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BLOOD COMPONENT THERAPY 2002 EVAN G. PIVALIZZA, FFA Department of Anesthesiology University of Texas at Houston A. BLOOD PRODUCTS 22 x 10 6 components p.a. 50-70 % peri-operatively 18-57% inappropriate (NIH reviews in 80’s) Blood preservation and storage

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blood component therapy

BLOOD COMPONENT THERAPY

2002

EVAN G. PIVALIZZA, FFA

Department of Anesthesiology

University of Texas at Houston

a blood products
A. BLOOD PRODUCTS
  • 22 x 106 components p.a.
  • 50-70 % peri-operatively
  • 18-57% inappropriate (NIH reviews in 80’s)
blood preservation and storage
Blood preservation and storage
  • 75 % RBC’s in circulation @ 24 hrs
  • Within 4 hrs, WB separated
  • WB: 63 ml preservative (HCT 36-40%)
    • CPD- A (citrate, phosphate, dextrose, adenine) shelf-life 35 days @ 1-60 C
  • PRBC: (HCT 60%)
    • CPD-A
    • ADSOL (adenine, dextrose, saline, mannitol) shelf-life 42 days
slide4
Deglycerolized blood
    • Frozen with glycerol for storage, washed before transfusion (years)
  • Leucocyte depleted blood (see later)
  • Washed (IgA deficiency)
do 2 vo 2
DO2 / VO2
  • DO2 = CO x [(Hb x SaO2 x 1.34) + PaO2 x 0.003]
  • Flow  pressure, 1/R4, viscosity
  • Balance hematocrit/ viscosity + 30%
slide6
Compensations chronic anemia
    •  viscosity =  flow, venous return, SV
    •  O2 extraction except cardiac and cerebral circulation
    • O2 DC shifted to right
    • DO2 adequate to Hct 18-25%
indications for prbc transfusion
Indications for PRBC transfusion
  • ONLY: Increase O2 carrying capacity
  • Use of single ‘trigger’ transfusion inappropriate
  • TRICC: ? more conservative trigger in ICU (7-9 vs 10-12)
    • NOT apply to > 55, bleeding, cardiac surgery
  • Determination transfusion based patient risks for complication of inadequate DO2
  • 10 ml/kg  Hct 10 %
indications for ffp transfusion
Indications for FFP transfusion
  • 2 million units p.a.
  • 200-260 ml: procoagulants (1U/ml) and fibrinogen (3-4 mg/ml)
  • Urgent reversal of coumadin therapy (5-8 ml/ kg)
  • Correction of known coagulation factor deficiencies (no concentrates available) to + 30% (10-15 ml/ kg)
  • Microvascular bleeding with PT/ PTT > 1.5 normal
slide9
Massive BT with microvascular bleeding
    • >1 BV/ 24 hours
    • > 50 % BV within 3 hrs
    • > 150 ml/min
  • Plasmapheresis for TTP
  • AT-III deficiency
  • Succinylcholine apnea
slide10
S.D plasma
    • Pooled plasma, Rx solvent and detergent
    • Virus inactivated,  bacteria, WBCs
    • Consistent coagulation factors (1 U  2-3%)

BUT:

    • Cost
    • ? Transmission unknown particles
indications for cryoprecipitate transfusion
Indications for cryoprecipitate transfusion
  • 10 ml: fibrinogen (150-250 mg), VIII (80-145 U), fibronectin, XIII
  • 1U/ 10kg  fibrinogen 50 mg/dL (usually a 6- pack)
slide12
Hypofibrinogenemia (congenital or acquired)
  • Microvascular bleeding with massive BT (fibrinogen < 80-100mg/dL)
    • 2 BVs = < 100 mg/dL
  • Bleeding patients with vWD (or unresponsive to DDAVP)
indications for platelet transfusion
Indications for platelet transfusion
  • 7 million units p.a.
  • 50 ml: 0.5- 0.6 x 10 9 platelets (some RBC’s and WBC’s)
  • Single donor apheresis OR
  • Random donor (x 6)
slide14
Decreased production
  • Prophylactic for surgical patient with platelets < 50,000
  • Microvascular bleeding in surgical patient with platelets < 50,000
  • Neuro/ ocular surgery > 75,000
slide15
Massive transfusion with microvascular bleeding with platelets < 100,000
    • 2 BVs = 50,000
  • Qualitative dysfunction with microvascular bleeding (may be > 100,000)
  • Assessment of platelet function (TEG, Sonoclot) in O.R.
b transfusion reactions
B. TRANSFUSION REACTIONS
  • RBC’s
  • Nonhemolytic
    • 1-5 % transfusions: fever, chills, urticaria
    • Slow transfusion, diphenhydramine
  • 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
slide17
Anesthesiologist major trauma hospital:
      • Transmit HIV once / 1,000 years
      • Hep C 200
      • Hep B 100
      • Administer incorrect blood 30
    • UK: 1996-99 – 97 life-threatening ABO incompatible transfusions
slide18
Complement activation, RBC lysis, free Hb (+ direct Coombs Ab test)
    • 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)
slide19
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 Ab’s against RBC membrane Ag
  • Related to future delayed hemolytic reactions and difficulty crossmatching
slide20
WBC’s
  • 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
slide21
TRALI (Transfusion related acute lung injury)
    • Donor Ab reacts with recipient Ag (1/ 10,000 but causes 15 % of mortality due to BT)
    • Noncardiogenic pulmonary edema
    • Supportive therapy
    • ? relation to multiparous donors (> 4 pregnancies)
slide22
GVHD
    • Rare: immunocompromised patients
    • Suggestion that more common with designated donors
    • BMT, LBW neonates, Hodgkin\'s disease, exchange Tx in neonates
slide23
Platelets

Alloimmunization

    • 50 % of repeated platelet transfusions
    • Ab-dependent elimination of platelets with lack of response
    • Use single donor apheresis
  • Post-transfusion purpura
    • Recipient Ab leads to sudden destruction of platelets 1-2 weeks after transfusion (sudden onset)
slide24
Immunomodulatory effects of transfusion
  • Wound infection: circumstantial evidence (? leukocyte filters for immunocompromised)
  • Beneficial effects on renal graft survival (now < 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
slide25
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
slide26
However, 2 recent prospective, randomized studies: no effect on tumor related morbidity/mortality, but poorer outcomes
  • Conservative trigger (< 3 units)
  • Clinical judgment to weigh risk-benefit ratio
c infectious complications
C. 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
slide28
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
slide29
HIV
  • 29 cases -transfusion recipients  93
  • 7,800 by 12/ 95
  • 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 < 16 days
slide30
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
slide31
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
slide32
CJD (and variant CJD)
  • BB implementing donor deferrals
    • 1980-96:
      • > 3 months UK
      • TF in UK
      • > 5 years in France
slide33
II. Bacterial
  • Contamination unlikely in products stored for > 72 hours at 1-6 0 C (10 cases Yersinia)
  • Platelets stored at room temperature for 5 days, with infection rate of 0.25%
  • III. Protozoal
  • Trypanosoma cruzi (Chaga’s disease)
d metabolic complications
D. METABOLIC COMPLICATIONS
  • Citrate toxicity
  • Citrate (3G/ unit WB) binds Ca2+ /Mg+
  • Metabolized liver, mobilization bone stores
  • Hypocalcemia ONLY if > 1 unit/ 5 min or hepatic dysfunction
  • Hypotension more likely due to  cardiac output/ perfusion than  calcium (except neonates)
  • Worse with hypothermia/ hepatic dysfunction
slide35
Hyperkalemia
  • After 3 weeks, K+ is 25- 30 mmol/l
  • Only 8- 15 mmol per unit PRBC/ WB
  • Concern with > 1 unit/5 min @ infants
slide36
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 > 7-10 mEq/l
slide37
2, 3 DPG
  • Depleted within 96 hours of storage
  • O2 Hb DC to left
  • Restored within 8- 24 hours of transfusion
e references
E. REFERENCES
  • Practice Guidelines for Blood Component Therapy (ASA Task Force). Anesthesiology 1996; 84: 732-47.
  • Safety of the Blood Supply. JAMA 1995; 274:1368--73.
  • Infectious Disease Testing for Blood Transfusions (NIH Consensus Conference). JAMA 1995; 274: 1374-9.
slide39
Blood Transfusion- Induced Immunomodulation. Anesth Analg 1996; 82: 187-204
  • ASA Questions and Answers about Transfusion Practices (3rd ed., 1997)
  • Immunomodulatory aspects of transfusion. Anesthesiology 1999; 91: 861-5.
slide40
“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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