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Blood Transfusion

Blood Transfusion. Dr Dupe Elebute MD, MRCP, MRCPath Consultant in Haematology and Transfusion Medicine. Objectives. Blood components Ordering blood & MSBOS Risks of blood therapy Adverse reactions Massive blood transfusion. Blood - Where From?. Human source - no synthetics yet

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Blood Transfusion

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  1. Blood Transfusion Dr Dupe Elebute MD, MRCP, MRCPath Consultant in Haematology and Transfusion Medicine

  2. Objectives • Blood components • Ordering blood & MSBOS • Risks of blood therapy • Adverse reactions • Massive blood transfusion

  3. Blood - Where From? • Human source - no synthetics yet - not risk free • Scarce resource • 1 donor can give 1 unit every 4 months • Need 10,000 units of blood/day in U.K. • Use carefully!

  4. When To Use Blood? • Balance between benefits vs risks • Doctor’s decision • Definite indication must be recorded in the patient’s medical records • Correct anaemia pre-operatively • Try to reduce unnecessary exposure to blood products

  5. Blood components • Unpaid, volunteer donor • Pooled products • Single donations by apheresis

  6. Blood donors • Medical selection process to protect both recipients and donors • Minimum age: 17 years • Maximum age: 70 years (60 for first time donations) • Donor deferral system

  7. Blood donations Tested in the UK for: • Hepatitis B, C • HIV-I, II • Syphilis • ABO and RhD blood group • ?vCJD  universal leucodepletion

  8. Blood components available in the UK

  9. Preparation of Blood Components

  10. Blood components issued in the UK (2001-2002) • Red cells 2,683,463 • Platelets 251,451 • Fresh frozen plasma 385,236 • Cryoprecipitate 88,253 TOTAL 3,408,402

  11. Red cells • Whole blood (450ml; PCV 0.35-0.45) • <1% used as ‘whole blood’ in UK • Deficient in labile clotting factors • Packed red cells (350ml; PCV 0.55-0.75) • Stored at 2-6 ºC for up to 35 days • 1 unit -> Hb rise by 1g/dl in adult • New Hb trigger of 8g/dl

  12. White cells (granulocytes) • Very rarely used in the UK • Only for severe infections in neutropenic patients unresponsive to antibiotics/antifungal Rx • Transfused as ‘buffy coats’ or collected by apheresis

  13. Platelet concentrates • Adult single dose (1 pool): 300 x 109/L • Stored at room temperature for up to 5 days (kept agitated) • Obtained in two ways: • Pooled platelets from 4-5 single donations • Single donor platelets collected by cell separator machine (apheresis)

  14. Platelet concentrates (2) Indications for platelet transfusions: • Bone marrow failure (aplastic anaemia) • Post chemotherapy, BMT • Massive blood transfusion (dilutional) • Platelet dysfunction (CABG, aspirin)

  15. Fresh frozen plasma (FFP) • Stored frozen at –30ºC for up to 1 yr • Not routinely virally inactivated in UK • To be sourced from USA (volunteer, non-transfused male donors) • Provides replacement for most coagulation factors • Methylene blue FFP for neonates and children born after 1st January 1996

  16. Fresh Frozen Plasma (2) • Essential to give adequate volume • Dose: 12-15ml/kg • ABO compatible • Definite indications only: • Massive blood transfusion • DIC • Coagulation defect with no available factor concentrate

  17. Cryoprecipitate • Separated by freezing FFP, allowing it to thaw to 4-8ºC • Re-frozen & stored at –30ºC for up to 1 yr • Enriched with FVIII, vWF and fibrinogen • Indications: • DIC • Fibrinogen deficiency

  18. Plasma products • Albumin • Factor VIII concentrate • Factor IX concentrate • Human Ig Blood products derived by fractionation of plasma:

  19. Ordering blood • Can only be done by a registered medical doctor • Weigh up advantages vs risks! • Consider alternatives • Take blood sample for ‘group & screen’ • ABO and RhD group • Screen for antibodies

  20. ABO Blood Groups † O  B blood:

  21. RhD Group Antibody

  22. Blood sampling • Label request form with: • Patient’s surname • Patients first name(s) • Date of birth (not age) • Hospital number (or A&E number) • Label sample bottle at bedside • Addressograph labels must not be used

  23. Patient identification • Positively identify conscious patient by asking him/her to state their name and date of birth • Check information against patient’s identification wrist band

  24. Record in hospital notes • Reason for blood transfusion • Blood loss • Nature of surgery • Pre-transfusion Hb • Number of units to be transfused • Planned date (and time) of transfusion

  25. Maximum Blood Order Schedule • Pre-operative schedule of units to be cross-matched for each surgical procedure • Clear guidelines in Transfusion handbook • Blood sample still required 24 hours pre-op to check for antibodies • Does not apply to emergencies; acute bleeding; patient known to have red cell antibodies

  26. Risks of blood transfusion • Infections: - hepatitis B, C - HIV I & II - bacteria - protozoa (malaria) - vCJD (?) • Transfusion reactions • Immunological reactions • Getting the wrong blood!

  27. Overview of 478 cases from SHOT report 2001-2002

  28. Distribution of errors (n=552) from SHOT report 2001-2002

  29. Transfusing blood Inform patient! • Indication • Benefits • Risks • Alternatives

  30. Transfusing blood (2) • Check blood!! A. Check blood pack against patient’s wrist band B. Check blood pack against pink blood bank form

  31. The final check! • Must be done at the bedside • Must be done by TWO people • Must NOT be done by untrained staff • If any discrepancy is found: • Do NOT transfuse blood • Inform blood bank immediately

  32. Adverse effects of transfusion • Immunological reactions: • Immediate (ABO incompatibility, TRALI) • Delayed (DHTR, PTP, GvHD) • Non-immunological: • Immediate (Bacterial, fluid overload) • Delayed (e.g. viral infections, malaria)

  33. Transfusion Reactions • Acute haemolytic: • Incompatible blood; can be fatal • Febrile non-haemolytic: • Due to cytokines from transfused WBCs • Acute bacterial infection • Allergic/urticarial

  34. Transfusion Reactions (2) • Fever >38ºC • Rash • Rigors • Acute haemolytic specific: • Hypotension, loin pain, dark urine • Febrile non-haemolytic specific: • Urticaria, pruritis

  35. Transfusion Reactions (3) • STOP the transfusion (spigot off) • Using a new giving set, keep line open with normal saline • Check I.D of patient, bag and cross-match form • Refer to handbook for further management

  36. Massive blood loss • Any blood loss >2L (SGH) • Medical emergency • Usually occurs in A&E, operating theatre or obstetric department • High morbidity & mortality from: • Underlying cause of haemorrhage • Pre-existing disease (liver, renal) • Complications of massive blood transfusion

  37. Massive Blood Loss (2) • Ensure adequate venous access • Attempt to maintain blood volume with saline/plasma expanders • Inform blood bank • Send 2 group & X-match samples • If ‘flying squad’ blood used, inform BB

  38. Massive Blood Loss (3) • Call Blood Bank for : “Code Red” “Code Blue” - Obstetric patients • Necessary blood products issued automatically • Haematology SpR will co-ordinate

  39. Code Red Procedure Blood components issued: • First Stage • 6 units blood • 1 litre FFP • 2 pools platelets

  40. Code Red Procedure (2) Second Stage • 6 units blood • 10 units cryo if fibrinogen <0.8g/l • 2 pools platelets if count <100 x 109/L • Send blood for repeat FBC, chemistry, coagulation screen

  41. Complications of Massive Tx • Hypothermia • Hypokalaemia • Hypocalcaemia • Acidosis • ARDS • Monitor U & Es Calcium, arterial pH • ECG, CXR

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