BLOOD TRANSFUSION IN SURGERY

Dr kabiru salisuSurgery dept. AKTH

26th march, 2013

Introduction Donor selection and blood donation Blood component and their indications Pre-transfusion blood handling - blood grouping and compatibility testing - storage of blood - blood ordering Principles of blood administration Massive blood transfusion Autologous blood transfusion Complications and their management Blood substitutes Conclusion References

Out line

Process of administering blood or blood products into one’s circulation intravenous

Blood transfusion should only be considered when the benefit out weight the risk

Improvement in donor selection, blood screening and component isolation made BT a valuable tool for a surgeon

Introduction

Jean-Baptiste Denis 1667

Dr. Philip Physick 1825

Karl Landsteiner in 1900

Historical background

Homologous (Allogenic) blood transfusion when blood transfusion is done with blood

from another compatible donor of the same specie

Autologous blood transfusionAutologous blood transfusion is the collection

and subsequent re-infusion of the patient’s own blood

Classification

Donor selection involves History:

◦ Age 18-65years◦ Not in high risk group◦ No blood donation in past 6 months◦ No pregnancy within last 12 months, not lactating◦ No dental procedure in last 72 hours◦ No major surgery in past 6 months◦ No blood transfusion or organ transplant in past

12 months

BLOOD DONATION

◦ No tattoo or skin piercing in last 12 months◦ No needle stick injury or acupuncture in last

12month◦ Not vaccinated in last 4 weeks◦ No history of HIV infection, HBV, syphilis◦ Not on cytotoxics, hypoglycaemic agents, or

teratogenic drugs◦ Medical history: no HTN, DM, cardiac renal or liver

disease, cancer, bleeding disorder, SCD Examination

◦ Clinically stable◦ Weight >51kg◦ Normal BP, Pulse, chest and abdominal findings

Investigations◦ Hb 12.5g/dl or more (F), 13.5g/dl or more (M)◦ Seronegative for HIV I & II, HBsAg, HCV, VDRL

antibodies◦ No MPs◦ Negative for anti-CMV antibodies in some cases◦ Blood group

Severe haemorrhage following trauma or tumour

Preoperatively anaemia correction During major operation in which blood loss

is inevitable Postoperative anaemia To arrest haemorrhage or as a prophylactic

measure prior to operation in patients with haemorrhagic states

Anaemia from chronic surgical conditions

Indication for transfusion

1- Whole blood Contains all blood components

◦ Cellular element: RBC: 4.5-6.5 x 109/L (M), 3.9-5.6 x 109/L (F) WBC: 4-11 x 109/L Platelets: 150-400 x 109/L

◦ Plasma: clotting factors, proteins, electrolytes, gasses, glucose, minerals

Blood component and their indications

Fresh if collected and used within 3hours Use is limited to where fractions are not

available Indications-

◦ Sudden haemorrhage with loss of up to 20% of blood volume

◦ EBT◦ Lack of appropriate blood component

2- RBC Products Packed RBC:

◦ Obtained after centrifugation of whole blood at 3000r/m and removing the supernatant

◦ 1 unit increases Hb by 1g/dl in 70kg man◦ Indications Patients with chronic anaemia ElderlySmall childrenPatients prone to fluid overload & cardiac failure

Washed RBC:◦ Washed in saline to remove plasma proteins◦ Used in uncontrollable febrile or anaphylactic

reactions to plasma proteins◦ Shelf life is 24 hours

Irradiated RBC:◦ Gamma irradiation ◦ Indication is prevention of GvH disease in

Immunocompromised patients Intrauterine foetal blood transfusion

3- Platelet concentrates Obtained in 2 ways

◦ Manually: WB at 1000r/m for 3min , then supernatant at 3000r/m for 5min

◦ Automatically using processors Stored at 20-24oC with continuous agitation 5unit of WB give a pint Shelf life is 5 days Indicated Thrombocytopenia Consumptive coaglophaty Aplastic anaemia

4- Fresh frozen plasma WB- 3000r/m, separate and rapidly freeze

the supernatant for 8 hrs in CO2+ ethyl alcohol

Contains all components of coagulation and fibrinolytic system

Stored at -30 to -70 oC for up to 1 year Thaw at 37oC before use Dose= 10-15mls/kg

5- Cryoprecipitate

Is the precipitate when FFP is allowed to thaw at 4oC and the supernatant plasma removed

Rich in F8, F13, vWF, fibrinogen Stored at -30oC, shelf life is 12months

Indications haemophilia vonWillibrand’s diseas

6 - Granulocyte concentrates - These are prepared from single donors by

using cell separator Should be used within 24 hours (6hrs)

Indications for transfusion are uncommon Severe neutropenia <0.5 x 109/L Focal bacterial infection unresponsive

to antibiotics

Others Albumin concentrates Coagulation factor concentrates Immunoglobulins Anti thrombin III concentrate Protein concentrates

Pre transfusion blood handling

- storage of blood - blood grouping - compatibility testing - blood ordering

Standard blood bag contains 450 +/- 45mls blood, with 60mls of anticoagulant preservative

Stored at 2-6oC Anticoagulants include

◦ Heparin: 24 hours◦ Acid-citrate-dextrose (ACD) : 21 days◦ Citrate-phosphate-dextrose (CPD): 28 days◦ Citrate-phosphate-dextrose-adenine(CPDA): 35

days

Storage

RBC- - 1% cell population are lost per day of

storage - Viability decreases as ATP and 2,3 DPG

levels fall Increase affinity of Hb to O2 and

decrease O2 release at tissue level

Leucocytes and platelets-◦ Not viable after 24 hours of storage

Effects of storage

Electrolytes-◦ K+: plasma levels increase at rate of 1mmol/day◦ Na+: concentration increases because of the

sodium citrate in the CPD anticoagulant◦ Ca2+: no ionized calcium, it displaces sodium in

the anticoagulant forming unionized calcium citrate

pH-◦ Falls from 7.2 to about 6.8 at 20 days due to

increase lactic acid concentration from continuing anaerobic RBC glycolysis

Clotting factors-Activity of clotting factors fall after 24hrs

most lost activity after 7days

There are >30 major blood group system The most important blood group are the

ABO and Rh ABO system base on present of antigen A

or B Rh is base on presence of antigen D (Rh

factor) Other; Kell, duffy, MNS, lewis, kidda etc

Blood grouping

Blood group Antigen Antibody ( plasma agglutinin)

Donors

A Ag A Ab B A & O

B Ag B Ab A B & O

AB Ag A & B NONE ALL

o None Ab A&B O

ABO grouping

Cross matching is done to detect the rare Ags present on the recipient RBCs such as Kell, duffy

Plasma protein Ag capable of causing reaction can be detected

Compatibility testing

Maximal surgical blood ordering schedule ( MSBOS )

This is the system of blood ordering for elective surgeries

Blood bank know the standard require for each surgical procedure

For patient at high risk of bleeding extra pint are saved above requested

For patient with history of previous reaction or those fit can be arrange for PABD

Blood ordering

Should only be done when necessary Only what is needed should be given Indication should be clearly stated Counselling and consent Strict asepsis Doubly checked: name, age, hospital

number

Principles of blood administration

Check blood bag for damage, expiry date, discoloration of the blood

Pre transfusion vital signs IV line must be secure and patent before

opening the bag Warming with blood warmer when

necessary Administration must commence within

30mins of leaving the blood bank Monitoring is crucial esp. In 1st 30min

Determine volume to be transfused Use blood giving set, or infusion pump Symptoms of adverse effects usually occur

during transfusion of the first 100mls◦ Thus start at 20-30 d/m (2-3mls/min), then

increase to 60-80d/m after 1 hour◦ In children and elderly 40d/m

ADMINISTRATION AND RATE

The replacement by transfusion of bloodequivalent to or greater than a patient’s total

blood volume within a 24 hour period or

Replacement of more than half of the patient’s blood volume in 1 hour

Massive blood transfusion

Haemorrhagic shock fromTrauma eg #s, splenic ruptureRuptured aortic aneurysmMassive GI haemorrhageLiver transplant

INDICATIONS

1. Technical & clerical errors

2. Circulatory overload

3. Hypothermia

4. Hyperkalaemia

5. Hypocalcaemia (citrate toxicity)

6. Acidosis

7. ARDS

8. DIC

complications

1 - Platelet concentrate and fresh frozen plasma 1unit/5units of banked blood

2- 10mls of 10% Ca gluconate /L of blood

3- Fresh blood 1unit / 3unit of banked blood

precaution

Autologous blood transfusion is the collection and subsequent re-infusion of the patient’s own blood

1. Preoperative Autologous blood donation (PABD)

2. Acute Isovolemic Hemodilution

Autologous blood transfusion

1- Intra operative

Shed blood from a wound or body cavity during surgery is collected and subsequently re-infused into the same patient

blood Salvage

Methods of blood salvage should be Aseptic Anticoagulant filtration; 4-6 layers of gauze or special

filters Shelf life 4hrs at room temperature or

24hrs at 4o

Haemonetic cell savers can be use Contraindicated in tumour surgery,

contamination Complication;- Bleeding

2- post operative blood salvage

Blood shed after surgery can be collected and re-infuse to patient

Surgical procedure and autologous technique

IMMEDIATEREACTIONS I. Febrile non-haemolytic reaction 2. Allergic and anaphylactic reaction 3. Haemolytic reaction 4. Bacterial contamination 5. Circulatory overload 6 Cardiac arrest 7. Air embolism 8. Non-cardiogenic pulmonary oedema

complication

DELAYED REACTIONS 1. Thrombophlebitis.

2. Delayed haemolytic reaction.

3. Post-transfusion Thrombocytopaenic purpura

4. Transmission of diseases: (i) Viral hepatitis A, B, C, D (ii) Malaria (iii) Syphilis (iv) Cytomegalovirus infection (v) Trypanosomiasis (vi) Toxoplasmosis, brucellosis (vii) Infectious mononucleosis (viii) Variant Creutzfeldt-lacob Disease (vC1D). (ix) AIDS

5. Ironoverload(Transfusionhaemosiderosis)

6. Immunosuppression. Due probably to transfused leucocytes

7. Post-transfusion graft-versus-host disease

Include ◦ Plasma substitutes◦ Red cell substitutes◦ Platelet substitutes

BLOOD SUBSTITUDE

Plasma substitutes include◦Crystalloids: NS, RL◦Colloids: Dextrans- dextran 70, 40, 110 Gelatins- haemacel, gelofuscine

◦Stable plasma protein solution◦Albumin◦Hydroxyethyl starch preparations: Hetestarch, Pentastarch

Red cell substitutes◦ Diaspirin cross linked Hb: similar O2 transport and

exchange properties as whole blood◦ Perfluorocarbons: dissolve O2 and release to

tissues by diffusion◦ Encapsulated Hb◦ Stroma free Hb: high O2 affinity, nephrotoxic◦ Recombinant DNA derived Hb

Platelet substitute◦ Pegylated Recombinant Human Megakaryocyte

Growth and Development Factor (PEG-rHuMGDF)

Blood is a powerful therapeutic agent rational and judicious use is paramount

A surgeon must have have a sound knowledge on rational blood use

CONCLUSION

1. Badoe E. A; principles and practice of surgery, 4th edition

2. Morris P. J; Oxfort Text Book of surgery second edition, 2000

3. Courtney M. T; Sabiston Textbook of surgery 6th edition.

4. Drew p. & charles R. J; In Oxford handbook of clinical haematology, 2nd edition

5. Ganong W. F. In Review of Medical Physiology, 22nd edition.

6. Autologous blood transfusion, bloodindex.com7. M. Saleh Massoud M. D; Massive blood transfusion

Ain-Shams University

REFERENCES

Thank you