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Blood transfusion. พญ.เพชรรัตน์ วิสุทธิเมธีกร พ.บ., ป. ชั้นสูงสาขาวิสัญญีวิทยา, วว. ( วิสัญญี ) ภาควิชาวิสัญญีวิทยา วิทยาลัยแพทยศาสตร์กรุงเทพมหานคร และวชิรพยาบาล. Topic modules. Blood blank practices Indication to blood transfusion Complication

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Blood transfusion

Blood transfusion

พญ.เพชรรัตน์ วิสุทธิเมธีกร

พ.บ., ป. ชั้นสูงสาขาวิสัญญีวิทยา, วว.(วิสัญญี)

ภาควิชาวิสัญญีวิทยา

วิทยาลัยแพทยศาสตร์กรุงเทพมหานคร

และวชิรพยาบาล


Topic modules

Topic modules

Blood blank practices

Indication to blood transfusion

Complication

Alternative strategies for management of blood loss during surgery


Blood blank practices

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


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


Blood blank practices1

Blood blank practices

# Antibody screen : Indirect Coombs test

(45 mins)

the subject serum + red cells

( antigenic composition)----- red cell agglutination

# Type&screen

# Emergency transfusion


Type and screen vs Type and crossmatch

T&S -determines ABO and Rh status and the presence of most commonly encountered antibodies – risk of adverse rxn is 1:1000

-takes about 5 mins

T&C -determines ABO and Rh status as well as adverse rxn to even low incidence antigens – risk of rxn is 1:10,000

-takes about 45 mins


Type and screen vs type and crossmatch

:

Type and screen vs Type and crossmatch

T&S:

Type O red cells are mixed with pt serum Antibody screen

T&C

Type O red cells are mixed with pt serum Antibody screen

Donor red cells are then mixed with the pt’s serum to determine possible incompatibility


Blood blank practices2

Blood blank practices

All units – RBC @ PRC 1unit (250 ml Hct.70%)

--platelet@ 1 unit (50-70 ml, stored at 20-24c for 5 days)

--plasma @ FFP

--cryoprecipitate @ high conc. Of factor VII, fibrinogen


Intraoperative transfusion practices

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*( Hctตั้งต้น –Hctที่ยอมรับได้)/ Hctเฉลี่ย

Hct. 30% not magic number

Jehovah” s witness


Practice guideline

Practice guideline

$$ case series : reports of Jehovah witness; some may tolerate very low Hb< 6-8 g/dl in the perioperative period without an incresae in mortality


Practice guideline1

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 Hb> 10 g/dl and is almost always indicated when Hb< 6 g/dl

American Society Anesthesiologist : 1996



Intraoperative transfusion practices1

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 transfusionwith microvascular bleeding

Complications (PATCH) Platelets – dec,Potassium – inc., ARDS, Acidosis,Temp dec., Citrate intoxication, Hepatiti

>1 BV/ 24 HR> 50 % BV within 3 hrs > 150 ml/min

antithrombin III deficiency

TTP ( Thrombotic thrombocytopenic purpura )

Do not use for volume


Intraoperative transfusion practices2

Intraoperative transfusion practices

3.PLATELETS

**thrombocytopenia or dysfunction platelets in the presence bleeding

* prophylactic : plt.counts below 10,000-20,000

* prophylacticpreoperative : plt.counts below 50,000

*Microvascular bleeding in surgical patient with platelets < 50,000

*Neuro/ ocular surgery > 75,000


Intraoperative transfusion practices3

Intraoperative transfusion practices

  • *Massive transfusion with microvascular bleeding with platelets < 100,000

    • 2 BVs = 50,000

  • *Qualitative dysfunction with microvascular bleeding (may be > 100,000)

3.PLATELETS


Intraoperative transfusion practices4

Intraoperative transfusion practices

3.PLATELETS

50 ml: 0.5- 0.6 x 10 9 platelets (some RBC’s and WBC’s)

Single donor apheresis OR

Random donor (x 6)


Intraoperative transfusion practices5

  • 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 < 80-100mg/dL)

    • 2 BVs = < 100 mg/dL

  • Bleeding patients with vWD (or unresponsive to DDAVP)

Intraoperative transfusion practices


Alternative strategies for management of blood loss during surgery

Alternative strategies for management of blood loss during surgery

Autologous transfusion

Blood salvage & refusion

Normovolemic hemodilution


“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


คุณหมอขาตัวหนูแดงทั้งตัวแล้ว แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ


Transfusion reactions
TRANSFUSION REACTIONS แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

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


Transfusion reactions1
TRANSFUSION REACTIONS แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

@RBC’s !

  • 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)


Acute Hemolytic Transfusion Reaction แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

Pathophysiology

Ab (in recipient serum) + Ag (on RBC donor)

-Neuroendocrine responses

-Complement Activation

-Coagulation Activation

- Cytokines Effects

Acute hemolytic transfusion reaction


Acute hemolytic transfusion reactions
Acute Hemolytic Transfusion Reactions แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • Acute onset within minutes or 1-2 hours

    after transfuse incompatible blood

  • Most common cause is ABO-incompatible

    transfusion


Signs and symptoms of ahtr

Chills , fever แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

Facial flushing

Hypotension

Renal failure

DIC

Chest pain

Dyspnea

Generalized bleeding

Hemoglobinemia

Hemoglobinuria

Shock

Nausea

Vomitting

Back pain

Pain along infusion vein

Signs and Symptoms of AHTR


  • Anesthesia: hypotension, urticaria, abnormal bleeding แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


Laboratory investigation for ahtr
Laboratory investigation for AHTR แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


  • Delayed แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ: (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


@WBC’s! แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


  • TRALI ( แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะTransfusion related acute lung injury)

    • Donor Ab reacts with recipient Ag (1/ 10,000)

    • noncardiogenic pulmonary edema

    • Supportive therapy


Transfusion related acute lung injury trali
Transfusion-related Acute Lung Injury แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ(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


Transfusion related acute lung injury trali1
Transfusion-related Acute Lung Injury แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ(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


Transfusion related acute lung injury trali2
Transfusion-related Acute Lung Injury แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ(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


  • Transfusion-associated Graft-versus-Host แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะDisease ( TA-GVHD)

    • Rare: immunocompromised patients

    • Suggestion that more common with designated donors

    • BMT, LBW neonates, Hodgkin's disease, exchange Tx in neonates


Transfusion associated graft versus host disease ta gvhd
Transfusion-associated Graft-versus-Host แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะDisease ( TA-GVHD)

Pathophysiology

Infusion of Immunocompetent Cells

(Lymphocyte)

Patient at risk

proliferation of donor T lymphocytes

attack against patient tissue


Graft versus host reaction
Graft-versus-Host Reaction แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

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


@Platelets! แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

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


Immunomodulatory effects of transfusion แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


  • Cancer recurrence (mostly แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะretrospective)

    • 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


Infectious complications
INFECTIOUS COMPLICATIONS แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

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


NANB and Hepatitis C แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


HIV แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


HTLV I, II แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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)


CMV แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


II. Bacterial แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • Contamination unlikely in products stored for > 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 (Chaga’s disease)

  • Malaria

  • Toxoplasmosis

  • Leishmaniasis


Serological testing for infectious markers
Serological Testing แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะfor Infectious markers

  • HIV – Ag

  • Anti – HIV

  • HBsAg

  • Anti – HCV

  • Test for syphilis


Metabolic complications
METABOLIC COMPLICATIONS แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

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


Hyperkalemia แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • After 3 weeks, K+ is 25- 30 mmol/l

  • Only 8- 15 mmol per unit PRBC/ WB

  • Concern with > 1 unit/5 min @ infants


Acidosis แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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


2, 3 DPG แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • Depleted within 96 hours of storage

  • O2 Hb DC to left

  • Restored within 8- 24 hours of transfusion


E references
E. REFERENCES แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

  • 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.


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