This document discusses transfusion medicine and guidelines for blood transfusion therapy. It covers: 1. The main components transfused (red blood cells, platelets, fresh frozen plasma) and their functions in supplementing oxygen carrying capacity, coagulation factors, and blood volume. 2. Indications for transfusion based on vital signs, blood tests, and patient factors like blood loss levels and prognosis. 3. Guidelines for transfusing specific components like red blood cells, platelets, and fresh frozen plasma based on concentration thresholds and conditions. 4. Risks of transfusion therapy and the importance of informed consent and risk management.

1. Kanto-Koshinetsu Block Blood Center
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Ten Peaks, Banff
09/27/15
CANADA
Transfusion Medicine
Shoichi Inaba MD
January19, 2016

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1．Supplement of Oxygen carrying capacity
(Red Blood Cells; RBCs)
2．Supplement of coagulation factors
a) Fresh Frozen Plasma (FFP)
Mainly supplement of Fibrinogen
b) Platelets (PCs)
3．Supplement of Blood Volume (Albumin, RBCs)
Transfusion is not a cure therapy, it’s only a supplement therapy
Indication of transfusion therapy

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Body change due to blood loss
 Hypotension
 Vaso-spasms
to maintain blood pressure due to decrease vasucular space
 tachycaridia
increase cardiac output
 Acidosis
increase oxgen release
30% of blood loss is life-threatning (limit is 2ℓ at adult)
Shock means insufficient peripheral circulation

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Vital signs
Blood gas analyses
Cell blood count
Coagulation tests
Patient prognosis
Age (young patients should endure and elder is loose ）
Evidencies for decision making of
transfusion therapy

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Body Water Distribution
0 10 20 30 40 50 60 70 80 90 100
Intra-cellar fluid 40%
（ICF)
Extra-cellar fluid 20%
*ISF≒15%
Blood ≒7%
(*ISF: interstitial fluid)
Dry weight 40%

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Distribution of Body water
Kanto-Koshinnetsu Block Blood Center
ISF 15% of Body weight
ISF 30% of Body weight
Plasma 5% of Body weight
Rather obesity Middle Obesity Thin
Long life
Body Fluid (% body weight)
Child
Adult
(male)
Adult
(female)
Thin 80 65 55
Middle 70 60 50
Obesity 65 55 45

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Body fluid movement at acute blood loss
（５０ｋｇBW adult)
Bleeding Plasma ECF
Body fluid loss
Within 20% of blood loss is toｌerable

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Composition of blood components
Plasma 1.025～1.029
Platelet 1.040
RBC 1.095
(40～50%)
(50～60%)
(< 0.25%)

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Blood components has different distribution in the body
＊each component has different distribution in the body
Differencies of blood component distribution
Intra-vascular Extra Celllular
Fruid
Spleen
RBCs ≒100%
PCs 70% 30%
Albumin 40% 60%

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Production rate of blood components
＊each component has different life span & production rate
Intra-vascular
reserve
Extra-vascular
reserve
Life span
Production
rate ( /day)
RBCs ≒100% 1.5% 120days 0.83%
PC 70％ 30% 10days 12.8%
Granulocytes 10-30％ 70～90% 14Hrs －
Albumin 40％ 60% 40Day 3.75%
Fibrinogen 100% － 1day 100%
Distribution

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Conponent transfusion is common in Japan
血液製剤調査機構作成
Direct use of whole blood decreased to almost zero
Million
Thousand
RBC
FFP
PC
No. of whole blood usage
0.9/5,000,000 (0.02%)
About 3.5million of whole blood donors per year

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Basic guideline of the blood transfusion therapy
for the surgical bleeding
Lundsgaard-Hansen (1980)
Blood loss (%)

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Oxygen dissociation curve
PCO2 , right shift
pH , Body temperature
2,3DPG
（
動
脈
血
）
（静
脈
血
）
PaO2
Bohr’s Effect
Arterial blood
Venous blood
(%)
Oxygen saturation
Metbolic acidosis happen by PaCO2 increase at shock

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Supply of oxgen carrying capacity
1g Hemoglobin (Hb) increment
increase 70ml/dl O2 carrying capacity
400ml whole blood derived RBCs has same effect
Oxygen required at basal metabolism is 150ml/min
Purpose of RBC transfusion

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Relation between Oxygen consumption
and Oxgen Carrying Capacity
O2 Carrying Capacity
dependent phase
Independent phase
critical point
≒Hb5g/dl
（trigger）
O2 Consumption

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50kgBW adult needs 750kcal/day (15kcal/kg/day), and 1ml O2 produce 3.5cal
O2 consumption require 150ml/min (3ml/kg/min)
Available O2 = O2 Carrying capacity (DO2) X O2 Extraction rate (ER)
= 1.35 X Hb(Hemoglobin) X Cardiac output (CO) X ER
Body limitations
ER should bt within 30% for safety
CO should be within 10L/min for safety
(CO = one beat volume X pulse rate)
PR should be within 160/minfor safety
Hb7.0g/dl can carry 500ml O2 at PR 84/min
Oxygen (O2) consumption at basal metabolism

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C: additive preserved (Day 42)B: ACD-A preserved (Day 21)A: fresh blood
Morphology of additive preserved RBC
Additive preserved RBCs has
alomost same shape of fresh blood
Aditive solution contains
Mannitol, Adenine,Glucose

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O2 O2
O2O2
Hemoglobin molecule
Trigger value of RBC transfusion
Trigger value decreased
10/30 （Hb/Hct) 7/20
Hb level: 8～10g/dl (limited transfusion)
is better than
Hb level ＞12g/dl (moderate transfusion)
ICU survival rate was high

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1g Hb increment needs 250g RBCs (400ml whole blood derived) in 50kgBW adult
RBCs administration and Hb increment

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Emergency Cases
• Traffic injury
• Obstetrics bleeding
• Gunshot wound (GSW)
• Rupture of esophagus varix
• Rupture of aortic aneurysm etc.
Indication of type O blood (no need of cross mating test)
Transfusion against Oligemia
1. Bleeding without BLS (basic life support)

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2. Bleeding under BLS
• General anesthesia, infusion rouite are accomplished
• If there is enough of blood, the bleeding of dozens of liters can
support.
Cases
• Heart or big vessel surgery (thrachic aorta or abdominal aorta)
• Hepatectomy including liver transplant surgery etc.
Level-1
RIS: rapid infusion system

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Long preserved RBC has worsen
prognosis of cardiac surgery?
Preserved within 2 weeks has better
prognosis than preserved > 4 weeks
RBC transfusion
Ambiguous indication
NEJM 358:1229-1239, 2008

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a) Surgical indication
less than 50,000/ul
effective for hemostat at cardiac surgery
b) Indication for bone marrow suppression
less than 20,000/ul
Mainly due to chemotherapy
contribution of safety
Indication of PCs transfusion

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Pletelet recovery rate
Estimation method of PC transfusion effect:
1.Prospected pLT increment
0.6×transfused PLT number÷blood volume
2.CCI(corrected count increment）
PLT increment（/μl）×body mass aria（㎡）
＝
transfused PLT number

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Increment of PCs transfusion
1Bag PC contains 2～3X1011 platelets
Increment of PLT count 3～5x104/ul

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Standard of PC administration
Indication: Decrease of number or mal-functions
Disease standard (thousand /uL)
Active bleeding less than 50
Invasive examinations less than 50
Pre-ope for difficult hemastasis ope. 70～100
PLT decrease at intra and post ope. less than 30
C-P bypass less than 30
Massive bleeding depend on bleeding volume
Chemotherapy less than 20
DIC 50
APLA・MDS 0.5～10

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Ambiguous indication
Trigger value 10,X104/ul or 20X104/ul is not clear
2010年2月のNEJM報告

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Abnormal coagulation Lab. Data
Measurement of PT, APTT, Fibrinogen
PT>16”、APTT>45”、Fibrinogen＜100mg/dl
to avoid FFP transfusion without Lab. data
FFP transfusion at PT<14” is meaningless
Indication of FFP transfusion

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No correction effect of PT (PT 14～17 sec)
PT does not shorten by dose of FFP
Transfusion
Volume 46, Issue 8, August 2006, Pages: 1279 –1285
Effect of fresh-frozen plasma transfusion on prothrombin
time and bleeding in patients with mild coagulation
abnormalities

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Indication of FFP is not clear
(big difference of usage between university hospitals)
0
2
4
6
8
10
12
14
0～4.9 5.0～9.9 10.0～14.9 15.0～19.9 20.0～24.9 25.0～29.9 30.0～34.9 35.0～39.9
FFP/Bed
Public or National
Private

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1:1 RBC/FFP transfusion recommend
to emergency patients
J Trauma 2009; 66: 693-7.
Vox Sang 2008; 95: 112-9

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1) minimum requirement
2) Zero risk is impossible at transfusion therapy
3) Transfusion therapy is thought to be
necessary evil
Transfusion without Lab. test is not desirable
Reasonable transfusion therapy

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Risks of transfusion therapy
FTR (severe) 700/year
TRALI・TACO < 80/year
ABO mismatch < 20/year
TTI < 20/year
total < 1,000/year
Recipients in japan ≒ 1million
Severe complications ≒ 1/1,000
Fetal rate ≒ 1/100,000

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（44.8%）
（44.3%）
（40.2%）
（43.0%）
Allergic reactions
Severe FTR (feblire transfusion reactions)

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Informed consent
Dr. should explain the risks of
transfusion therapy
•Necessity of transfusion
•Adverse reactions of transfusion
•National insurance covered TTI

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Risk management cooperation with patient
Call patient’s name by himself
To avoid ABO mismatch transfusion

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Problems of transfusion teaching stuffs
• Like to teach cats
(each doctor has a different opinion
without evidence)
• To reqiue enthusiastic zeal and
efforts
To teach reasonable transfusion therapy to
many doctors have a lot of difficulties

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Thank you for your attention!
Mt.Fuji from Shonan bay
Big Budda at Kamakura