This document discusses transfusion therapy for a 22-year-old man with multiple penetrating chest wounds who has drained 1500mL of blood from his right chest. The most appropriate next step is to arrange transfusion and transfer to the operating theater. Transfusion therapy involves administering blood components like packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate to replace lost blood and clotting factors. The risks and complications of transfusion include acute reactions like hemolytic, febrile, allergic, and transfusion-related acute lung injury as well as delayed issues such as alloimmunization, iron overload, and transfusion-transmitted infections.

1. TRANSFUSION THERAPY
Dr.Sajid Nomani
Deptt. Of Emergency medicine,
Peerless hospital and B.K.Roy research centre
Kolkkata.

2. ???………….A mcq
A 22 yr old man sustain multiple penetrating wounds to
upper rt.chest,his wounds are all above the nipple. He is
intubated,closed tube thoracostomy is performed, and
1500ml of blood has drained from rt.chest,2 liters of
crystalloid are infused. His BP is now 60/?,HR-160b/m
The most appropriate next step in managing this pt. is
a. Perform FAST
b. Obtain a CT chest
c. Perform an angiography
d. Arrange transfusion & transfer to OT.
e. Infuse colloids

3. 15thJune 1667 – Jean Baptiste Denys

4. Early 1800’s
First successful human-human transfusion

5. 1902– Karl Landsteiner
Won the 1930 Nobel
Peace Prize
Isolated the A, B, & O
blood types.
Type AB blood was
identified two years
later.
Beginning of safe and effective transfusion medicine

6. RELATIONSHIP BETWEEN BLOOD TYPE & ANTIBODIES
Blood type Antigen on RBC Can
donate to
Antibodies in
serum
Can receive
from
A A A & AB ANTI B A ,O
B B B & AB ANTI A B ,O
AB A &B AB NONE A ,B,O
O NONE ALL ANTI A & ANTI B O

7. Well, it gets more complicated here, because there's
another antigen to be considered –
the Rh antigen.
• Rh was 1st identified of a rhesus monkey → rhesus factor
• A person with Rh factor on his RBC said to be Rh+ve
• Will not make anti Rh antibodies
• A person with out Rh factor on his RBC said to be Rh –ve
• This will produce anti Rh antibodies
• Rh incompatibility dangerous in pregnancy.

9. Term &Definitions
BLOOD PRODUCT :Any therapeutic substance prepared from
human blood
WHOLE BLOOD :Unseparated blood
BLOOD COMPONENT : A constituent of blood ,separated from
Red cell concentrate
PRBC
FFP
PLATELETS
CRYOPRECIPITATE
→ Leucoreduced / Irradiated / washed

10. Why Separation of blood components ????
• The storage life of whole blood is less than that
of individual components
• Allows optimal survival for each component.
• Allows transfusing specific blood components.
• Several patients can be treated from one unit.

11. Decision making
• Whom to transfuse?
• What to transfuse?
• How much to transfuse?

12. So…whom you would transfuse !!!!
i. 23 yo asymptomatic, healthy woman with
menorrhagia,Hb 8.0 g/dl,MCV- 72 fl
ii. 61 yo,k/c/o Htn,with severe gram negative sepsis –
BP-100/70,cold periphery,AMS & Hb 8.0 g/dl.
iii. 54 yo woman post hemicolectomy Hb 8.0g/dl.
iv. 73 yo man presenting with acute upper GI bleed;
BP 80/60, Pulse 120 thready – Hb 8.0 g/dl,MCV- 90fl

13. Objectives of transfusion therapy
• Maintain blood volume
• Maintain O2 carrying capacity
• Maintain coagulation
• Red Cell Transfusion SHOULD not be solely used as a
‘plasma expander’ – but primarily as a method to
increase oxygen carrying capacity.

14. So…what is threshold for transfusion ???
• Difficult to set a transfusion threshold that holds true for all
patients.
• Depends upon clinical status & co-morbidities.
• Use "10/30― rule.

15. STATEMENT
American society of Anaesthesiologists (ASA) state that:
“Red blood cell transfusion is rarely indicated when
the hemoglobin concentration is greater than 10
g/dl and is almost always indicated when it is less
than 6 g/dl”

16. Transfusion guidelines have been published by the
following societies:
• American Society of Anesthesiology
• British Committee for Standards in Hematology
• Australian and New Zealand Society of Blood Transfusion
• Eastern Association for Surgery of Trauma (EAST) & American
College of Critical Care Medicine of the Society of Critical Care
Medicine (SCCM)
• European Society of Cardiology (ESC)
• AABB (formerly the American Association of Blood Banks)
• American College of Physicians

17. Some recommended threshold
• Hgb <6 g/dL – Transfusion recommended .
• Hgb 6 to 7 g/dL – Transfusion generally likely to be indicated
• Hgb 7 to 8 g/dL – Transfusion should be considered in postoperative
surg.pts.
•
• Hgb 8 to 10 g/dL – Transfusion generally not indicated, but should be
considered for some populations (eg, those with symptomatic
anemia, ongoing bleeding, acute coronary syndrome with ischemia)
• Hgb >10 g/dL – Transfusion generally not indicated except in exceptional
circumstances

18. • Transfusion Requirements in Critical Care (TRICC)
Hebert PC, et al. N.Engl J Med. 1999;340(6):409-17
A multicenter, randomized, controlled clinical trial of transfusion requirements in
critical care has demonstrated that you can adopt a
• transfusion threshold of 7 g/dL and maintain critically ill
patients between 7 and 9 g/dL
• Patients with acute MI and unstable angina may possibly
benefit from Hb> 8 g/dL

20. Blood component…..
Doses , Indications & Response

21. component indication Approx / U typical
doses
Doses effects
PRBC
1 U=250ml
Acute ongoing hemorrhage
Sever symptomatic anaemia
RBC-80%
Hct-70%
2 units or
15ml/kg
↑Hb-2gm/dl
↑Hct-6%
Platelets
1 U=250ml
<10000/mm3 in asymptomatic pt.
<20000/mm3 in major bleeding
<50000/mm3 for invasive
procedure
<100,000/mm3 with neoro/cardiac
surgery
1 unit or
5 mL/kg
↑50,000/mm3
but less in
many cases
(↑consumption/
Active thrombosis/
Destruction due to
plt.antibodies.)
3–6 x 1011
FFP
1 U=250 ml
1 u of each
coagl.factor
&
Fibrinogen-
2mg/ml
Coagulation Factor
deficiency, fibrinogen
replacement, DIC, liver
disease, exchange transfusion
massive transfusion, warfarin
overcoagulation effect
Cryoprecipi
-tate
1U=50ml
Four units or
15 mL/kg
Raises most
coagulation
factors levels
approx. 20%
Fibrinogen /
factor VIII /
vWF / factor
XIII
/fibronectin.
10 units or
1 unit/5 kg
Raises fibrinogen
75 milligrams/dL
Bleeding with a fibrinogen level
of <100 milligrams/dL
Fibrinogen deficiency
vonWillebrands Disease
Factor VIII or XIII deficiency

22. Special processing of RBC
leukocyte-reduced PRBCs
•↓nonhemolytic febrile reactions.
•↓ risk of virus transmission.
•to prevent sensitization in pt. for bone
marrow transplantation
Irradiated PRBCs should be considered in transplant patients,
neonates, and immunocompromised
patients
washed PRBCs
•↓risk of anaphylaxis in IgA deficient pt.
•↓risk of reaction in pt.with recurrent /
severe allergic reaction to blood products.

23. Massive Transfusion
• 10 units of PRBCs within a 24-hour period.
• Replacement of a blood volume equivalent within 24hr
• >10 unit within 24 hr
• Transfusion > 4 units in 1 hr
• Replacement of 50% of blood volume in 5 hrs
• A rate of loss >150ml/hr

24. Importance of Massive Transfusion
• 39% of trauma related deaths – uncontrollable
bleeding (Leading cause of preventable death)
• 2% of trauma patients – need massive
transfusion
• Bleeding 2 main causes
• Vascular injury (surgical)
• Coagulopathy (non-surgical)

25. Haemorrhage
Hypotension
Resuscitation
Haemodilution
Coagulopathy
HypothermiaLethal triad

26. So.....What is Haemostatic /damage
control Resuscitation?
• A ground breaking concept!
• Prevents post traumatic coagulopathy
• Aims to reduce use of blood products in the intensive
care phase.
Expert’s openion
RBC:FFP:PLT
1:1:1
Traditionally
PLT: <50,000/mm3
FFP : INR >1.5
Crypts : fibrinogen
<100ml/dl

27. Evidence of Haemostatic Resuscitation
• Massive transfusion practices around the globe and a
suggestion for a common massive transfusion protocol
Debra L Malone, John R Hess, Abe Fingerhut ;The Journal of trauma. 01/07/2006; 60(6
Suppl):S91-6.
Suggested – RBC:FFP - 1:1
• Indications for early fresh frozen
plasma, cryoprecipitate, and platelet transfusion in
trauma
Lloyd Ketchum, John R Hess, Seppo Hiippala; The Journal of trauma. 01/07/2006; 60(6 Suppl):S51-8.
Early use of FFP,PLT - ↓ incidence of coagulopathy

28. Transfusion’s Complications
• Up to 20% may lead to some type of adverse reaction.
• Mostly within 24 h.
• Most are minor reactions./ don’t miss the life threatening
• Acute vs Delayed reaction.
• Infectious & non infectious.
• Difficult to recognized in Critically ill patient

29. Acute Transfusion Reactions
• Hemolytic Reactions (AHTR)
• Febrile Reactions (FNHTR)
• Allergic Reactions
• TRALI
• Coagulopathy with Massive transfusions

30. AHTR
1 to 4 per 1 million units transfused.
Most commonly by ABO incompatibility.
Transfused cells are destroyed
↓ ↓ ↓
Activation of the coagulation system
with DIC & release of Anaphylotoxins &
other vasoactive amines
↓ ↓ ↓
• High fever/chills
• Hypotension
• Back/abdominal pain
• Oliguria / Hemoglobinuria
• Dyspnea
• Pallor
• requires a high degree of
suspicion in critically ill

31. What to do? If an AHTR occurs
• STOP TRANSFUSION
• A /B /C’s
• Maintain IV
• Give diuretic
• Blood & urine transfusion reaction workup
• Send remaining blood back to Blood Bank
Renal st-BUN/ Creat
Coagl.st-PT/aPTT/fibrinogen/plt.
Hemolysis-Bill/LDH/haptoglobin

32. Febrile transfusion reaction
Commenst among all
1 per 300 units of PRBC infused & 20%
of plt.infusion.
Result from a combination of recipient
antibody against donor leukocytes
and the release of cytokines that are
produced during storage.
Pretreatment with acetaminophen can
mask this reaction.
• Rise in patient temperature >1 C
(associated with transfusion without
other fever precipitating factors)
• fever / chills,
• Headache / myalgias,
• Tachycardia /dyspnea /chest pain.
• difficult to differentiate from more
serious hemolytic transfusion
reaction or sepsis.

33. What to do?If an FNHTR occurs
• STOP TRANSFUSION
• Use of Antipyretics
• Suspect and manage as AHTR
• Initially difficult to distinguish
between the two.
• Use of Corticosteroids for severe
reactions
• Use of Narcotics for shaking chills
• Future considerations
• May prevent reaction with
leukocyte filter.
• Use single donor platelets
• Use fresh platelets.
• Washed RBC’s or platelets

34. Transfusion Related Acute Lung injury
(TRALI)
• Clinical syndrome similar to ARDS
• Transfusion related noncardiogenic pulmonary edema
• Usually after FFP & Platelets transfusion
• Rare but , most common cause of transfusion related death
• Caused by WBC antibodies present in donor blood that result in
pulmonary leukostasis
• Occurs 1-6 hours after receiving plasma-containing blood products
• High mortality

35. TRALI Criteria
• Acute onset dyspnea during or within 6 hours of
transfusion
• Clinical evidence of hypoxemia
• Bilateral infiltrates on frontal chest radiograph
• No evidence of left atrial hypertension (i.e. circulatory
overload)
• Absence of other attributable causes
Treatment is supportive

36. DELAYED REACTION
• Alloimmunization
• Transfusion Associated Graft Verses Host disease
(GVHD)
• Iron Overload
• Transfusion Transmitted Infection

37. Alloimmunization
• Can occur with erythrocytes or platelets
• Erythrocytes
• Antigen disparity of minor antigens (Kell, Duffy, Kidd)
• Minor antigens D, K, E seen in Sickle patients
• Platelets
• Usually due to HLA antigens
• May reduce alloimmunization by leukoreduction
(since WBC’s present the HLA antigens)

38. Transfusion Associated GVHD
• Mainly seen in infants
• Etiology—Results from engraftment of donor
lymphocytes of an immunocompetent donor into an
immunocompromised host
• Symptoms—Diarrhea, skin rash, pancytopenia
• Usually fatal—no treatment
• Prevention—Irradiation of donor cells

39. Etiology Estimated Frequency: One Infection
per Number of Units Transfused
HIV-1 1 per 2–3 million
HIV-2 Unknown, but extremely low
Human T-cell lymphotrophic virus type I
and II
1 per 640,000
Hepatitis B 1 per 100,000–200,000
Hepatitis C 1 per 1–2 million
Parvovirus B19 1 per 10,000
Bacterial sepsis 1 per 6 million platelet concentrates
1 per 500,000 packed red blood cells

40. • THANKS YOU