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Blood transfusion in surgery
The document provides an overview of blood transfusion, including donor selection, blood components and their indications, pre-transfusion handling, administration principles, massive transfusion, autologous transfusion, complications and their management, and blood substitutes. Donor selection involves medical history screening and health assessments. Key blood components discussed are packed red blood cells, platelet concentrates, fresh frozen plasma, and cryoprecipitate. Proper storage, grouping, compatibility testing and administration procedures are outlined to ensure safety. Complications can be immediate or delayed, including infections transmitted and reactions to plasma proteins. Blood substitutes under development aim to replace functions of plasma, red cells and platelets.
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Blood transfusion in surgery
- 1. Dr kabiru salisu Surgerydept. AKTH 26th march, 2013
- 2. Introduction Donorselection and blood donation Blood component and their indications Pre-transfusion blood handling - blood grouping and compatibility testing - storage of blood - blood ordering Principles of blood administration Massive blood transfusion Autologous blood transfusion Complications and their management Blood substitutes Conclusion References
- 3. Process ofadministering blood or blood products into one’s circulation intravenous Blood transfusion should only be considered when the benefit out weight the risk Improvement in donor selection, blood screening and component isolation made BT a valuable tool for a surgeon
- 4. Jean-Baptiste Denis1667 Dr. Philip Physick 1825 Karl Landsteiner in 1900
- 5. Homologous (Allogenic)blood transfusion when blood transfusion is done with blood from another compatible donor of the same specie Autologous blood transfusion Autologous blood transfusion is the collection and subsequent re-infusion of the patient’s own blood
- 6. Donor selection involves History: ◦ Age 18-65years ◦ Not in high risk group ◦ No blood donation in past 6 months ◦ No pregnancy within last 12 months, not lactating ◦ No dental procedure in last 72 hours ◦ No major surgery in past 6 months ◦ No blood transfusion or organ transplant in past 12 months
- 7. ◦ No tattooor skin piercing in last 12 months ◦ No needle stick injury or acupuncture in last 12month ◦ Not vaccinated in last 4 weeks ◦ No history of HIV infection, HBV, syphilis ◦ Not on cytotoxics, hypoglycaemic agents, or teratogenic drugs ◦ Medical history: no HTN, DM, cardiac renal or liver disease, cancer, bleeding disorder, SCD Examination ◦ Clinically stable ◦ Weight >51kg ◦ Normal BP, Pulse, chest and abdominal findings
- 8. Investigations ◦ Hb12.5g/dl or more (F), 13.5g/dl or more (M) ◦ Seronegative for HIV I & II, HBsAg, HCV, VDRL antibodies ◦ No MPs ◦ Negative for anti-CMV antibodies in some cases ◦ Blood group
- 9. Severe haemorrhagefollowing trauma or tumour Preoperatively anaemia correction During major operation in which blood loss is inevitable Postoperative anaemia To arrest haemorrhage or as a prophylactic measure prior to operation in patients with haemorrhagic states Anaemia from chronic surgical conditions
- 10. 1- Whole blood Contains all blood components ◦ Cellular element: RBC: 4.5-6.5 x 109/L (M), 3.9-5.6 x 109/L (F) WBC: 4-11 x 109/L Platelets: 150-400 x 109/L ◦ Plasma: clotting factors, proteins, electrolytes, gasses, glucose, minerals
- 11. Fresh ifcollected and used within 3hours Use is limited to where fractions are not available Indications- ◦ Sudden haemorrhage with loss of up to 20% of blood volume ◦ EBT ◦ Lack of appropriate blood component
- 12. 2- RBC Products Packed RBC: ◦ Obtained after centrifugation of whole blood at 3000r/m and removing the supernatant ◦ 1 unit increases Hb by 1g/dl in 70kg man ◦ Indications Patients with chronic anaemia Elderly Small children Patients prone to fluid overload & cardiac failure
- 13. Washed RBC: ◦Washed in saline to remove plasma proteins ◦ Used in uncontrollable febrile or anaphylactic reactions to plasma proteins ◦ Shelf life is 24 hours Irradiated RBC: ◦ Gamma irradiation ◦ Indication is prevention of GvH disease in Immunocompromised patients Intrauterine foetal blood transfusion
- 14. 3- Platelet concentrates Obtained in 2 ways ◦ Manually: WB at 1000r/m for 3min , then supernatant at 3000r/m for 5min ◦ Automatically using processors Stored at 20-24oC with continuous agitation 5unit of WB give a pint Shelf life is 5 days Indicated - Thrombocytopenia - Consumptive coaglophaty - Aplastic anaemia
- 15. 4- Fresh frozenplasma WB- 3000r/m, separate and rapidly freeze the supernatant for 8 hrs in CO2+ ethyl alcohol Contains all components of coagulation and fibrinolytic system Stored at -30 to -70 oC for up to 1 year Thaw at 37oC before use Dose= 10-15mls/kg
- 16. 5- Cryoprecipitate Isthe precipitate when FFP is allowed to thaw at 4oC and the supernatant plasma removed Rich in F8, F13, vWF, fibrinogen Stored at -30oC, shelf life is 12months Indications haemophilia vonWillibrand’s diseas
- 17. 6 - Granulocyteconcentrates - These are prepared from single donors by using cell separator Should be used within 24 hours (6hrs) Indications for transfusion are uncommon Severe neutropenia <0.5 x 109/L Focal bacterial infection unresponsive to antibiotics
- 18. Others Albumin concentrates Coagulation factor concentrates Immunoglobulins Anti thrombin III concentrate Protein concentrates
- 19. - storage ofblood - blood grouping - compatibility testing - blood ordering
- 20. Standard bloodbag contains 450 +/- 45mls blood, with 60mls of anticoagulant preservative Stored at 2-6oC Anticoagulants include ◦ Heparin: 24 hours ◦ Acid-citrate-dextrose (ACD) : 21 days ◦ Citrate-phosphate-dextrose (CPD): 28 days ◦ Citrate-phosphate-dextrose-adenine(CPDA): 35 days
- 21. RBC- - 1%cell population are lost per day of storage - Viability decreases as ATP and 2,3 DPG levels fall Increase affinity of Hb to O2 and decrease O2 release at tissue level Leucocytes and platelets- ◦ Not viable after 24 hours of storage
- 22. Electrolytes- ◦ K+:plasma levels increase at rate of 1mmol/day ◦ Na+: concentration increases because of the sodium citrate in the CPD anticoagulant ◦ Ca2+: no ionized calcium, it displaces sodium in the anticoagulant forming unionized calcium citrate pH- ◦ Falls from 7.2 to about 6.8 at 20 days due to increase lactic acid concentration from continuing anaerobic RBC glycolysis
- 23. Clotting factors- Activityof clotting factors fall after 24hrs most lost activity after 7days
- 24. There are>30 major blood group system The most important blood group are the ABO and Rh ABO system base on present of antigen A or B Rh is base on presence of antigen D (Rh factor) Other; Kell, duffy, MNS, lewis, kidda etc
- 25. Blood group AntigenAntibody ( plasma agglutinin) Donors A Ag A Ab B A & O B Ag B Ab A B & O AB Ag A & B NONE ALL o None Ab A&B O
- 26. Cross matchingis done to detect the rare Ags present on the recipient RBCs such as Kell, duffy Plasma protein Ag capable of causing reaction can be detected
- 27. Maximal surgicalblood ordering schedule ( MSBOS ) This is the system of blood ordering for elective surgeries Blood bank know the standard require for each surgical procedure For patient at high risk of bleeding extra pint are saved above requested For patient with history of previous reaction or those fit can be arrange for PABD
- 28. Should onlybe done when necessary Only what is needed should be given Indication should be clearly stated Counselling and consent Strict asepsis Doubly checked: name, age, hospital number
- 29. Check bloodbag for damage, expiry date, discoloration of the blood Pre transfusion vital signs IV line must be secure and patent before opening the bag Warming with blood warmer when necessary Administration must commence within 30mins of leaving the blood bank Monitoring is crucial esp. In 1st 30min
- 30. Determine volumeto be transfused Use blood giving set, or infusion pump Symptoms of adverse effects usually occur during transfusion of the first 100mls ◦ Thus start at 20-30 d/m (2-3mls/min), then increase to 60-80d/m after 1 hour ◦ In children and elderly 40d/m
- 31. The replacement bytransfusion of blood equivalent to or greater than a patient’s total blood volume within a 24 hour period or Replacement of more than half of the patient’s blood volume in 1 hour
- 32. Haemorrhagic shock from Traumaeg #s, splenic rupture Ruptured aortic aneurysm Massive GI haemorrhage Liver transplant
- 33. 1. Technical &clerical errors 2. Circulatory overload 3. Hypothermia 4. Hyperkalaemia 5. Hypocalcaemia (citrate toxicity) 6. Acidosis 7. ARDS 8. DIC
- 34. 1 - Plateletconcentrate and fresh frozen plasma 1unit/5units of banked blood 2- 10mls of 10% Ca gluconate /L of blood 3- Fresh blood 1unit / 3unit of banked blood
- 35. Autologous blood transfusionis the collection and subsequent re-infusion of the patient’s own blood 1. Preoperative Autologous blood donation (PABD) 2. Acute Isovolemic Hemodilution
- 36. 1- Intra operative Shed blood from a wound or body cavity during surgery is collected and subsequently re-infused into the same patient
- 37. Methods of bloodsalvage should be - Aseptic - Anticoagulant - filtration; 4-6 layers of gauze or special filters - Shelf life 4hrs at room temperature or 24hrs at 4o - Haemonetic cell savers can be use - Contraindicated in tumour surgery, contamination - Complication;- Bleeding
- 38. 2- postoperative blood salvage Blood shed after surgery can be collected and re-infuse to patient
- 40. IMMEDIATEREACTIONS I. Febrilenon-haemolytic reaction 2. Allergic and anaphylactic reaction 3. Haemolytic reaction 4. Bacterial contamination 5. Circulatory overload 6 Cardiac arrest 7. Air embolism 8. Non-cardiogenic pulmonary oedema
- 41. DELAYED REACTIONS 1.Thrombophlebitis. 2. Delayed haemolytic reaction. 3. Post-transfusion Thrombocytopaenic purpura
- 42. 4. Transmission ofdiseases: (i) Viral hepatitis A, B, C, D (ii) Malaria (iii) Syphilis (iv) Cytomegalovirus infection (v) Trypanosomiasis (vi) Toxoplasmosis, brucellosis (vii) Infectious mononucleosis (viii) Variant Creutzfeldt-lacob Disease (vC1D). (ix) AIDS
- 43. 5. Ironoverload(Transfusionhaemosiderosis) 6. Immunosuppression.Due probably to transfused leucocytes 7. Post-transfusion graft-versus-host disease
- 44. Include ◦ Plasmasubstitutes ◦ Red cell substitutes ◦ Platelet substitutes
- 45. Plasma substitutesinclude ◦ Crystalloids: NS, RL ◦ Colloids: Dextrans- dextran 70, 40, 110 Gelatins- haemacel, gelofuscine ◦ Stable plasma protein solution ◦ Albumin ◦ Hydroxyethyl starch preparations: Hetestarch, Pentastarch
- 46. Red cellsubstitutes ◦ Diaspirin cross linked Hb: similar O2 transport and exchange properties as whole blood ◦ Perfluorocarbons: dissolve O2 and release to tissues by diffusion ◦ Encapsulated Hb ◦ Stroma free Hb: high O2 affinity, nephrotoxic ◦ Recombinant DNA derived Hb Platelet substitute ◦ Pegylated Recombinant Human Megakaryocyte Growth and Development Factor (PEG-rHuMGDF)
- 47. Blood is apowerful therapeutic agent rational and judicious use is paramount A surgeon must have have a sound knowledge on rational blood use
- 48. 1. Badoe E.A; principles and practice of surgery, 4th edition 2. Morris P. J; Oxfort Text Book of surgery second edition, 2000 3. Courtney M. T; Sabiston Textbook of surgery 6th edition. 4. Drew p. & charles R. J; In Oxford handbook of clinical haematology, 2nd edition 5. Ganong W. F. In Review of Medical Physiology, 22nd edition. 6. Autologous blood transfusion, bloodindex.com 7. M. Saleh Massoud M. D; Massive blood transfusion Ain-Shams University
- 49.
Editor's Notes
- #5 The first known successful transfusion recorded was by Jean-Baptiste Denis in France. In 1667, he gave three pints of sheep blood to a person, with no apparent ill effects. Subsequent attempts to give blood to a young man "to mollify his fiery nature" failed, with the patient dying shortly after the transfusion. An 1825 medical journal noted a transfusion administered by Dr. Philip Syng Physick [53] of Philadelphia, perhaps the first recorded successful transfusion of human blood. The discovery of the A, B, and O blood types by Karl Landsteiner in 1900
- #14 Irradiation Destroy neutrophils and viruses
- #15 Thrombocytopaenic patients undergoing operations Patients undergoing chemotherapy for leukemia Aplastic anemia. Accelerated platelet consumption or destruction (eg, acquired immunodeficiency syndrome, sepsis, disseminated intravascular coagulation). Surgical indications (eg, cardiopulmonary bypass surgery or surgery in patients recently treated with drugs which impair platelet function).
- #16 Indications: emergency treatment of warfarin overdose, vitamin k deficiency, TTP, DIC, massive blood transfusion, factor replacement when specific concentrates are not available
- #19 Albumin There are two preparations: 1. Human albumin solution (4.5 per cent), previously called plasma protein fraction (PPF), contains 45 g/l albumin and 160 mmol/l sodium. It is produced in 50-, 100-, 250-, and 500-ml bottles. 2. Human albumin solution 20 per cent, previously called ‘salt-poor' albumin, contains approximately 200 g/l albumin and 130 mmol/l sodium and is produced in 50- and 100-ml bottles.
- #24 F8: declines rapidly, activity falls by 40%after 24 hours of storage, and by75% after 5 days, little activity after 7 days F5: declined rapidly after 24 hours, little activity after 7 days F9: declines rapidly after 7 days, no activity after 14 days F10: looses its activity after 7 days FW: declines after 14 days Fibrinogen and F11: stable after 14 days
- #31 1 unit of packed cells raises Hb by 1g/dl In children: deficit Hb x weight (kg) x constant (6 for whole blood, 3 for packed RBC)
- #34 esp in elderly & debilitated, chronic anaemia, cardiopulm., renal or hepatic disease Can lead to pulmonary oedema or CCF. Rx: stop transfusion & prop pt up; give frusemide; emergency phlebotomy; digitalisation 3.Hypothermia I.V infusion of cold blood & a cold environment thermal dysregulation shock, cardiac depression & arrhythmias Rx: Warming of blood (esp if infusion rate is ≥ 60ml/min in an adult) 4.Hyperkalaemia K+ leaks out of the red cells during storage; thus, large amounts of stored blood infused rapidly can precipitate arrhythmias 5.Hypocalcaemia (citrate toxicity) Follows calcium chelation by citrate Manifests as depressed myocardial functions & neuromuscular abnormalities; tetany & cardiac arrest by potentiating action of hyperkalaemia Prevention: give 10mls of 10% Ca gluconate/L of transfused blood 6.Acidosis Results from excess citrate ions in ACD/CPD solution & lactic acid production by red cells. May cause depressed myocardial contractility, increased irritability & ventricular fibrillation Mgt: Check acid-base balance & electrolyte status frequently & correct 7.Respiratory complications (a) ARDS: follows sequestration of µaggregates in the stored blood which pass through the standard filter Mgt: use µfilters This follows reduction of 2,3-DPG concentration in red cells when stored. Regeneration is however, complete within a few hours following transfusion 8.Bleeding diasthesis May occur due to: Thrombocytopaenia Clotting factors V & VIII deficiency in banked blood Hypocalcaemia Mgt: Give platelet concentrates & FFP (1unit/5 pints of banked blood);10mls of 10% Ca gluconate/L of blood transfused or 500mls of fresh blood /1500mls of banked blood
- #36 PABD i. Candidate should meet criteria for autologous donation. ii. Donations should be 3-7 days apart and the last one should not be within 72hrs of surgery. iii. Pre donation PCV on each occasion should be >10g/dl. iv. Ferrous sulphate is given in this environment to raise the patients hemoglobin. Recombinant erythropoietin may also be given where available. AIHD Aim: To hemodilute the blood to a PCV= 27% thereby reducing effective blood volume lost. 1-4 units are collected immediately prior to surgery Hemodilution is effected by infusing either Crystalloids (3mls for every ml of blood) or Colloids (volume for volume) concurrently. Vital signs are closely monitored and an experienced anaesthetist is required. Transfused within 8hrs at room temperature or 24hrs when stored at 2-6°C
- #37 is useful in ruptured ectopic pregnancy, ruptured spleen. penetrating injuries, haemothorax. cardiovascular surgery and some orthopaedic operations. The shed blood in a body cavity is collected with a ladle or gallipot into a kidney dish or large bowl containing an anticoagulant. The blood is filtered into a bottle through 4-6 layers of sterile gauge. placed in a funnel. The blood is then sealed and the blood re-infused. v. The blood may then be re infused within 4hrs or stored at 2-6°c and used within 24hrs at 1-6°c