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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

slide4

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

slide6

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%)

[email protected] 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

slide20

“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

slide21

คุณหมอขาตัวหนูแดงทั้งตัวแล้ว แล้วคุณหมอเป็นไงบ้าง หัวบวมหรือยังคะ

transfusion reactions
TRANSFUSION REACTIONS
  • is any unfavorable transfusion-related event occurring in a patient during or after transfusion of blood components
transfusion reactions1
TRANSFUSION REACTIONS

@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)

slide24

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

acute hemolytic transfusion reactions
Acute Hemolytic Transfusion Reactions
  • 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

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
slide27
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
laboratory investigation for ahtr
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

slide29
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

slide30
@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
slide31
TRALI (Transfusion 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 (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 (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(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
slide35
Transfusion-associated Graft-versus-HostDisease ( 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-HostDisease ( 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

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

slide38
@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
slide39
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
slide40
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
infectious complications
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
slide42
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
slide43
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 < 16 days
slide44
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)

slide45
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
slide46
II. Bacterial
  • 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 Testingfor Infectious markers
  • HIV – Ag
  • Anti – HIV
  • HBsAg
  • Anti – HCV
  • Test for syphilis
metabolic complications
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
slide49
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
slide50
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
slide51
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.
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