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BLOOD TRANSFUSION

Col. Dr Nagendra Bahadur KC


Consultant Anesthesiologist,
Birendra Hospital
Associate Prof. NAMS
(2069-11-21)
Blood Transfusion
• Introduction
• Blood group
• Source
• Preparation of blood products
• Storage
• Blood Products
• Things to consider Blood Transfusion
• Indication Of Blood Transfusion
• Complications
• Alternatives to transfusion
introduction
• Blood is a viscous fluid composed of cell and
Plasma
• Red cell(more than 99%),white cell,platelets &
plasma
• Normal blood vol = 60-80 ml/kg
• The percent of the Blood that is cells is
called the Hematocrit
• PCV or Hct<l/l> = 0.40-0.50<m> & 0.37-0.47<f>
• Plasma = 40-50ml/kg
• Hb = 13-18gm% (M); 11-16gm% (F)
• Neonates:
– Premature 95ml/kg
– Full term 85ml/kg
• Infants 80ml/kg
• Adults:
– Male 75ml/kg
– Female 65ml/kg
Blood Group: ABO system
• First described by Landsteiner in 1901
• Distribution of ABO blood group and
their Red cell antigen (surface
glycoprotein) and antibodies (IgM)
naturally occurring in serum
• Accidental transfusion of ABO-
incompatible Blood- Rapid intravenous
hemolisis.
ABO system (contd)
Type RBC Ag Se Ab %

A A Anti B 45

B B Anti A 8

AB A&B - 4

O - Anti A Anti B 43
43
Blood Group: Rh System
• Described in 1940 by Landsteiner &
Wenier
• Rh –ve: lacking D antigen
• Rh +ve ( 80-85%): D present,
• Antibodies rarely occur naturally,
clinically significant antibody occur
after exposure to Rh antigen
• A delayed transfusion reaction may occur
Sources of blood
• Allogeneic / Homologous-donor
• Autologous- collection & reinfusion of Blood
to the same Pt.
Preperation of Blood Products
• Whole Blood is first separated PRBCs and Platelet
rich plasma (PRP) by slow centrifugation.
• PRP then centrifuged in high speed to yield one unit
of Platelets and one unit of FFP
• Cryoprecipitate is produced by thawing FFP to
precipitate the plasma proteins, which are then
separated by centrifugation
Preparation……..
• Platelets also collected by apheresis technology, that
is collection of multiple units from a single donor.
• Plasma also be collected by apheresis.
• Plasma derivatives such as albumin, intravenous
immunoglobulin, antithrombin 3 and coagulation
factor concentrates are prepared from very large
pools(20,000 donors per pool)
Whole blood enters the centrifuge on the
left and separates into layers so that
selected components can be drawn off on
the right
Storage & Preservation of Blood
• Donor blood is screened for Hb, Blood typed,
screen for Ab and tested for HBV, HCV, syphilis,
HIV1&2, CMV, HTLV1&2
• Preservative anticoagulant solution is added
• CPDA (citrate, phosphate, dextrose, adenine)
– lifespan = 35 days
– stored to 1-6OC( inhibits bacteria, slows RBC
glycolysis, preserves 2,3 DPG)
Storage Contd.
• Citrate: acts as anticoagulant
• Phosphate: acts as buffer
• Dextrose: as energy source for red cell
• Adenine: to increase the red cell survival ,
which re synthesize the ATP
• Shelf life 35 days in CPDA and 42 days in AS- 1
(Adsol) or AS –3 (Nutrice) ADSOLE contains : Adenine, glucose,
mannitol and sodium chloride, NUTRICE contains : Glucose, adenine ,
citrate, phosphate and sodium chloride
Storage……
• During storage a series of biochemical
reaction is going on:
- Decrease PH : From 7.55 to 6.73
- The storage temp (1-6’ C) stimulate Na K
pump : Na 169 to 153, K 4.2 to 17.2 meq/Lit
- Osmotic fragility of RBC increased, Lysis of RBC
, Increase in HB % 0.5 to 46 mg/dl
Blood Products
Whole Blood
• each unit = 450 ml with Hct 40%
• Stored at 4’C
• no functioning platelets after 2-3days
• decrease 2,3 DPG by two weeks
• Normal albumin and clotting factors except V
and VIII
• Risk of transmission of pathogen
• Use: active bleeding, blood loss > than 25%
Blood product
Packed red cells
• Volume =250 ml , hemetocrit 70%
• 1 unit of pcv raised hemoglobin by 1.5-
2g%
• Use-when volume replacement is not
necessary like in chronic anemic pt
• No functioning platelets
Blood Products (contd)
• Deglycerolized RBC/frozen RBC
– Stored in the frozen state in a hypertonic
glycerol solution for up to 10 yrs
– Indicated for prolong storage of rare red
cells
-expensive but the chance of reaction &
diseases transmission is less
- Glycerol must be separated from RBC
before transfusion
Blood Products (contd)
• Washed red blood cells
– Patients who had previous severe allergic
reactions(severe urticarial or anaphylactic
reaction)
• Leukocyte reduced RBC
– Indicated for patients with the h/o previous
febrile transfusion reactions
– Reduce alloimmunization, transfuse transmitted
infection.
– Probably more used in future.
Blood Products
Platelets concentrates
• Volume-50 ml
• Only blood products which are stored at room
temp
• 1 unit of platelets increases the count by
5000-10000
• Transfused platelets survive only for 2-7 days
• ABO compatible platelet should be used
• Uses-thrombocytopenia(< 20,000/cu mm, For
surgery <50,000/cu mm)
Blood products
fresh frozen plasma
• Volume-225 ml
• Prepared from single donation , centrifuging whole
blood and the supernatant is frozen
• Contains all plasma proteins, factor V and VIII
• Risk of transmission of infection and anaphylaxis,
Sensitization to foreign Proteins.
• Each unit of FFP increases the level of each
clotting factor by 2-3%
Blood Products
FFP (contd)
Use-
• Urgent Reversal of warfarin therapy.
• Correction of multiple coagulation factor
deficiency ( DIC)
• Correction of microvascular bleeding in
Massive blood transfusion.
• Anti thrombin III deficiency
• Treatment of immunodeficiency
• Treatment of thrombotic thrombocytopenic
perpura
Blood Products
Cryoprecipitate
• Volume-10 ml , Prepared from FFP by slow
thawing,
• High in factor Vlll, fibrinogen, Von
willebrand’s factor,and Factor XIII,
fibronectin
• Use-DIC,VW disease, hemophilia A
(factor Vlll deficiency)
Hypofibrinogenemea
Prothrombin Complex
• Complexes of II, VII ,IX and X
• Two commercial preparation now available:
Konyne and Proplex
• Used in treatment
- factor IX deficiency that is Hemophilia B
(Christmas disease)
- Hypoprothrombinemic bleeding disorder
• Limited use because of risk of Hepatitis
Blood Products (contd)
. Human serum albumin

-Comprised of 96% albumin & 4 percent a & b globulin.


-Fractionation from multiple units of plasma pasteurized at
60ºC for 10 hr,
- available at 5% & 25% in isotonic saline
-May be stored for several months in liquid form at
4ºc
- No need of ABO typing and cross match
-use: severe hypoalbuminaemia & to replace plasma eg
burns, as a volume expanders
* very expensive and short supply
Blood Products (contd)

• Immunoglobulin product
-Fraction of plasma as 90% IgG
– No risk of infection
– Use: Immune deficiency states
• Granulocyte concentrate
– Prepared by continuous flow or intermittent flow
leukopharesis
– Dificult to obtain , so only used in higher center
– Uses- severely leukopenic (<500mm3) patients with
evidence of septicemia & fever
Things to consider before transfusion
• Checked by two individuals
• Identification with patients name and bag
number
• Blood grouping and X match
• Date of collection and expiry
• Inspected for bacterial contamination such as
discoloration, bubbles, or any suspended
particles and clots inside the bag
Things to consider before transfusion
(contd)
• Warming up to 37’ C
– Rapid transfusion of large amount of cold bloods
– Pediatric patients
– Warming may not be necessary if 1 or 2 units of
blood are slowly transfused to normo thermic
adult patients
• A standard blood transfusion set with a pore
size of 170 m to trap any clots or debris
Compatibility testing
To demonstrate harmful antigen-antibody interaction in vitro so that
harmful in Vivo antigen-antibody interaction could be prevented

• ABO-Rh type
• Cross match: donor red blood cells are mixed with recipient serum(45-60
min) ; 3 phase : immediate phase, incubation phase, antiglobulin phase
- Trial transfusion in test tube
- preventing serious hemolytic transfusion reaction
• Antibody screen
- To screen donor serum for unexpected antibodies in order to prevent
their introduction into the recipient serum.
- also carried in 3 phases
Emergency Transfusion
• Type specific partially crossmatched blood
* ABO – Rh typing
* immediate phase of cross match
adding the pt’s serum to donor red cells at
room temp, centrifuging it and then reading it
for macroscopic agglutination(1-5 min)
Emergency……………
• Type specific, Un cross matched Blood
- ABO-Rh typing
- First time transfusion is successful
- previous exposure might be hazardous
• Type O Rh Negative (universal donor)
- When no time for typing and cross match
Blood Products (contd)

• plasma substitutes
-include gelatin solutions (gelofusin,
haemaccel)
-used to restore circulating volume until
blood becomes available
-crystaloids
Indication of blood transfusion
• whole blood in case of surgical condition
– during a major operation
– severe blood loss or hemorrhage
– post operatively in a severe debilitated and anemic
patient
– as a prophylactic measure preoperatively in
hemorrhagic tendencies as in haemophilia,ITP
Indication………
• American college of surgeons classes of acute
haemorrage:
- Class I : 750 ml, 15%, crystalloid
- Class II : 750-1500 ml, 15-30%, crystalloid
- Class III : 1500-2000 ml, 30-40%, crystalloid +
Blood
- Class IV : > 2000ml, > 40%, Blood
Indication……
• The Practice Guidelines for Blood component
therapy developed by the ASA state that: “Red blood
cell transfusion is rarely indicated when the
haemoglobin concentration is greater than 10 gm/dl
and is almost always indicated when it is less than 6
gm/dL”
• Clinical judgement-Cardiovascular status,nature of
surgical/medical illness,Age,anticipated additional
blood loss,arterial O2tension,etc
• EABL =
(Hct starting – Hct allowable )  TBV
-------------------------------------------
Hct starting
• Blood volume to be transfused =
(Hct desired – Hct present )  TBV
-------------------------------------------
Hct transfused
-Estimated total Blood volume= weight in Kg x blood volume in ml/kg
Complications

• Immune
– Hemolytic Reaction
– Non hemolytic Reaction
• Infective
• Due to massive blood transfusion
• Others
Immune related reactions

• Due to sensitization of recipients to donor


blood cells (red, white, platelets) and plasma
protein.: Antibodies
Hemolytic reactions

• specific destruction of donor RBC by recipient


Ab or that of recipient RBC by donor Ab
• Types
– Acute
– Delayed
Acute Hemolytic transfusion Reaction
• usually due to ABO incompatibility (1:6000)
• Preformed antibodies that bind and lyse donor erythrocytes
• symptoms:
– conscious patients: chills, fever, nausea, chest and flank
pain, hypotension, diffuse bleeding, oliguria or anuria and
hemoglobinuria
– During Anaesthsia: tachycardia, Hypotension,
haemoglobinuria and diffuse woozing, DIC, shock, renal
failure
– Monitoring the patient's vital signs before and during the
transfusion is important to identify reactions promptly
Acute Intravascular Hemolysis

Treatment
– Stop the transfusion immediately
– Send both recipient and donor blood
specimen for repeat grouping and X
matching
– Treat hypotension aggressively with iv
fluids
Acute Intravascular Hemolysis

Treatment contd..
– Maintain urine output : iv fluid, diuretics,
dopamine, (induce diuresis)
– Monitor K level : Massive hemolysis can
release K
– Check for hemoglobinuria, bilirubin,
coagulation profile (PT, PTT, Platelet count,
fibrinogen level)
Delayed Hemolytic and serological
transfusion reaction

• Not completely preventable


• Previously sensitized to RBC alloantigen
• Occuring 1-2 weeks after transfusion due to
Ab to non D Ag of Rh system or to other
systems such as Kell, Duffy, or Kidd
– Mild form :Fever, malaise, jaundice, failure
to rise Hb or Hct
– Supportive treatment
Non-Hemolytic Transfusion Reaction
• Reaction associated with the transfusion of cellular blood
components( WBC, Platelets) in whole blood.
• Cause is the incompatible mixing of antibodies and antigens
between the blood of the donor and that of the recipient.
• Relatively common (1-3% of transfusion)
• Fever without features of hemolysis
• Also known FEBRILE NHTR
• Use of 20-40 micron filter, WBC free RBC transfusion
• If temp rise <1.5 C, observation; if stable, give paracetamol.
Non-Hemolytic Reaction

Allergic Reaction

• Sensitization to transfused plasma protein,


• Erythema, itching , rash, headache without
fever
• Common (1% of transfusion), mild form
• Use of Packed cell decrease risk
• Temporarily stop transfusion and treat with
anithistamines
Non-Hemolytic Reaction
Anaphylactic Reaction
• Only few milliliter blood component can trigger
• Rare ( 1 in 150 000) but very severe,
• Difficulty breathing, hypotension, bronchospasm, respiratory
arrest, shock, unconcious
• occur in patients with IgA deficient (presence of anti IgA
antibodies) patients when receive IgA containing blood
• Prevention by washed packed cells, deglycerelized frozen red
cells, IgA free blood cells
• Treatment with: adrenaline, fluids, steroids, antihistamines
Non-Hemolytic Reaction
TRALI
• Defined as new acute lung injury occuring during or
within 6 hrs after a transfusion with a clear temporal
relationship to the transfusion
• Uncommon reaction results from the transfusion of
donor Plasma that contains high titer anti-HLA
antibodies that binds the corresponding antigens on
reciepient leukocytes ,which aggregate in the
pulmonary vasculature releasing mediators increasing
capillary permeability : NON CARDIOGENIC PULM
OEDEMA
• Supportive treatment with 100%O2, Usually recover
without sequelae.
Non-Hemolytic Rxn
Graft Vs Host disease
• Immune compromised patient either diseased or on immunosuppressant
drugs
• Occurs when recipients immune system cant destroy incompatible WBCs
specially lymphocytes of donor blood.
• Transfusion related GVHD is mediated by donor T lymphocytes that
recognize host HLA antigens as foreign and mount an immune response.
• Fever, characteristic cutaneous eruption, diarrhea, and liver fuction
abnormalities.
• Clinical manifestation at 8-10 days and death occure at 3-4 weeks.
• Frequent complication of allogenic bone marrow transplantation
• Prevented by depletion of WBCs & blood irradiation before transfusion
Non-Hemolytic Rxn

Immune suppression

• Transfusion of leukocyte containing blood


products appears to be immunosuppressive
• Evident in renal transplant recipient in whom
preoperative blood transfusions appear to
improve graft survival
ALLOIMMUNIZATION
• Transfused Blood containing leukocytes reacts and
creates antibodies against them. This immune
response is called Alloimmunization.
• Cause pt to become refractory (resistant) to
subsequent platelet transfusion.
• No benefit from Platelet transfusion.
• Leukocyte reduced blood product should be
transfused.
Transfuion associated Infection

• Viral:
– HBV,
– AIDS (1:250 000 and 1:500 000)
– CMV
• Parasitic: malaria, toxoplasma
• Bacteria :staphylococcus, salmonella,
yersinia
• Spirochetes
Massive Blood Transfusion

Acute administration of more than one blood


volume over several hours.
• Administration of TBV in 24 hrs OR
• Half of TBV in 6 hrs OR
• One unit blood in 5 mins OR
• 5 units blood in 60 mins
Massive Blood Transfusion (contd)

• Coagulopathy:
– Dilutional thrombocytopenia
– Lack of coagulation factors V & VIII
– DIC associated with hypoperfusion or
hemolytic reaction
Massive Blood Transfusion (contd)

• Metabolic problems related to blood storage


– Citrate toxicity:- Hypocalcemia
– Hyperkalaemia
– Acid base abnormality : initially metabolic acidosis and
alkalosis later on (citrate metabolism , RL infusion)
– Hypothermia (Blood stored at 4’C) : ventricular dysrhythmia
even cardiac arrest. Warm blood should be given.
– Impaired O2 carrying capacity due to reduce 2,3 DPG
– Iron overload: Each unit contain 200-250 mg of iron
Autologous transfusion
• Any procedure whereby the pt’s own
previously donated or shed Blood is re
tranfused:
* Pre-operative donation (PAD)
* Acute Normovolaemic
Hemodilution (ANH): collected in ACD bag and can stored
up to 6-8 hrs in room temp and at 4’C up to 24 hrs.

* Intra operative cell salvage (ICS)


Autologous…………
• ICS:
- Collection and reinfusion of shed Blood from the
operative field or surgical drains
- Shed blood is anticoagulated, filtered, washed,
concentrated RBC SUSPENDED IN NORMAL SALINE
and returned in system or collected.
- This is PRBC, deficient in plasma, clotting factors and
platelets,
- Washing removes 95-98% of contaminants
- Contraindicated in the presence of Bacteria,
malignant cells, amniotic or ascitic fluid.
- used in emergencies
Synthetic Blood Products
• Perflurochemical emulsion called Fluosal DA:
• Stroma free Haemoglobin solution
- prepared from outdated human Blood)
• Genetically engineered hemoglobin
- E Coli produce human red cell
• Lyposome encapsulated Hb solutions
Crystalloids

• Replacement is 3 X because of distribution to


the extracellular space, has transient effect
• Normal Saline: iso-osmotic, mild
hypernatremia and hyperchloremia with large
volumes
• R/L: causes fewer electrolyte disturbance
Colloids

• Replacement volume is equal to blood loss


• Albumin 5% , 25%:
• Hetastarch (Hespan): affects coagulation, use
moderate amounts < 20 ml/kg
• Dextran: potential for anaphylaxis
Conclusion
• Allogenic transfusion confers a risk of immunomodulation,
trasmission of diseases, allergic reaction, alloimmunization,
and most imp is clerical errors.
• Allogenic transfusion should be reduced
* Transfusion protocol
* Surgical technique
* Medical Technique
- Controlled Hypotension : Sodium Nitroprusside
- Erythropoietin : anemic pt with Iron and folic acid
- Aprotinin : reduce bleeding in cardiac and liver surgeries –
may counteract aspirin related bleeding
- Oxygen carrying solutions :
- AUTOLOGOUS transfusion
THANK YOU

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