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Progress and Future of Transfusion Medicine

Progress and Future of Transfusion Medicine. Shanghai Blood Center Qian Kaicheng. Guideline and Strategy of Transfusion Therapy. Progress and Future of Transfusion Medicine. Progress of Transfusion Medicine. Revealing Human Blood Circulation 1628 William Harvey

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Progress and Future of Transfusion Medicine

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  1. Progress and Future of Transfusion Medicine Shanghai Blood Center Qian Kaicheng Guideline and Strategy of Transfusion Therapy

  2. Progress and Future of Transfusion Medicine

  3. Progress of Transfusion Medicine • Revealing Human Blood Circulation1628 William Harvey • Animal-human transfusion1667 Dennis and Emmerrez • Human allogeneic blood transfusion 1818 England James Blundell • Revealing ABO （1900）、Rh type（1940） Karl Landsteiner • Blood anticoagulationindirect transfusion1915Richard-Citric acid anticoagulation1943 Mollison-ACD • Component blood transfusion • Evidence-based transfusion science—Rational transfusion

  4. Transfusion is Important • Blood transfusion was the first successful tissue transplantation • Blood transfusion is an indispensable supporting condition in modern medicine • Blood transfusion is an important carrier of future medicine

  5. Transfusion Medicine GB/T13745—2009《Subject classification and code》national standards Amendment No. 2 一、Under “320 clinical medicine”, adding secondary discipline 32032“transfusion medicine” 二、Under 32032“Transfusion Medicine”, adding three-level disciplines “Basic Transfusion、Donation Service、Transfusion Technology、Clinical Transfusion、Blood Transfusion Managementand Transfusion Medicine Others” National Standard Committee July 25th ,2016

  6. Transfusion Has Risk SHOT categories 1996-2016(n=18258)

  7.  Focus of Modern Blood Transfusion Medicine • Improving the curative effect of blood transfusion • Whole blood transfusion • Component blood transfusion • Rational blood transfusion • Reducing the risk of blood transfusion • Apply non - remunerated blood donation to eradicate benefit-driven blood supply • Developing blood borne Pathogens and Immunohematological detection techniques • Develop blood techniques such as blood pathogen inactivation, leukocyte filtration, γ-ray irradiation, etc. • Rational blood transfusion 钱开诚

  8. Legal Requirements of Rational Blood Transfusion • Law of the People's Republic of China on Blood donation（1998） Article 13 ：Medical institutions must check clinical blood use； Article 16 ：Medical institutions should draw up blood use plan for clinical use, follow the rational principal The State encourages the research and popularization of new techniques • Technical Specification for Clinical Blood Transfusion （2000） Article 2Blood resources must be protected and used rationally to avoid waste and eliminate unnecessary blood transfusions. Article 3Indication of blood transfusion should be strictly grasped by clinicians and transfusion technicians，Proper application of mature blood transfusion technology and blood protection technology, including component transfusion and autologous blood transfusion. • Measures for Management of Clinical Blood Use in Medical Institutions（2012） Article 1 In order to strengthen the management of clinical blood use in medical institutions, to promote the clinical rational use of blood, to protect blood resources and to ensure the safety and quality of clinical blood use, these measures are formulated in accordance with the Law of the people's Republic of China on Blood Donation. 钱开诚

  9. Rational Blood Transfusion • Based on evidence-based medicine and its derived viewpoint, guide clinical practice of blood transfusion, maximize the curative effect and minimize the risk, so as to obtain the best outcome of the disease.

  10. Progress of Rational Transfusion Theory • Component blood transfusion Whole blood separation，preparation of high concentration and high purity blood products. Transfusion therapy with different blood components according to the need of illness • Restricted application of blood components According to the patient's condition and limited transfusion indications ,apply corresponding blood components to achieve the expected hematological indicators. • Bloodless operation Case of “Jehovah's Witnesses”refuse transfusion provide clinical evidence of compensatory ability of organism to cope with anemia Treatment model of "bloodless operation" and "bloodless medical treatment" has been derived and proved to be feasible. • Blood protection Protection and preservation of patients' blood， Using appropriate techniques to prevent blood loss ，Avoid or reduce allogeneic blood transfusion as much as possible • Patient blood management

  11. Patient blood management（PBM） • PBM is a new concept of blood transfusion that has been widely accepted since the 21st century. Generally，based on evidence of evidence-based medicine research， with multidisciplinary technical approach ， carrying out overall management of patients' own blood and expected blood transfusion needs， so as to let the patient obtain the best outcome.

  12. No. 12 of the 63rd WHA (2010) Advocates the Implementation of PBM

  13. Major Views of PBM • Weighing the pros and cons of patients before blood transfusion • Careful and multidisciplinary assessment and management of patients' blood transfusion needs • Concept of restrictive blood transfusion and blood protection / Treatment plan that infuse allogeneic blood as less as possible. • Provide updated、correct、easy/whole information, including why take transfusion, determined benefit, accept(refuse) risk, as well as effective alternatives and informed consent • Try best to improve the hematological parameters of patients before surgery • Preoperative use of appropriate measures to improve hemoglobin levels and correct coagulation disorders • Minimization of blood loss due to the collection and testing

  14. Major Views of PBM • Avoid or reduce allogeneic blood transfusions as far as possible,if without adequate medical evidence • Reasonable arrangement of preoperative stored autologous blood collection and isovolemic hemodilution • Develop blood conservation strategies during anesthesia to optimize cardiac output, ventilation, and oxygenation during operation • Use blood free surgical techniques; use drugs, such as fibrinolytic agents, to minimize perioperative blood loss； • Monitoring, prevention and management of postoperative hemorrhage • Implementation of perioperative blood recovery when conditions meet

  15. PBM Summary • Multi-disciplinary and comprehensive assessment /management of patients' blood transfusion needs,non-transfusion intervention measures as far as possible .Promote hematopoiesis and correct anemia and coagulation function of patients. • Maximum control of blood loss • Priority given to auto-transfusion and blood replacement therapy • Rational application of allogeneic blood • Obtain the best outcome as far as possible QianKaicheng

  16. Progress of rational blood transfusion theory • Component blood transfusion Whole blood separation，preparation of high concentration and high purity blood products. Transfusion therapy with different blood components according to the need of illness • Restricted application of blood components According to the patient's condition and limited transfusion indications ,apply corresponding blood components to achieve the expected hematological indicators. • Bloodless operation Case of “Jehovah's Witnesses”refuse transfusion provide clinical evidence of compensatory ability of organism to cope with anemia.Treatment model of "bloodless operation" and "bloodless medical treatment" has been derived and proved to be feasible. • Blood protection Protection and preservation of patients' blood， Using appropriate techniques to prevent blood loss ，Avoid or reduce allogeneic blood transfusion as much as possible • Patient blood management Based on the evidence of evidence-based medicine research, a multidisciplinary technical approach is adopted to achieve the best outcome for patients in need of blood transfusion.

  17. Progress and Outlook of Clinical Transfusion Theory 20th century、modern medicine 21st century、 evidence-based medicine Based on the evidence of evidence-based medicine research, taking multi-disciplinary measures ,rational use of blood, best outcome of the patient is the focus. Based on the classical medical theory and practical experience, the application of blood and blood components,as well as the change of patients' hematological indexes are the focus

  18. Guideline and Strategy of Transfusion Therapy Shanghai Blood Center Qian Kaicheng

  19. Guideline and Development of Transfusion Therapy • Principle ofchoice if irreplaceable （“Strictly follow the indications of blood transfusion”principal） • Principle of satisfying physiological needs • Principle of risk aversion Qiankaicheng

  20. Influence from Theory Development to Clinical Stragery Measures of blood management for patients undergoing selective surgery Blood Transfusion treatment for massive blood loss -massive Blood Transfusion Blood component （replacement） therapy Risk of Blood Transfusion and countermeasures 。。。。。 20

  21. Rational Transfusion of RBC • Product of RBC to select • Indications of erythrocyte infusion • Infusion dosage • Assessment of the infusion effect 钱开诚

  22. Clinical Product of RBC to Select • Suspension RBC Remove the upper plasma and add additives • Leukocyte-depleted RBC Filtration • Washed RBC Repeatedly washed by Normal Saline • Frozen RBC 40% glycerin/below -65℃ • Irradiated RBC 25~30Gy r-radiation • Whole blood 钱开诚

  23. Not Suitable for Whole Blood • Cardiac insufficiency or failure • Chronic anemia with normal blood volume • Person in need of repeated blood transfusion • Plasma allergy • Existing anti-platelet or anti-leukocyte antibody • Potencial tissue/organ transplantation 钱开诚

  24. RBC Transfusion Indication Pathological condition of insufficient blood supply to tissues due to the decrease of hemoglobin level. • Acute hemorrhage  • Chronic anemia 钱开诚

  25. Acute hemorrhage -RBC Infusion Oxygen carrying capacity of RBC is 1.39 ml/g Hb, a small amount of oxygen is dissolved in the plasma, and the oxygen carrying capacity is actually 20 ml / 100 ml ,blood Cardiac output is 5 ~ 6L Arterial blood oxygen saturation is 98% and venous blood is 75% Compensatory response to acute hemorrhage • The oxygen utilization coefficient of tissue in quiescent state is 25% • Blood oxygen supply is about 1000ml/min • Tissue oxygen consumption is about 250ml/min • In acute blood hemorrhage, 2,3-DPG increase, resulting in decreased hemoglobin oxygen affinity • oxygen dissociation curve moves to the right • The oxygen utilization coefficient of tissue can be increased to 75% • P50in tissue up to15mmHg • Blood oxygen supply of 330ml/min （Hb50g/L), can meet quite condition（250ml/min） P50 钱开诚

  26. Acute Hemorrhage -RBC Infusion Compensatory response to acute hemorrhage • Physiological reserve RBC are released • Bone marrow erythrocyte production is enhanced From 15 ml /day to 50 ml/day • Liver albumin production is enhanced Up to 50 % Up to 400 – 500 ml plasma/day (normal adult liver produces about 12g of albumin per day, equivalent to 300ml of albumin in plasma) 钱开诚

  27. Indication and Dose of Acute RBC Hemorrhage Transfusion 钱开诚

  28. Chronic Anemia-RBC Infusion Compensatory response to chronic anemia • Increased cardiac output • Blood viscosity decreases and blood flow increases • 2, 3-dpg increases blood oxygen release in tissues • Bone marrow hematopoiesis • When Hb is less than 50%, there will be compensatory insufficiency QianKaicheng

  29. Indication and Dose of Chronic Anemia Transfusion • Indication ：Hb<70g/L, cause cannot be removed shortly， • Dosage accounting ： Wt x V x(expected Hb－pre-transfusion Hb ) RBC infusion units = total Hbper RBC unit Mark：Wt patient weight(Kg) V Blood volume per Kg，adult 0.07L/Kg.BW，infant 0.08L/Kg .BW total amount of Hb per unit of red blood cells was 24g (200ml whole blood preparation) Annex 4(guidelines for internal blood transfusion) to clinical blood transfusion specifications: transfusion may be considered when hemoglobin < 60g/L or hematocrit < 0.2.

  30. Example Male adult patients with anemia, weight 60Kg, Hb before transfusion was 60g/L. The expected Hb value is 100g/L 60×0.07×(100-60) RBC infusion unit= 24 The patient should transfuse 7 units products made from 200ml of red blood cell. 钱开诚

  31. Evaluation of Efficacy of Erythrocyte Transfusion • 24 hours after transfusion, check Hb value and recovery rate of HB Wt x V x (after transfusion Hb－pre-transfusionHb) Rate＝ ×100％ total infusion Hb • Evaluation • Recovery rate of hemoglobin >80% significantly effective • Recovery rate of hemoglobin >50-79% effective • Recovery rate of hemoglobin 20－49％ not effective • Recovery rate of hemoglobin <20％ no effect

  32. Countmeasures of Poor or Ineffective RBC Transfusion • Active hemorrhagic foci Control bleeding • Cause of anemia not removedTreatment • Immunehematologic factors Expert consultation

  33. 钱开诚

  34. 钱开诚

  35. American Society of Anesthesiologists 1. Transfusion is rarely indicated when the hemoglobin level is above 10 g/dL and is almost always indicated in patients when the hemoglobin level is below 6 g/dL; 2. The determination of transfusion in patients whose hemoglobin level is 6-10 g/dL should be based on the patient’s risk of complications due to inadequate oxygenation. 钱开诚

  36. Blood Transfusion and the AnaesthetistDr Dafydd Thomas Section 7 Guidelines for transfusion of red cells • Normally patients should not be transfused if the haemoglobin concentration is above10g／dl • A strong indication for transfusion is a haemoglobin concentration below 7g ／ dl • Transfusion will become essential when the haemoglobin concentration decreases to 5g ／ dl • A haemoglobin concentration between 8 and 10 g ／ dl is a safe level even for those patients with significant cardiorespiratory disease. • Symptomatic patients should be transfused. 钱开诚

  37. Rational Transfusion of Platelet • Optional platelet products • Indications and signs for platelet transfusion • Platelet infusion dose • Inefficacy of platelet transfusion and its treatment 钱开诚

  38. Optional Platelet Products • Conventional platelet • Platelet from multiple donors • Apheresis platelet • Oligocyte platelets 钱开诚

  39. Indications for Platelet Transfusion • Platelet dysplasia • Acute thrombocytopenia • Platelet dysfunction 钱开诚

  40. Indications for Platelet Transfusion Technical specification for clinical blood transfusion Annex 3 ： Surgery/trauma, platelet>10×1010/L， no transfusion platelet<5×1010/L， could transfuse platelet5~10×1010/L，depend on if active bleeding Technical specification for clinical blood transfusion Annex 4 ： platelet >5×1010/L， generally no transfusion platelet 1~5×1010/L， could transfuse platelet <0.5×1010/L， Immediate transfusion

  41. Platelet Infusion Dosage Platelet Infusion Dosage ＝(expected platelet value－ pre-transfusion platelet value)×surface area×2.5 Mark： weight(Kg)＋height(cm)－160 surface area(M2)=1＋ 100 2.5 for volume of blood （L） /surface M2 Platelet counting unitsplatelet value/L

  42. Evaluation of Efficacy of Platelet Transfusion Recovery rate of platelet transfusion (after-transfusion platelet value－ pre-transfusion platelet value)×W×0.07) PPR= total infusion platelet(1011)×F 注：platelet unit tansfer to 1011 F Correction factor for platelets actually entering circulatory blood after passing through the spleen normal spleen function F=0.62 no spleen F=0.91 splenomegaly F=0.23 • after-transfusion 1hr PPR>0.60 or after-transfusion24hr PPR>0.50，strongly effective • after-transfusion 1hr PPR0.3~0.6 or after-transfusion24hr PPR0.20~0.50effective • after-transfusion 1hr PPR<0.3 or after-transfusion24hr PPR<0.20, ineffective

  43. Reasons and Prevention of Ineffective Platelet Transfusion Reason Non-immune factors: hypersplenism, infection, high fever, DIC, etc Immune factors: HLA, platelet specific antigen, ABO Antigen – induced immune response Prevention Strict control of prophylactic platelet transfusion Select aphesis platelet  Select white blood cell free platelets

  44. Management of Ineffective Platelet Transfusion Donor select HLA matching donor  Platelet specific antigen matching donor Intravenous immunoglobulin infusion Plasma exchange

  45. Rational Plasma Transfusion • Available plasma products • Indications for plasma transfusion • Plasma infusion dosage • Plasmapheresis

  46. Available Plasma Products • Fresh frozen plasma (FFP) • Frozen plasma (FP) • Virus inactivates fresh frozen plasma • Virus inactivates plasma

  47. Indications for Plasma Transfusion • Acquired multiple coagulant factor deficiency • Congenital coagulant factor deficiency • Plasma exchange • Passive immunotherapy

  48. Several Implications for Plasma Applications • Plasma should not be used as the first choice to correct hypoalbuminemia • Plasma should not be used for supplementing nutrition • Plasma should not be considered as the best way to maintain the osmotic pressure and expand the blood volume

  49. Plasma Effect of Maintaining the Colloid Osmotic Pressure is Limited The expansion effect is not ideal Plasmapheresis effect was only 76%, and hemodynamic effect was not ideal (Ahnefeld 1965). Risk associated with blood transfusion • Transfusion-related infectious risk: HCV,HBV,HIV • Acute lung injury associated with blood transfusion • Allergic reaction

  50. Comparison of the Potency of Different Liquid Capacities

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