Overview of Blood Transfusion for Management of Complicated Cases

Prof. Dr. Husne Ara Begum

Transfusion Medicine Dept. Dhaka Medical College

For better Management we should strictly maintained

Proper selection of donor Screening of donor Compatibility tasting Rational use of blood component therapy

Objectives of B.T & Component therapy

Restoration of blood volume Enhance the O2 carrying capacity of blood Maintain Homeostasis
Platelet Coagulation Factors Fresh blood FFP or Appropriate component

Blood Transfusion
20% loss no need 20%-30% loss - plasma substitution >30% - Blood transfusion

Before transfusion we must determine me WHAT for any procedure

- Whether required
- How much required
- Actual component required
- Time of duration of transfusion

Complication of Blood Transfusion

A. Immediate reactions
Febrile reaction Allergic reactions Hemolytic transfusion reaction Circulatory over load Air embolism Potassium toxicity Citrate toxicity Reaction due to infected blood

Delayed transfusion reactions

Thrombophlebitis TTDs / TTI AIDS (HIV) Hepatitis (HBV, HCV) Syphilis (Treponema pallidum / Spirochetes) Malaria (M.P), C.M.V & other Immunological sensitization or alloimmunization Transfusion haemosiderosis Post transfusion purpura HTR Graft-versus-host disease (GVHD) Complication of massive transfusion

HTR
A. Incompatibility between donors and recepient

99% caused of human error preventable by

Adequate knowledge of blood groups Careful attention to all details of the techniques Blood group incompatible Outdated and infected blood Haemolysed blood Incorrect anticoagulant

Initial FFP therapy

4-5 units of FFP- deterioration of normal hemostasis There after 4 units of FFP for every 06 units of red cells
Cryoprecipitate hypofibrinogenemia Calcium gluconate If needed

HTR
Symptoms
Severe aching in the transfused vein Pain in lumber region & back Dyspnoea Nausea Vomiting Flushing of the face Chill & rigors Temperature Anxiety Restless Feeling of constriction of chest

HTR
Signs
Temp. Tachycardia B.P Unexplained bleeding (DIC) Shock - urinary output Anuria Death

HTR
Under anesthesia and sedation
Symptomless Signs
Bleeding from wound / needle sites Persistent hypotension Tachycardia

HTR
Investigations
Stop transfusion 10 ml blood sample in test tube 2 ml in oxalated tube Urine sample- collected for 2-3 days measure & examine Blood for GM staining & C/S Exclude clinical error

HTR
Lab investigation
Re-grouping the donor and recipient Re cross match Examine Post transfusion sample for agglutinated RBC Coombs test Screen donor sample

HTR
Biochemical Test
Post transfusion sample for free Hb & bilirubin and compare with pre transfusion sample Urine for free Hb & RBC casts Schumms test for met Hb

HTR
Hematological test
Blood for Hb, TC of RBC PBF with post transfusion sample for morphology of RBC

HTR
Bacteriological test

From donor blood residue for gram staining & C/S

Diagnosed after recheck

- Visual inspection of serum & urine - Lab, Investigation , follow up

HTR
AIM

Management

- Fluid and Electrolyte Balance - Nutrition Stop transfusion - keep IV channel open with saline & hydrocortisone Maintain input output chart Inj. Frusemide Inj. Heparin FFP/compatible fresh whole blood Infusion mannitol If no diuresis peritoneal dialysis

Period of Oliguria 7-21 days

50% glucose solution 500 ml/day Input output chart Infection antibiotic Anemia Packed RBC High CHO & low protein diet

If no satisfactory response - renal unit

Period of diuresis
Fluid

- 1L/day + urinary loss on previous day - High CHO & Low protein diet

Pathophysiology of DIC
Massive issue injury Sepsis Extensive endothelial injury

Release of tissue factor

Widespread microvascular thrombi Activation of plasmin Platelet aggregation

Microangiopathic Microvascular hemolytic anemia occlution

Fibrinolysis Proteolysis of clotting factor FDP

Inhibition of thrombin, platelet aggregation, fibrin polymerization

Ischemic tissue injury

Bleeding

Clinical features
Severe acute DIC manifest with mucosal oozing, gastrointestinal blood loss, bleeding from surgical incisions or sites of venous access. Deposition of thrombi in the microcirculation can lead to multiple organ failure. Renal failure to hypovolemia & fibrin deposition in the renal vasculature Usually by gm (ve) organism Occasionally by gm (+ve) organism Peripheral vasodilatation causes hypotension shock death

Management of DIC
Principles are a. elimination of precipitating factor if possible b. replacement of coagulation factors platelet fresh whole blood FFP fibrinogen c. inhibition of the clotting process with heparin or other agents

Monitor
Prothrombin time (PT), Thrombin time (TT) Platelet count Fibrinogen level APTT FDP or SFM (Soluble fibrin monomers)

Massive transfusion
It is defined as transfusion / infusion of whole blood equal to or exceeding the persons blood volume within 24 hrs period.

Indications

Medical emergencies Major surgery Exchanged transfusion

Problem of massive blood transfusion

Physical

Hypothermia
Chemical

Hypocalcaemia Acidosis Hypokalemia associated with metabolic alcalosis

Problem of massive blood transfusion..

Physiological

O2 dissociation curve shift to the left

Depletion of labile coagulation factors Dilutional thrombocytopenia

Objective of massive blood loss

To

restore & maintain adequate blood volume To maintain sufficient O2 carrying capacity To secure haemostasis

Following haematological parameters should be performed & correctly measure taken

Investigation Hb/Hct Pl. Count PT PTT Fibrinogen

Target value 10 gm/dl 32% >50,000/cmm <15 x control <1.5 x control >0.8 gm/l