous blood transfusion • Where blood component therapy is unavailable. • Massive blood transfusion
- 10. Packed Red cell Preparation • Wholeblood is centrifuged at 3000 revs/min (or 5000 x g) for 5 min. • The plasma removed to give a Hct of 0.55-0.75 (PCV 55- 75%). • One unit raises the Hb by approximately 1g/dl in a 70kg adult. • Stored like whole blood, with shelf life of 42days. • Indications • Acute blood loss (after crystalloid fluid resuscitation) • Symptomatic chronic anemia: • Leukemia • aplastic anemia • Malignancies • CRF • Pre-op transfusion (before emergency surgery. If elective surgery, use other appropriate means) • Severe burns with risk of hyperkalemia • The elderly • cachetic patients.
- 11. Platelet concentrate • It isthe precipitate after platelet rich plasma is centrifuged at 3000rev/min (or 5000 x g) for 5 min • Platelet-rich plasma is the supernatant plasma after whole blood is centrifuged at 1000/min or2000x g for 3 min. • Each unit has a volume of 50-60ml, containing 5.5x109 Platelet. • One unit of platelet concentrate raises the platelet count by 5-10 x 109/L in an adult. • Platelets are stored at room temperature (20-240C) under constant agitation to prevent clumping • Shelf life of 3-5days • Transfused at a rate of 0.1unit/kg
- 12. Platelet concentrate Indications • Management ofsevere or life-threatening thrombocytopaenia • Thrombocytopenia caused by massive blood loss and replacement with platelet-poor products. • Qualitative platelet disorders. • Chemotherapy Induced marrow suppression • Massive blood transfusion
- 13. Granulocyte concentrate • Prepared byleukopharesis • Vol 220ml which contains 1 x 1010granulocytes /unit. • Should be irradiated to prevent graft-vs-Host disease • Shelf life is 24Hr • Indication • Congenital neutrophil defects with refractory bacterial or fungal infection. • Patients with severe neutropenia (<500 PMNs/uL). • Patients on Intensive chemotherapy & transplant • Reversible bone marrow hypoplasia
- 14. Leucocyte Depleted RBC • TheWBC has been reduced to <5x106 WBC • Reduces risk of CMV • Stored as whole blood. • Shell life: 24hr • Indication • Patient on repeated transfusion. • Patient with previous reaction to red cell transfusion
- 15. Plasma derived bloodproducts • Plasma products: • Fresh frozen plasma, Cryoprecipitate • Coagulation factor concentrates: • Factor VIII, Factor IX, X, XII, VII • Oncotic Agents: • Human albumin solution • Immunoglobulins (Immune Serum Globulin): • Immune serum globulin (IgG), Hepatitis B immune globulin..ETC
- 16. Fresh frozen plasma •Blood is centrifuged within 8hrs of collection at 3000 revs/min or 5000xg for 7min. • The supernatant liquid portion that is separated is rapidly frozen • It contains normal plasma levels of stable clotting factors, immunoglobulins, fibrinolytic and complement factors, fat, CHO and minerals • One unit raises clotting factors by 3% • Stored at -18oC to -400C or colder • It has a shelf-life of 1yr • It can transmit diseases, such as HIV
- 17. Fresh frozen plasma •Indication • Congenital clotting factor deficiency • Sever liver disease with abnormal coagulation • Deficiencies of coagulation factors or inhibitors of coagulation for which specific concentrates are not available • Emergency treatment of warfarin overdosage and Vit K deficiency when factor IX complex concentrate is not available. • Rx of thrombotic thrombocytopaenic purpura. • Rx of DIC • In massive blood transfusion
- 18. Cryoprecipitate • It isthe precipitate when fresh frozen plasma is allowed to thaw to 4°C and the supernatant plasma removed. • It is rich in Factors VIII and XIII, fibrinogen and von Willebrand's factor. • It is stored at -18 to -40oC or colder. • Shell life….1yr. Thaw 24hr • Indication • Used in Rx of haemophilia A • Hypofibrinogenaemia • Von Willebrand's disease • Factor XIII deficiency • DIC
- 19. Coagulation factor concentrate 1.Factor VIII concentrate • Contains 250 IU of factor VIII per vial • Stored @ +2 to +60C • Indication: • Rx of Hemophilia A • Rx of Von Willebrand dx • Recombinant factor VIII and IX are available but are very expensive. However, they are free from diseases transmitted by blood derived concentrates 2. Factor IX concentrate • Contains 350-600 IU per vial of factor IX. • Stored @ +2 to +60C. • Indication: Rx of Hemophilia B. 3. Antithrombin III concentrate
- 20. • Human Albuminsolution • Albumin 5%, 20%, 25% • Stored @ Room temperature, with a shelf life of 3 years. Thaw 4hr @ 20-400C • Indication • Treatment of diuretic-resistant Edema • IMMUNUGLOBULINS • Conc. solution of IgG antibody component of plasma • Indication • Treatment of immunodeficiency state
- 21. Principles of bloodtransfusion • Established indication: • Benefits should clearly outweigh the risks • Avoid top-up transfusions • 5-way test • Does the patient need the transfusion? If only 1 unit is needed, it is wasteful • Are there alternatives • Will it improve the patient’s well-being? • Which component is needed? • What is the likelihood of complications? • Obtain informed consent • Use of required component of blood • Use of compatible blood of same group
- 22. Principles of bloodtransfusion • Double check the patient’s data, more than one person should check • Check for signs of discoloration, leakage, haemolysis, clot. • Warm blood before commencement • Administration must commence within 30mins of leaving the blood bank • Get appropriate resuscitation materials • Get appropriate disposable materials • Appropriate sized canula: sterile, never reuse. • Blood giving set: 170-200 micron filter, change every 12hr • Close monitoring of vital signs: pre, intra & post-transfusion • Write a transfusion order
- 23. Principles Of BloodTransfusion • Procedure • Secure IV access under aseptic conditions, using a wide bore canula (16G or larger) • Strict asepsis in setting up the transfusion drip • IV furosemide given (pt @ risk of circulatory overload) • Appropriate rate: • Initial rate 20-30 drops/min (2-3ml/min) for initial 100ml (which is when complications are more likely). • It is increased after 30mins to 60-80 drops/min • However, if the rate of on-going blood loss is rapid, the infusion should also be rapid, with squeezing of the plastic bag if necessary • In the elderly or very young, the rate should be slow, 40 drops/min or less • TIME LIMIT FOR TRANSFUSION • Whole blood & red cell…………4hr • Platelet…………20min • FFP……………. 20min • Monitoring is crucial esp. In 1st 30min
- 24. TRANSFUSION STRATEGY &TRIGGER • The indications and triggers for RBCT are on-going issues. • Based on studies to date, there are two strategies : a) In 1988, the “10/30 Rule”( liberal strategy) was • Hb 10 g/dL and Hct 30% and transfusions were performed based on those values b) Recently, the restrictive strategy (Hb level below 7 g/dL) • more accepted due to evidence regarding the negative impact on prognoses following RBCT per the liberal strategy as well as the complications and costs associated with RBCT
- 25. Damage control resuscitation •Identify at risk group as early as possible • centers on the application of several key concepts, the permissive hypotension, the use of blood products over isotonic fluid for volume replacement, and the rapid and early correction of coagulopathy with component therapy. • Early use of blood components as the primary resuscitation fluid instead of crystalloid/colloids • Use in the same ratio as they are lost through haemorrhage • PRBC:FFP:Platelets 1or2:1:1
- 26. PROPPR Trial, JAMA2015 • Pragmatic Multi-centre RCT • Mortality with 2 different blood product ratios (1:1:1) vs 1:1:2 (FFP/Plts/RBC) • 12 Level 1 Trauma Centres • 680 severely injured patients – expected ≥ 10 units RBCs Method Holcomb et al. Transfusion of Plasma, Platelets etc. JAMA 2015; 313(5):471-482
- 27. PROPPR Trial, JAMA2015 • Results • Fewer deaths from exsanguination in 24hrs • More patients achieved haemostasis • Reduction in mortality at 24hrs (12.7% vs 17%),mortality at 30 days (22.4% vs 26.1%) • No increased ARDS/Sepsis/DVT/PE in 1:1:1
- 28. Massive blood transfusion • Inadults. • Transfusion of half of a patient’s blood volume in 4 hours. • Administration of 10 or more packed red blood cell within 24hrs (adult blood volume is approximately 70 mL/kg). • Transfusion of >4 RBC units in 1 h with anticipation of continued need for blood product support. • In children • Transfusion of more than 40 mL blood/kg in 24 hrs (blood volume of children older than neonates is approximately 80 mL/kg).
- 29. Complications of massiveblood transfusion 1. Volume overload over-transfusion (monitor Hb regularly, titrate according to needs) 2. Hypothermia 3. Dilutional coagulopathy of clotting factors and platelets 4. Citrate toxicity causing metabolic acidosis and hypocalcaemia 5. Hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy) 6. Disease transmission 7. Transfusion related acute lung injury (consider use of filters, leukodepletion) 8. Clerical error. 9. Bleeding diathesis 10. Poor oxygen delivery—due to reduced 2,3 DPG
- 30. Precautions in patientsfor massive transfusion • Adequate care in documentation etc- to prevent clerical errors • Warm the blood- to prevent hypothermia • Calcium gluconate: After every 1L of blood • FFP: For every 6 units of RBCs, give 6 units of FFP (1:1 ratio) • Platelets: for every 6 units of RBCs (& FFP), give one 6-pack of platelets. Aim to keep platelet counts > 100,000 • Cryoprecipitate: After 1st 6 units of RBCs, check fibrinogen level. If <100mg/dl, give 20 units of cryoprecipitate (which contains 2g of fibrinogen). Repeat as needed, depending on fibrinogen level
- 31. Autologous Blood Transfusion •Refers to the collection & subsequent re-infusion of the patient’s own blood. • Types 1. Preoperative autologous blood donation 2. Acute autologous isovolemic haemodilution 3. Blood salvage.
- 32. Pre-op autologous blooddonation (PABD) • Pre-donation of up to 1-5 units of blood before elective surgery • Donations should start at least 40days before surgery, collect 1 pint every 3-5 days apart and the last one should not be less than 3-days (72hrs) of surgery. • The patient is placed on haematinics (ferrous sulphate) or recombinant human erythropoietin to boost haemoglobin concentration • The patient's haemoglobin should be over 10g/dl and the PCV over 30%. • Patients with bacteraemia, serious cardiac disease and sickle cell disease should be excluded.
- 33. Acute autologous isovolemic (normovolaemic)hemodilution (AIVH) • 1-4 units of the patient's own blood are removed immediately prior to the commencement of op (from one line) and replaced simultaneously with a crystalloid or colloid • The autologous blood collected is re-infused during or after the operation. • The patient's initial haemoglobin and PCV should be > 12gldl and 36% respectively and must not fall below 9 g/dl and 27% respectively after haemodilution. • The pulse, blood pressure and urine output should be monitored during the collection.
- 34. Blood salvage • Intra-op/post-opblood salvage • Useful in setting of trauma, ruptured spleen, haemothorax, cardiovascular surgery • Contra-indicated in patients undergoing tumour resection. • Shed blood from a wound or body cavity during surgery is collected using a gallipot into a kidney dish or large bowl containing an anticoagulant • The blood is filtered into a bottle through 4-6 layers of sterile gauze placed in a funnel • The bottle is then sealed and the blood re-infused within 24Hrs into the same patient.
- 35. Autologous Blood Transfusion •Why • Rare blood group • Avoids alloimmunisation • Prevents TTIs • Pre-condition • Sufficient Hb • Sepsis free • Physically fit for blood donation • Consent: documented • Complications • Air embolism • Fat embolism • Preoperative myocardial ischemia from anaemia induced by preoperative donation • Autologous units given to wrong patient • Transfusion-related bacterial sepsis
- 36. Complications of bloodtransfusion • Early problems • Febrile nonhemolytic reaction • Allergic Reaction • Hemolytic reaction • Circulatory Overload • Presents with cough, orthopnoea, puffiness • There is ↑JVP, posteriobasal crepitation • Cardiac arrest • Air embolism • Bacterial contamination. • Transfusion related acute lung injury
- 37. Complications Delayed: • Thrombophlebitis • Delayedhemolytic reaction • Post transfusion thrombocytopenic purpura • Transmission of diseases such as: • Viruses( HIV, HBV,HCV,CMV,) • Bacteria(Treponema, • Protozoa(Malaria, trypanosomiasis, toxoplasmosis) • CVJDx • Immunosuppression • Transfusion graft-vs-host Dx
- 38. ALTERNATIVES TO BLOODTRANSFUSION • RED CELL SUBSTITUTES • Per fluorocarbon • Porphyrin • Recombinant haemoglobin: Diaspirin Cross-linked Hemoglobin, Polymerized stroma-free Hemoglobin. • PLASMA SUBSTITUTES • Crystalloids • Colloids • Stable plasma protein solution • Albumin solution • Dextran • Synthetic gelatin colloids (hemaccel, gelofusine) • Hydroxyethyl starch preparations (hetastarch, pentastarch) • Platelet substitute: Pegylated Recombinant Human Megakaryocyte Growth and Development Factor (PEG-rHuMGDF) • Others • Erythropoietin • Desmopressin: in mild factor 8 deficiency
- 39. CHALLENGES OF BLOODTRANSFUSION • Shortage of voluntary blood donors • TTIs: • Parasitic: malaria, T. Cruzi • Viruses: HBV, HCV, HIV, CMV, HTLV 1 & 2, parvovirus • Prions • Bacteria • Ineffective blood transfusion: anaemic paid donor • Absence of a coordinated blood transfusion service • Weak regulatory mechanisms • Poor transport and communication networks • Limited awareness • Infrastructural inadequacy • Storage problems (erratic power supply) • Lack of facilities for preparation of blood products • Low level of community participation
- 40. Conclusion • Blood isa powerful therapeutic agent, rational and judicious use is paramount • A surgeon must have a sound knowledge on rational blood and blood product use and prompt identification of complications.
- 41. References • Badoe E.A; principles and practice of surgery, 5th edition • Handbook of transfusion medicine by McClelland B • Advances in blood transfusion. American Society of Haematology • Update on Blood transfusions and Blood substitutes by Miller R.N. IARS Review course lectures • Courtney M. T; Sabiston Textbook of surgery 6th edition.
- 42.
Editor's Notes
- #7 1. resulting in increased affinity of Hb for O2, with less O2 delivery to the tissues. 2,3-DPG recovery takes place within 24hrs after transfusion
- #8 and by 75% after 5 days.
- #11 Hb concentration alone is not enough indicator of need for blood transfusion, but should be based on Hx, PE, Inv (indication should be symptomatic anemia).
- #12 . One unit of platelet concentrate has a volume of approximately 50 mL. Platelet preparations are capable of transmitting infectious diseases and can account for allergic reactions similar to those caused by red blood cell transfusion. A therapeutic level of platelets is in the range of 50,000 to 100,000/μL, but is very dependent on the clinical situation. Recent evidence suggests that earlier use of platelets may improve outcomes in bleeding patients.
- #14 The daily dose of granulocytes in adults and children is 1.5 to 3 × 108/kg of body weight (i.e., chronic granulomatous disease failing to respond to appropriate antimicrobial therapy for more than 24 to 48 hours may be considered for granulocyte transfusion.
- #16 , Varicella – zoster immune globulin, Rh immune globulin, Tetanus immune globulin, Rabies immune globulin, Rubella immune globulin, Hepatitis A immune globulin.
- #18 FFP is an effective volume expander because of the plasma proteins that it contains
- #19 Contain about half of Factor VIII & Fibrinogen in donated whole blood Factor VIII: 80-100 IU/pack. Fibrinogen 150-300iu/pack
- #23 (name, blood group, hospital number, ward) against the blood to be transfused (date of collection, expiry date, blood group of donor)
- #29 ‘Critical bleeding’ may be defined as major haemorrhage that is life threatening and likely to result in the need for massive transfusion.
- #34 (3.0ml for every 1.0ml of blood collected) or colloid (1ml for every 1ml of blood collected) through another line to maintain the circulating blood volume.