Blood transfusion

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Blood transfusion

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Topic modules

1. Blood blank practices
2. Indication to blood transfusion
3. Complication
4. Alternative strategies for management of blood
   loss during surgery

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Blood blank practices

• Human red cell membrane least 300 different
  antigen
• fortunately, only the ABO and the Rh systems are
  important in the majority of blood transfusion
• History
• Hct.
• Infection Hepatitis B,C syphillis
  HIV-1,2 HTLV-I,II

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Blood blank practices

• Crossmatching (50 min)
• Confirms ABO and Rh typing
• Detects antibodies to the other blood group
  systems
• Detects antibodies in low titers or those that do
  not agglutinate easily

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Blood blank practices

• Antibody screen Indirect Coombs test
• (45 mins)
• the subject serum red cells
• ( antigenic composition) ----- red cell
  agglutination
• Typescreen
• Emergency transfusion

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Type and screen vs Type and crossmatch

• TS -determines ABO and Rh status and the
  presence of most commonly encountered antibodies
  risk of adverse rxn is 11000
• -takes about 5 mins
• TC -determines ABO and Rh status as well as
  adverse rxn to even low incidence antigens risk
  of rxn is 110,000
• -takes about 45 mins

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Type and screen vs Type and crossmatch

• TS
• Type O red cells are mixed with pt serum Antibody
  screen
• TC
• Type O red cells are mixed with pt serum Antibody
  screen
• Donor red cells are then mixed with the pts
  serum to determine possible incompatibility

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Blood blank practices

• All units RBC _at_ PRC 1unit (250 ml Hct.70)
• --platelet_at_ 1 unit (50-70 ml,
  stored at 20-24c for 5 days)
• --plasma _at_ FFP
• --cryoprecipitate _at_ high conc. Of
  factor VII, fibrinogen

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Intraoperative transfusion practices

• PRC
• Ideal for patients requiring red cells
  but not volume replacement Only one Increase O2
  carrying capacity
• AGE
  BLOOD VOLUME
• Neonates
• Premature
  95 ml/kg
• Full-term
  85 ml/kg
• Infants
  80 ml/kg
• Adults
• Men
  75 ml/kg
• Women
  65 ml/kg
• Allowable blood loss EBV( Hct???????
  Hct????????????)/ Hct??????
• Hct. 30 not magic number
• Jehovah s witness

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Practice guideline

• case series reports of Jehovah witness some
  may tolerate very low Hblt 6-8 g/dl in the
  perioperative period without an incresae in
  mortality

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Practice guideline

• In healthy, normovolemic individual, tissue
  oxygenation is maintained and anemia tolerated at
  Hct as low as 18-25(Hb 6-8gm)
• RBC transfusion is rarely indicated when Hbgt
  10 g/dl and is almost always indicated when Hblt 6
  g/dl
• American Society
  Anesthesiologist 1996

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Intraoperative transfusion practices

• 2. FFP ( initial therapeutic dose 10-15 ml/kg )
• isolated factor deficiencies
• reverse warfarin therapy
• correction of coagulopathy associated with
  liver disease
• used in patients who are received massive
  blood transfusion with microvascular bleeding
• Complications (PATCH)
  Platelets dec,Potassium inc., ARDS,
  Acidosis,Temp dec., Citrate intoxication,
  Hepatiti
• gt1 BV/ 24 HRgt 50 BV within 3
  hrs gt 150 ml/min
• antithrombin III deficiency
• TTP ( Thrombotic thrombocytopenic purpura )
• Do not use for volume

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Intraoperative transfusion practices

• 3. PLATELETS
• thrombocytopenia or dysfunction platelets
  in the presence bleeding
• prophylactic plt.counts below
  10,000-20,000
• prophylactic preoperative plt.counts
  below 50,000
• Microvascular bleeding in surgical patient
  with platelets lt 50,000
• Neuro/ ocular surgery gt 75,000

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Intraoperative transfusion practices

• 3. PLATELETS

• Massive transfusion with microvascular
  bleeding with platelets lt 100,000
• 2 BVs 50,000
• Qualitative dysfunction with microvascular
  bleeding (may be gt 100,000)

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Intraoperative transfusion practices

• 3. PLATELETS
• 50 ml 0.5- 0.6 x 10 9 platelets (some RBCs
  and WBCs)
• Single donor apheresis OR
• Random donor (x 6)

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Intraoperative transfusion practices
4. CRYOPRECIPITATE 10 ml
fibrinogen (150-250 mg), VIII
(80-145 U), fibronectin, XIII
1U/ 10kg ? fibrinogen 50 mg/dL (usually a 6-
pack) Hypofibrinogenemia (congenital or
acquired) Microvascular bleeding with massive BT
(fibrinogen lt 80-100mg/dL) 2 BVs lt 100 mg/dL
Bleeding patients with vWD (or unresponsive to
DDAVP)

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Alternative strategies for management of blood
loss during surgery

1. Autologous transfusion
2. Blood salvage refusion
3. Normovolemic hemodilution

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• Blood is still the best possible
  thing to have in our veins - Woody Allen
• Blood transfusion is a lot like
  marriage.
• It should not be entered upon lightly,
  unadvisedly or wantonly, or more often than is
  absolutely necessary - Beal

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TRANSFUSION REACTIONS

• is any unfavorable transfusion-related event
  occurring in a patient during or after
  transfusion of blood components

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TRANSFUSION REACTIONS

• _at_RBCs !
• Nonhemolytic 1-5 transfusions
• Causes -Physical or chemical destruction
  of
• blood freezing, heating, hemolytic
  drug
• -solution added to blood
• -Bacterial contamination
• fever, chills, urticaria
• Slow transfusion, diphenhydramine , antipyretic
  for fever
• Hemolytic
• Immediate ABO incompatibility (1/ 12-33,000)
  with fatality (1/ 500-800,000)
• Majority are group O patients receiving type
  A, B or AB blood
• Complement activation, RBC lysis, free Hb (
  direct Coombs Ab test)

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Acute Hemolytic Transfusion Reaction


Pathophysiology
Ab (in recipient serum) Ag (on RBC donor)
-Neuroendocrine responses -Complement
Activation -Coagulation Activation - Cytokines
Effects
Acute hemolytic transfusion reaction
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Acute Hemolytic Transfusion Reactions

• Acute onset within minutes or 1-2 hours
• after transfuse incompatible blood
• Most common cause is ABO-incompatible
• transfusion

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Signs and Symptoms of AHTR

• Chills , fever
• Facial flushing
• Hypotension
• Renal failure
• DIC
• Chest pain
• Dyspnea
• Generalized bleeding

• Hemoglobinemia
• Hemoglobinuria
• Shock
• Nausea
• Vomitting
• Back pain
• Pain along infusion vein

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• Anesthesia hypotension, urticaria, abnormal
  bleeding
• Stop infusion, blood and urine to blood bank,
  coagulation screen (urine/plasma Hb, haptoglobin)
• Fluid therapy and osmotic diuresis
• Alkalinization of urine (increase solubility of
  Hb degradation products)
• Correct bleeding, Rx. DIC

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Laboratory investigation for AHTR

• sample from blood bag Repeat ABO, Rh,
  Ab screening
• Patient sample
• Pre Tx sample Repeat ABO,
  Rh, Ab screening
• Post Tx sample Repeat ABO,
  Rh, Ab screening, DAT,
• CBC,
  UA, Bilirubin, BUN, Cr,
• 
  Coagulation screening
• Repeat compatibility test
• - Pre Tx sample Donor unit
• - Post Tx sample Donor unit

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• Delayed (extravascular immune)1/ 5-10,000
• Hemolysis 1-2 weeks after transfusion
  (reappearance of Ab against donor Ag from
  previous exposure)
• Fever, anemia, jaundice
• Alloimmunization
• Recipient produces Abs against RBC membrane
  Ag
• Related to future delayed hemolytic reactions
  and difficulty crossmatching

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• _at_WBCs!
• Europe All products leukodepleted
• USA Initial FDA recommendation now reversed
  pending objective data (NOT ? length of stay for
  ? expense)
• Febrile reactions
• Recipient Ab reacts with donor Ag, stimulates
  pyrogens (1-2 transfusions)
• 20 - 30 of platelet transfusions
• Slow transfusion, antipyretic, meperidine for
  shivering

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• TRALI (Transfusion related acute lung injury)
• Donor Ab reacts with recipient Ag (1/ 10,000)
• noncardiogenic pulmonary edema
• Supportive therapy

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Transfusion-related Acute Lung Injury (TRALI)

• Pathophysiology
• Leukocyte Ab in donor react with pt. leukocytes
• Activate complements
• Adherence of granulocytes to pulmonary
  endothelium with release of proteolytic enz.
  toxic O2 metabolites
• Endothelial damage
• Interstitial edema and fluid in alveoli

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Transfusion-related Acute Lung Injury (TRALI)

• Acute and severe type of transfusion reaction
• Symptoms and signs
• Fever
• Hypotension
• Tachypnea
• Dyspnea
• Diffuse pulmonary infiltration on X-rays
• Clinical of noncardiogenic pumonary edema

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Transfusion-related Acute Lung Injury (TRALI)

• Therapy and Prevention
• Adequate respiratory and hemodynamic supportive
  treatment
• If TRALI is caused by pt. Ab ? use LPB
• If TRALI is caused by donor Ab ?no special blood
  components

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• Transfusion-associated Graft-versus-Host Disease
  ( TA-GVHD)
• Rare immunocompromised patients
• Suggestion that more common with designated
  donors
• BMT, LBW neonates, Hodgkin's disease, exchange Tx
  in neonates

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Transfusion-associated Graft-versus-Host Disease
( TA-GVHD)

• Pathophysiology
• Infusion of Immunocompetent Cells
• (Lymphocyte)
• Patient at risk
• proliferation of donor T lymphocytes
• attack against patient tissue

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Graft-versus-Host Reaction

• Signs Symptoms

• Onset 3 to 30 days after transfusion
• Clinical significant pancytopenia
• Other effects include fever, liver enzyme,
• copious watery diarrhea,
• erythematous skin erythroderma
• and
  desquamation

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• _at_Platelets!
• Alloimmunization
• 50 of repeated platelet transfusions
• Ab-dependent elimination of platelets with lack
  of response
• Use single donor apheresis
• Signs Symptoms
• mild ? slight fever and Hb
• severe ? platelet refractoriness with bleeding
• Post-transfusion purpura
• Recipient Ab leads to sudden destruction of
  platelets 1-2 weeks after transfusion (sudden
  onset)
• Rare complication

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• Immunomodulatory effects of transfusion
• Wound infection circumstantial evidence (?
  leukocyte filters for immunocompromised)
• Beneficial effects on renal graft survival (now lt
  NB with CyA)
• 97 9 graft survival advantage after 5 years
• Nonspecific overload of RES
• ? lymphocytes, APCs
• Modification T helper/suppressor ratio
• Allogeneic lymphocytes may circulate for years
  after transfusion

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• Cancer recurrence (mostly retrospective)
• Colon 90 studies suggest increased recurrence
• Breast 70 studies
• Head and neck 75 studies
• Allogeneic blood products increase cancer
  recurrence after potentially curative surgical
  resection - Landers
• Evidence circumstantial NOT causal

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INFECTIOUS COMPLICATIONS

• I. Viral (Hepatitis 88 of per unit viral risk)
• Hepatitis B
• Risk 1/ 200,000 due to HBsAg, antiHBc screening
  (7-17 of PTH)
• Per unit risk 1/63-66,000
• 0.002 residual HBV remains in negative donors
  (window 2-16 weeks)
• Anti-HBc testing retained as surrogate marker for
  HIV

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• NANB and Hepatitis C
• Risk now 1/ 103,000 (NEJM 96) with 2nd/ 1/
  125,000 with 3rd generation HCV Ab/ HVC RNA tests
  
• Window 4 weeks
• 70 patients become chronic carriers, 10-20
  develop cirrhosis

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• HIV
• Current risk 1/ 450- 660,000 (95)
• With current screening (Abs to HIV I, II and p24
  Ag), window 6-8 weeks (third generation ELISA
  tests in Europe)
• ? sero -ve window to lt 16 days

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• HTLV I, II
• Only in cellular components (not FFP, cryo)
• Risk 1/ 641,000 (window period unknown)
• Screening for antibody I may not pick up II
• CJD (and variant CJD)

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• CMV
• Cellular components only
• Problem in immunocompromised, although 80
  adults have serum Ab
• WBC filtration decreases risk of transmission
• CMV -ve blood
• CMV -ve pregnant patients, LBW neonates, CMV -ve
  transplant recipient,
• CMV-ve/ HIV ve

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• II. Bacterial
• Contamination unlikely in products stored for gt
  72 hours at 1-6 0 C
• gram ve, gram ve bacteria
• most frequent Yersinia
  enterocolitica
• Produced endotoxin
• Platelets stored at room temperature for 5
  days, with infection rate of 0.25
• III. Protozoal
• Trypanosoma cruzi (Chagas disease)
• Malaria
• Toxoplasmosis
• Leishmaniasis

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Serological Testingfor Infectious markers

• HIV Ag
• Anti HIV
• HBsAg
• Anti HCV
• Test for syphilis

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METABOLIC COMPLICATIONS

• Citrate toxicity
• Citrate (3G/ unit WB) binds Ca2 / Mg
• Metabolized liver, mobilization bone stores
• Hypocalcemia ONLY if gt 1 unit/ 5 min or hepatic
  dysfunction
• Hypotension more likely due to ? cardiac output/
  perfusion than ? calcium (except neonates)
• Worse with hypothermia/ hepatic dysfunction

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• Hyperkalemia
• After 3 weeks, K is 25- 30 mmol/l
• Only 8- 15 mmol per unit PRBC/ WB
• Concern with gt 1 unit/5 min _at_ infants

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• Acidosis
• Acid load after after 3 weeks 30-40 mmol/l (pH
  6.6 - 6.9)
• Metabolic acidosis more likely due to decreased
  perfusion, hepatic impairment, hypothermia
• NaHCO3 or THAM if base deficit gt 7-10 mEq/l

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• 2, 3 DPG
• Depleted within 96 hours of storage
• O2 Hb DC to left
• Restored within 8- 24 hours of transfusion

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E. REFERENCES

• Practice Guidelines for Blood Component Therapy
  (ASA Task Force). Anesthesiology 1996 84
  732-47.
• Safety of the Blood Supply. JAMA 1995
  2741368--73.
• Infectious Disease Testing for Blood Transfusions
  (NIH Consensus Conference). JAMA 1995 274
  1374-9.