The document discusses various functions and properties of blood, including transport, regulation, and protection. It then summarizes different blood products like packed red blood cells, platelets, fresh frozen plasma, and cryoprecipitated antihemophilic factor. It discusses their indications, storage requirements, and risks of transfusion such as allergic reactions, hemolytic reactions, febrile reactions, bacterial contamination, transfusion-related acute lung injury, and disease transmission.

1. Blood transfusion therapy RENE PSA MENDOZA, MD, MHSA Associate Professor, Department of Surgery FEU-NRMF Institute of Medicine

2. Functions and Properties of Blood A vehicular organ that perfuses all other organs Blood and interstitial fluid deliver nutrients to cells and remove wastes Hemostatic governors are carried to and from appropriate sites

3. Functions of Blood Transport: suspended cells include rbc that carry O2 Platelets that contributes to the hemostatic process chemicals dissolved in plasma (nutrients, waste, hormones, etc) metabolic heat for disposal

4. Functions of Blood Regulation: plasma contains pH buffers plasma water absorbs heat plasma solutes maintain osmolality

5. Functions of Blood Protection: plasma precursor proteins form blood clot when stimulated suspended wbc attack bacteria and viruses ( body’s defense ) plasma contains antibodies and opsonins for immunity

6. Fluid compartments ICF ECF Interstitial Plasma Capillary Membrane Cell Membrane ~ 15% of body weight ~ 40% of body weight ~ 5% of body weight

7. Blood volume plasma + cells and cell fragments ~ 5% ~ 2-3% of body weight +

8. Banked Whole blood No components have been removed. consists of red blood cells, white blood cells and platelets in plasma can be stored for 5 weeks

9. Banked Whole blood Transfusions of whole blood are rarely required. stored in the refrigerator , the platelets are useless and factors V and VIII are greatly reduced.

10. Banked Whole blood transfusion of whole blood may be necessary certain types of major surgery ACUTE BLOOD LOSS > 15% major trauma such as a car accident or gunshot wound requiring emergency surgery

11. Changes in rbc Reduction pH from 7.00 to 6.68 2,3 DPG Intracellular ADP oxygen transport Poor source Platelets clotting factors V and VIII

12. Changes in rbc Increase levels Lactic acid from 20 to 150mg/dl Potassium concentration to 32 mEq/dl Ammonium concentration from 50 to 680 mg/dl Hemolysis is insignificant

13. Fresh whole blood Blood that is administered within 24 hours of its donation Rarely indicated Poor source of platelets and factor VIII

14. Blood Component Therapy The process of transfusing only that portion of the blood needed by the patient It allows a single unit (one pint) of donated blood to benefit more than one patient Red blood cells and platelets are the most frequently transfused blood components

15. Packed red cells The red cells from a donor unit, diluted with plasma to a hematocrit of about 75%. Volume is about 200 mL. Storing red cells (just above freezing) allows survival for 42 days but unfortunately decreases 2,3-DPG ruins the platelets and neutrophils.

16. Packed red cells Red blood cells contain hemoglobin carries oxygen throughout the body. Essentially provides oxygen-carrying capacity Product of choice for most clinical situations

17. Packed red cells Recent advances have made it possible to store red blood cells for up to 42 days. Indications acute trauma before surgery people with anemia who are having surgery

18. Packed red cells fastest way to increase the oxygen-delivering capacity of the blood. A unit of whole blood or packed red cells will raise the hematocrit by 3% and the hemoglobin by 1-1.5 gm/dL

19. Frozen red cells reduces the risk of infusing antigens, or foreign bodies, that the body might regard as potentially dangerous Previously sensitized patients Not available for use in emergency situations Rbc viability is improved ADP and 2,3 DPG maintained

20. Platelet concentrates Component: platelets, 50 ml plasma cellular components that help in the clotting process. Platelets are stored for up to five days at room temperature.

21. Platelet concentrates Indication used if there is a platelet disorder when massive blood loss has occurred

22. Platelet concentrates Platelets must be stored at room temperature, so are good only for 5 days or less. One unit will usually raise the platelet count 5-10k/microliter. Check one hour after transfusion. If the platelet count does not increase as expected (“refractoriness”), suspect DIC or immune platelet destruction (anti-HLA).

23. Fresh frozen plasma From freshly donated blood Source of vit k- dependent clotting factors Only source of factor V

24. Fresh Frozen Plasma Indication For coagulopathy and deficient clotting factors 1 unit FFP = 3% increase in CF levels At least 30% to ensure adequate coagulation

25. Cryoprecipitated antihemophilic factor an antihemophilic concentrate prepared from plasma and is rich in clotting factors used in people with hemophilia, von Willebrand's disease or other major coagulation abnormalities to prevent or control bleeding

26. Cryoprecipitated antihemophilic factor Its contents are the major portion of the Factor VIII, von Willebrand factor, fibrinogen, Factor XIII and fibronectin present in freshly drawn and separated plasma .

27. Replacement therapy Serologic compatibility A, B, O and Rh groups Crossmatching Donors’ red cell and Recipients’ sera Major crossmatch

28. Serologic compatibility

29. Rh groups Rh negative recipients should be transfused with Rh negative blood Rh negative group – 15% of the population Limited supply

30. A 50M pedestrian was hit by a car while crossing Commonwealth Ave. He sustained blunt trauma to the pelvis and an open femoral fracture on the L. At the ER, BP 90/50 HR 110 RR 28 with an estimated blood loss of 1L. The initial resuscitation fluid is A. Whole blood B. packed RBC C. Plain Lactated Ringers D. Dextran

31. After 2L of crystalloids, the BP 90/60 HR 120 RR 32. The SROD decided to give blood. What is the best blood product to administer? A. Fresh Whole Blood B. packed RBC C. plasma expanders D. platelets

32. Parameter Class I Class II Class III Class IV blood loss in mL <= 750 mL 750 − 1,500 mL 1,500 − 2,000 mL >= 2,000 mL blood loss as % TBV <= 15% 15 − 30% 30 − 40% >= 40% pulse > 100 > 100 > 120 >= 140 blood pressure normal normal decreased decreased capillary refill normal delayed delayed delayed respirations 14 − 20 20 − 30 30 − 40 > 35 urine output >= 30 mL/h 20 − 30 mL/h 5 − 10 mL/h minimal mental status slightly anxious mildly anxious anxious and confused confused and lethargic

33. A CT scan of abdomen was done with findings of Grade 2 renal injury, L with incomplete fracture, L iliac. He underwent ORIF, L femur and placed on complete bed rest. He was transfused 2 ‘u’ WB and 4 ‘u’ pRBC. What are the possible complications of blood transfusion?

34. Risks from a unit of ordinary red cells Non-hemolytic febrile transfusion reaction: 1-5% Minor allergic: 1-2% Real anaphylaxis: maybe 1 in ~20,000; fatality rate unknown

35. Transfusion reactions Hemolytic Reactions Allergic Reactions Febrile Reactions Bacterial Contamination Circulatory Overload Hypothermia

36. Transfusion reactions Alloimmunization Graft Versus Host Disease (GVHD) Transfusion related acute lung injury (TRALI)

37. Allergic / urticarial transfusion reactions most common usually due to allergies to specific proteins in the donor’s plasma can be avoided with future transfusions by pretreatment with antihistamines or steroids.

38. Allergic / urticarial transfusion reactions Some get “hay fever / hives / wheezing” from transfusions you can continue the transfusion when they are better and in the future, pre-treat with an antihistamine.

39. Allergic / urticarial transfusion reactions For severe (anaphylaxis), RBC’s and platelets are washed to remove all plasma indicated. Very fast, spectacular illness after transfusion only a few mL. IgA deficiency should be considered in the case of anaphylactic reactions.

40. Hemolytic Reactions transfusion of an incompatible blood component. Most are due to naturally occurring antibodies in the ABO antigen system and Rh groups may cause hemoglobin induced renal failure and a consumptive coagulopathy (DIC).

41. Immediate hemolytic transfusion reaction 1 in ~25,000 units; fatality rate 10% A disaster, almost always preventable. Most often due to ABO mismatch due to a clerical error (i.e., the wrong blood and/or the wrong recipient).

42. Clinical presentation fever, hypotension, nausea, vomiting, tachycardia, dyspnea, chest or back pain, flushing and severe anxiety pain at the infusion site Post-op site: diffuse bleeding hypotension

43. Intravascular destruction of RBC Hemoglobinemia free hemoglobin in the serum Hemoglobinuria may be noted and, may be the first sign of hemolysis Clinical presentation

44. Renal toxicity Precipitation of free hemoglobin in the tubules Acute tubular necrosis

45. DIC In the circulation, Ag-Ab complexes Activates complement system, factor XII DIC

46. Treatment Stop the transfusion Keep the vein open by running in saline Draw your post-transfusion samples check the urine for hemoglobin notify the blood bank Save the untransfused blood. Give mannitol to keep the kidneys open monitor for DIC. fluids, diuresis and transfusion support for bleeding

47. patient’s identification checked.. repeat crossmatch, bacterial culture most errors are clerical or due to misidentification of a patient at the bedside. mislabelled specimen sent to the blood bank A fatal hemolytic transfusion reaction occurs about once in 100,000 transfusions

48. DO NOT ASSUME IT IS SOMEONE ELSE'S RESPONSIBILITY TO CHECK!

49. Laboratory criteria Free hemoglobin > 5mg/dl Serum haptoglobulin of > 50 mg/dl Serologic criteria INCOMPATIBILITY OF THE DONOR THE RECIPIENT Positive Coombs’ test

50. Delayed hemolytic transfusion reactions 1 in ~6000; fatality rate 0.1% previously sensitized to an antigen through transfusion or pregnancy can result in symptomatic or asymptomatic hemolysis several days (2-10 days) after a subsequent transfusion

51. Delayed hemolytic transfusion reactions Not preventable. A new antibody or anamnestic response has probably developed.

52. Clinical presentation Extravascular hemolysis, mild anemia, indirect hemoglobinemia These present with flu-like symptoms recurrent anemia and jaundice

53. Delayed hemolytic transfusion reactions Most frequent: Transfusion of Rh positive red blood cells to an Rh negative woman of childbearing age can result in sensitization and hemolytic disease of the newborn in future pregnancies.

54. Febrile nonhemolytic transfusion reaction Defined to be a rise in temperature of 1 ° C or more and >=38 ° C, within 24 hours of transfusion without evidence of a hemolytic transfusion reaction. due to cytokines in the blood itself and/or produced in the patient from sensitivity to the HLA molecules on platelets and white cells.

55. Febrile transfusion reactions usually occur due to sensitization to antigens on cell components, particularly leukocytes. chills and a temperature rise 60-90 mins after transfusion

56. Bacterial contamination Rare Acquired from contaminated collection bags Poor cleaning of donor’s skin reactions are quite severe with high fever rigors and/or other systemic symptoms such as hypotension, nausea or vomiting.

57. Bacterial contamination Gram – organisms, Pseudomonas sp., Coliforms and Yersinia Pseudomonas sp can grow at 4 °C Are the most common Don’t transfuse the green or purple units.

58. Bacterial contamination Platelets (kept at room temperature during their 5-day shelf life) are a great culture medium especially for skin staphylococci from the venipuncture

59. Bacterial contamination Transfusion should be stopped and the bag sent for gram stain and culture. The Blood Center should be notified. The patient should have blood cultures obtained and, if appropriate, IV antibiotic therapy begun

60. Transfusion Related Acute Lung Injury (TRALI) “ noncardiogenic pulmonary edema” Defined to be ARDS within 6 hours of a transfusion with no other clear cause occurs when donor plasma contains an antibody, usually against the patient's HLA or leukocyte specific antigens.

61. Transfusion Related Acute Lung Injury (TRALI) 1 in 1000; fatality rate <1% with estimates varying widely The cause is apparently antibodies in the donor plasma against the patient’s neutrophils (which, in the sick, are marginated in the lung vessels). The donor antibodies cause these neutrophils to release toxic products and thus produce ARDS.

62. Clinical presentation dyspnea, hypotension and fever typically begin 30 minutes to 6 hours after transfusion chest x-ray shows diffuse non-specific infiltrates , “white out”

63. Treatment Therapy is primarily supportive Ventillatory support may be required for several days before resolution.. The Blood Center should be notified so that the donor may be tested for antibodies against the patient

64. Electrolyte toxicity (i.e., potassium) A real danger for newborns one may prefer washed red cells. If hemolyzed blood is administered (i.e., the blood was left on the radiator or the warmer was too hot), the result will be catastrophic .

65. Hypothermia Red cells and fresh frozen plasma are chilly. An extra blanket is much safer than an electric warming coil even “the special warmers for blood that don’t go over 104o F / 40o C.

66. Overtransfusion Rapid infusion of blood Plasma expanders, iv fluids Regulate BT 2-4 hrs each bag CVP diuresis

67. Transmission of diseases Malaria, Chagas’, syphilis Transmitted BT CMV Hepatitis C and HIV-1 Dramatically decreased Better antibody and nucleic acid screening 1 per 1,000,000 units Hepatitis B 1 per 100,000 units

68. Transmission of diseases Hepatitis A Very rare, no asymptomatic carrier state “ Pathogen in-activation system” Reduces infectious levels of all viruses and bacteria transmissible by transfusion

69. Pathogen Inactivation Technology for platelets and plasma use the small molecule amotosalen HCl which penetrates cells and pathogens and targets DNA and RNA. Once docked inside DNA and RNA, amotosalen is activated by ultraviolet light to form a chemical crosslink that locks-up the strands of nucleic acid, blocking replication . for red cells uses a different molecule (S-303) that forms crosslinks when activated by a change in pH.

70. Pathogen Inactivation Technology Treated pathogens are inactivated by the process and can no longer multiply and cause disease.

71. Pathogen Inactivation Technology

72. Indications for blood replacement Improve in Oxygen-carrying capacity Volume replacement Replacement of clotting factors

73. What are the indications for RBC transfusion in the critically ill surgical patient? No single measure can replace good clinical judgement as the basis for decision-making regarding perioperative transfusion Mild-to-mod anemia does not contribute to perioperative morbidity

74. .. indications for RBC transfusion “ Universal trigger” 70g/dL for a healthy low risk patient 10g/dL for patients with cardiopulmonary disease Wound healing and postop infection is not influenced by normovolemic anemia Transfusion should not be considered substitute for good surgical and anesthetic technique

75. Volume replacement Most common indication for Blood transfusion Acute blood loss Measures of hgb and hct Misleading in acute bleeding Normal in spite of severely contracted blood volume

76. Blood loss of 1L in a healthy adult Venous hct falls by 3% in the first hour 5% at 24 hours 6% at 48 hours 8% at 72 hours

77. The theoretical “ transfusion trigger ,” or the critical point at which a physician decides to transfuse a patient

78. RBC Infusion Rarely for Hgb>10g/dL Usually for Hgb <7g/dL Decision based on risk for complications related to inadequate oxygenation

79. Platelet Infusion Rarely for PLT>100,000 Usually for PLT<50,000 For PLT between 50,000 and 100,000 decision based on assessment of risk

80. FFP Infusion Microvascular bleeding present and PT or PTT is 1.5 times normal In the absence of lab results: After transfusion of 1 total blood volume

81. Transfusion indications

82. PACKED RED CELLS Hemoglobin less than 7 gm/dL Preoperative hemoglobin less than 9 gm/dL and operative procedures or other clinical situations associated with major predictable blood loss Symptomatic anemia in a normovolemic patient Acute loss of at least 15% of estimated blood volume with evidence of inadequate oxygen delivery following volume resuscitation

83. FRESH FROZEN PLASMA PT or PTT greater than 1.5 times the mean of the reference range (PT>16, PTT>39) in a non-bleeding patient scheduled to undergo surgery or invasive procedure Massive transfusion (more than 1 blood volume or 10 units) and coag tests are not yet available Emergency reversal of coumadin anticoagulation Coagulation factor deficiency

84. PLATELETS Platelet count less than 20,000 in a non-bleeding patient with failure of platelet production Platelet count less than 50,000 and impending surgery or invasive procedure, patient actively bleeding, or outpatient Patients during or after open heart surgery or intra-aortic balloon pump with diffuse bleeding Massive transfusion (more than 1 blood volume or 10 units) when platelet counts are not available Qualitative platelet defect (bleeding time greater than 9 minutes) with bleeding

85. Platelet concentrates Transfusion Guidelines: Platelet count < 20,000/mm3 Platelet count <50,000/mm3 if with microvascular bleeding Complicated surgeries with >10 units of blood transfused, with signs of microvascular bleeding Documented platelet dysfunction(prolonged BT, abnormal plt function tests)

86. CRYOPRECIPITATE Fibrinogen less than 100 mg/dL Fibrinogen less than 120 mg/dL with diffuse bleeding Von Willebrand disease or hemophilia unresponsive to desmopressin (DDAVP) and no appropriate factor concentrates available Uremic bleeding if desmopressin is ineffective Factor XIII deficiency

87. major indication for whole blood transfusion some cases of cardiac surgery massive hemorrhage when more than 10 units of red blood cells are required in any 24-hour period

88. Massive transfusion Death by exsanguination has been described as the loss of 150 mL of blood per minute, which results in loss of half the blood volume in 20 minutes It has also been classified as blood loss of more than 5,000 mL 10 units of blood transfused within 24 hours

89. Massive transfusion replacement of one entire blood volume within 24 hours 50% blood volume replacement within 3 hours transfusion of more than 20 units of erythrocytes requiring 4 units of blood within an hour with anticipation of ongoing usage

90. Massive transfusion Most MTPs call for the use of uncrossmatched type O negative (O-) blood as the first-line infusion preference.

91. O negative blood universality and timely availability from hospital blood banks when used during massive exsanguination is potential problems with crossmatching and incompatibility later in the patient’s hospital stay more than 4 units

92. O+ blood It has been shown to be generally safe and can help prevent blood shortages administer to men and postmenopausal women To woman of childbearing age can result in sensitization

93. Massive transfusion complications Coagulopathy is caused by a dilutional effect on the host's clotting factors and platelets, as well as the lack of platelets and clotting factors in packed red blood cells. Volume overload Hypothermia

94. Massive transfusion complications Hyperkalemia may be caused by lysis of stored red cells Metabolic acidosis and hypokalemia may be caused by the transfusion of a large amount of citrated cells. Hypocalcemia due to citrate toxicity may occur in those with hepatic failure, congestive heart failure (CHF), or other low-output states. It is increasingly uncommon with the use of component therapy.

95. Massive transfusion complications Use of blood from multiple donors increases the risk of hemolytic reactions as a consequence on incompatibility

96. Transfusion options Type-specific, non-cross-matched blood May be used in emergencies O-negative, type-specific is equally safe Also called the “ universal transfusion product ” Hemoglobin solutions Autologous tansfusion hemodilution

97. Methods of administering blood Rate depends on patient’s status Intravenous Intraperitoneal 90% enters the circulation Absorbtion for atleast a week Medullary cavity

98. Methods of administering blood

99. Special concern Jehovah’s Witnesses cannot accept donor packed red cells, platelets, white cells or plasma, and cannot accept autologous or cell-cycled intraoperative transfusion. The sect leadership used to be militantly anti-immunization, anti-germ theory, and anti-transplantation as well

100. Blood transfusion therapy Raymund AG Ong, MD FPCS FPALES Department of Surgery FEU-NRMF Medical Center