All u need to know, blood transfusion

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Moderator: Dr. Leul (consultant Orthopedic
surgeon)
Presenter: Dr. Getasew (OSR1)
Blood Transfusion

2. Objective
 know indications of blood components and
safely transfuse.
 pick different adverse transfusion reactions
and manage
 know alternatives to allogeneic blood
transfusion
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3. 3
Outline
 Introduction
 Blood group sytem
 Blood component and their indications
 Massive transfusion
 Adverse effect of blood transfusion
 Alternative to blood transfusion
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4. 4
Introduction
Early attempts
 Xenotransfusions
 Richard Lower in the 1660s.
 First blood transfusion between animals
 Dr. Jean Baptiste Denys in1667
 First fully documented blood transfusion from animal to human
 Done four, first 2 survived and last two died immediately.
 Human blood transfusions
 Dr. James Blundell In 1818
The first successful transfusion of human blood to treat PPH
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5. Introduction
Modern era
 Dr. Karl Landsteiner discovered ‘ABO’ system in 1901
 The immunological reaction occurs when the receiver has antibodies against
the donor blood cells.
 Rhesus factor
 discovered in 1937 by Karl Landsteiner and Alexander S. Wiener.
 transfusions had to be made directly from donor to receiver
before coagulation
 Lately, anticoagulant and refrigerators
 Paved the way for blood bank concept in WWl
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6. 6
Intro…
 Function of blood
Perfuse oxygen and nutrients and remove wastes from the
tissues.
 Blood is made of two parts:
1. Formed cellular -45%
2. plasma-55%
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7. 7
Blood Group System
 35 systems currently.
 ABO System
 Rh System
 Others Blood Group Systems like:
Lewis system
Kell system
Duffy system
Kidd system
MNS system
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8. 8
Rh Blood Types
• Five Rh antigens D, C, c, E, and e,
– D determines hemolysis risk, more antigenic
• So, if present →Rh positive, if not → Rh negative.
• No preformed antibodies
– Need sensitization
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9. 9
Blood Component
 Whole blood was the standard in transfusion until
the late 1970s
 Most patients require a specific element of blood
 Blood products currently used in clinical practice
Whole blood
RBC concentrates
Platelet concentrates
plasma
Plasma derivatives
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10. 10
Providing Safe Blood
 Includes all procedures undertaken to render
blood safe.
From donor selection to transfusion
Donation and processing
Ordering
transfusing
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11. 11
Whole Blood
Most used product in Ethiopia
Shelf life- 42 dys
Storage- +2°C to +6°C and transportation 1-10°C
One unit- increase 3%HCT
Infection risk
Appropriate indication
massive hemorrhage
exchange transfusion in neonate
 Administration
 X match
Start with in 30’ and finish it with in 3-4 hrs
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12. 12
Packed Red Blood Cells
 Is product of choice.
 Sediments of centrifugation.
 Storage and infection risk- as in whole blood
 Shelf life varies with A-P used
ACD-21dys
CPD-21dys
CPD-A-35dys
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13. 13
Cont...
Significance of packed RBC transfusion:
oxygen carrying capacity
Increase red cell mass during active bleeding
Patients at risk of circulatory overload
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14. Indications for transfusion
pRBC
• DO2= CO * arterial O2 content
• Oxygen delivery reserve
– Supply= 4(demand)
Impact of anemia on mortality and morbidity
(In 300 post op patients analysis a 30 day mortality -2014)
7.1-8= 0.9%
5.1-7=9.2%
3.1-5=26.7%
=<3=62.1%
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15. When to transfuse?
Many factors to consider
 Hgb level
Presence of symptoms
Clinical status
Comorbid conditions
Patient wishes
Follow restrictive strategy, not liberal
Start at low Hgb, give less, aim less
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16. Indications..
1. Symptomatic* patients
Severe enough and clearly related to anemia
Keep >10g/dl
2. Asymptomatic anemia with no risk:
6-7g/dl
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17. Indications…
3. Asymptomatic patients with comorbidities
Cardiac patients
ACS when<8g/dl, consider if 8-10g/dl
 ICU/sepsis- Keep>7g/dl
Trauma/MTPs- depend on hemodynamic status
Surgical* patients-7 to 8g/dl
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Platelets
 Prepared from whole blood
 Stored in 20- 24°C, 5 days in a shaker.
 Dose= 1 unit/10kg
 Increases about 5000/microL
 Indications:
Treatment of bleeding/prevent bleeding due to:
 .Platelet function defects
 In massive transfusion
 bone marrow failure.
 Thrombocytopenia in surgical patients.
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19. 19
Cont.
 Thrombocytopenia
<10 in bleeding patients and non infected
<20,000 in non bleeding patients and infected
<50,000 in acute hemorrhage, invasive procedures and
major surgeries.
Neurosurgery and ophthalmic surgery -100,000/mm3
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20. 20
Fresh Frozen Plasma
 Rich in coagulation factors
 is removed from fresh blood with in 8hrs and
stored at −30
 One unit FFP increases fibrinogen by 7 to 10
mg/dL.
 Usual dose is 10 to 15 mL/kg.
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Cont...
Administered in coagulopathies:-
 Acute DIC and patient is bleeding
 Replacement of a single coagulation factor deficiency
 Coagulopathy liver disease
 To reverse the effect of warfarin
 During Massive blood transfusion to avoid coagulopathy.
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Cryoprecipitate
 Is precipitate of FFP and is rich in fibrinogen,
Factor VIII, vWD factor, Factor XIII
 It is stored at −30°C
 Indications
For the above mentioned factor deficiencies.
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Warming Blood
 No evidence when transfusion is slow.
 keeping the patient warm more important.
 If necessarily, should only be warmed in a blood
warmer.
– Large volume transfusion
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Massive Blood Transfusion
 Component of DCR response to massive and
unresponsive hemorrhage.
Greater than 10 units within 24 hours.
 Transfusion 3-4 units in 1 hour.
Is life saving in combating lethal triad in
massive bleeding
 minimize aggressive crystalloid administration
Non respondents…..
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25. • Acidosis hypothermia
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Lethal
triads
coagulopathy
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26. • Current massive transfusion
protocol suggest 1:1:1 ratio
administration of PRBC to FFP to
Platelet to decrease the anticipated
complication.
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27. 27
Cont...
PROBLEMS OF MASSIVE TRANSFUSION
 Circulatory overload
 Hyperkalemia
 Dilutional coagulopathy
 Citrate toxicity
 Hypocalcemia
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Monitoring
 Monitor with
 PT
 aPTT &
 Platelet count
Determine need of FFP or platelet if no MT
is initiated
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29. Adverse Transfusion Reactions-ATR
“Right Blood for The Right patient @ the Right time”
 Immune and non-immune mechanisms.
 Immune-mediated reactions are often due to
 antibody
 Cellular elements.
 Non-immune causes of reactions are due to
 chemical and physical properties of the stored blood component and its additives.
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30. ATR-classification
A: Mild Reaction
C/P: Localized cutaneous reactions such as urticaria, rash or pruritus
Action:
 Slow the infusion
 Antihistamines
B: moderate reaction
C/P
• Flushing, pruritus, Rigors, Fever
• Restlessness, tachycardia, Mild dyspnea, Headache
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31. Action:
Stop the infusion
Notify the blood bank immediately
Send important investigations
Rx
 Antihistamines
 Hydrocortisone
 Antipyratics- paracetamol based on body wt
see the response for 15’.
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32. C: Life Threatening Reactions
C/P
 Immediate pain at the infusion site
 Fever, Tachycardia, Hypotension
 Rigors
 Anxiety and restlessness
 Haemoglobinuria
 DIC
 Chest pain
 Respiratory distress, shortness of breath, dyspnea
Action:
 “ABC” of life
 Stop transfusion and crystalloid fast
 Maintain air way and give high flow of oxygen by mask
 Adrenaline, hydrocortisone, diuretics
 investigations
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Cont...adverse effect
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34. • Metabolic complications
– Hyperkalemia
– Hypothermia
– Hypocalcaemia
– Citrate toxicity
– Acidosis
– Iron overload
– Hemostatic imbalance
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35. ‘Tea-Break’
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Oxford university researchers investigated
the Shroud of Turin, burial shroud of Jesus Christ,
and identified the blood group to be AB
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Trends in transfusion
 Alternatives
1. Preop evaluation and treating anemia
• Iron salts, vit-B6 and 12, folic acid
• EPO
2. Decrease intra/post op bleeding
• Fibrin tissue sealants
• Anti-fibrinolytics
• surgical techniques
3. acute normovolemic hemodilution
• Draw blood and dilute with crystalloid
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37. Cont.
4. Intraop blood salvage
• collect shed blood and re-infuse
5. Pre-deposit programmes
• Weeks before surgery mostly before 4-5 dys.
6. Blood substitutes
• Volume expanders
• Oxygen carrying artificial Hgb
1. Perflourocarbon based
2. Hgb based
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38. 38
summary
 Essential part of patient care
 Transfuse specific element of blood based on
indication.
 Carries potential risks and complications
 Do it only if indicated and benefit outweighs the
risk
 Use of right products to the right patient at the right
time prevents ABTRs
 When ever possible use alternative methods.
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Reference
• National guidelines for appropriate clinical
use of blood, FMOH, may, 2015.
• Schwartz principle of surgery,10th edition
• uptodate 21.6
• Practice guideline for perioperative blood
management,(ASA,jornal,2016)
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