The document discusses the use of blood and blood products in surgery. It covers the indications and uses of various blood products like whole blood, packed red cells, platelet concentrates, plasma derivatives, and coagulation factor concentrates. It discusses principles of blood transfusion like compatibility testing, administration procedures, and complications of transfusion. It also covers topics like massive blood transfusion protocols, autologous blood transfusion, and challenges in blood transfusion.

1. The use of blood and blood
products in surgery
Dr PJ Shindang

2. Outline
• Introduction
• Indication and 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 transfusion refers 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 and Storage
• 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 blood storage
• 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
• It contains 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
• Whole blood 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 is the 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 of severe 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 by leukopharesis
• 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
• The WBC 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 blood products
• 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 is the 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 Albumin solution
• 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 blood transfusion
• 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 blood transfusion
• 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 Blood Transfusion
• 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, JAMA 2015
• 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, JAMA 2015
• 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
• In adults.
• 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 massive blood 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 patients for 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 blood donation (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-op blood 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 blood transfusion
• 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
• Delayed hemolytic 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 BLOOD TRANSFUSION
• 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 BLOOD TRANSFUSION
• 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 is a 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. Thank you.