Download - Blood component therapy part I
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BLOOD TRANSFUSION AND
COMPONENT THERAPYDr.Indubala Maurya Assistant professor
Department of Anaesthesia & critical care MGMCRI
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Lecture Part 1 ( blood products and its uses ) Part 2 ( Complication of blood transfusion )
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What Is The Need For Transfusion
INADEQUATE O2 CARRYING CAPACITY - Anemia - Blood loss
INADEQUATE COAGULATION PROTEINS -To provide adequate homeostasis
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General Rules For Transfusion
Should not be the first choice Should have a policy regarding typing,
cross matching for those surgeries where it is not required
Autologous transfusion should be promoted
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Whole Blood Transfusion or
Component Therapy
Can give individual component for specific illness Patient does not require all the components This policy can benefit more than one individual
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One Unit Of Whole Blood One unit of RBC’S One unit of Platelets One unit of Cryoprecipitate One unit of Plasma (minus above 2 )
1 unit of whole blood = 450 ml blood 63 ml anticoagulant preservative
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Blood ComponentsCellular components Plasma components Plasma derivativesRed cell concentrate Fresh frozen plasma Albumin 5% and 25%Leucocytes-reduced red cells
Single donor plasma Plasma protein fractions
Platelet concentrate Cryoprecipitate Factor VIII concentrate
Leucocytes-reduced platelet concentrate
Cryo-poor plasma Other coagulation factors
Platelet apheresis Immunoglobulins
Granulocyte apheresis
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COMPATIBILITY TESTING
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Changes In RBC’s During Storage
Decrease in ATP (can be improved with glucose, phosphate & adenine)
Decrease in 2,3 DPG Hyperkalaemia , Acidosis in storage RBC lysis & decrease in Hb (6 weeks storage- RBC recovery 85%) Membrane damage making it difficult to penetrate microcirculation
( can be improved with Mannitol / Citrate) Decrease in viability ( shelf life of stored RBC’s is 35 – 42 days)
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Anticoagulants
AIM – To increase the RBC life, safety & overall effectiveness
1. CPDA (35 Days)2. SAGM- Saline ,Adenine , Glucose, Mannitol3. AS-1, AS-3 ,AS -5 ( Additive solution) (42 Days)4. Extended storage preservative solution containing - Dextrose - NaCl - Citric acid - Sodium citrate - Adenine and Mannitol
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Status Of Heparin
Though an anticoagulant ,but maintains viability only upto 24 – 48 hrs
MAIN USE - ECMO - Exchange transfusion
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LIGHT SPIN at 2000 rpm for 3 minutes at 22º
RESULT - Packed RBC - PRP
WHY LIGHT SPIN?
To avoid damage to Platelets Process required to be done within 6 hrs of whole blood collection Packed RBC’s are suspended in a hematocrit of 70% (CPDA-1) or 60 % ( AS -1 or AS- 3,5)
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HEAVY SPIN at 5000 rpm ,5 minutes & 4ºC
RESULT- PPP
Heavy spin → Damage to platelets
Volume → 200 – 400 ml per whole blood transfusion bag
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Platelet Poor Plasma (PPP)
FRESH PLASMA Prepared & infused within 6 hrs of preparation
FRESH FROZEN PLASMA Fresh plasma stored at -20ºC in a freezer
Is stable for 1 year
Both forms of PPP have all the Coagulation factors &
proteins
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High spin at 4 ºC to PPP
RESULT - Cryoprecipitate - Cryosupernant
Cryoprecipitate Concentrated source of Von- Willebrand factor, fibrinogen, Factor VIII
and fibronectin Stable for 1 year
Cryosupernant Remaining plasma after removal of cryoprecipitate
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Fresh Whole Blood
Packed Red Cells
Light spin, 22oC
Platelet Rich Plasma
Platelet Concentrate Fresh Plasma
Store at 22oC Freeze(FFP)
Heavy spin, 4oC
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Thaw at 4oC & heavy spin
Fresh Frozen Plasma
Cryoprecipitate
-Refrozen within 1 hr
-Store at < - 18oC
Cryoremoved Plasma
Freeze -80oC immediately
Stored at < -18oC
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VOLUME
WHOLE BLOOD → PPP → CRYOPRECIPITATE 450ml 250ml 10-20 ml
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Packed RBC’s
Most frequently required and used Benefit – Will increase amount of O2 delivery to tissues 1 unit PRBCs = 200 ml RBCs
100 ml additive solution
30 ml plasma Storage - 1ºC to 6 ºC Normally, 20 days viability in CPDA solution Post transfusion viability - 75 %
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Indications
Broadly Anaemia Haemorrhage
Other Indications Critically ill patients of sepsis and trauma Acutely bleeding patients - Rapid loss of > 15 % if preexisting Hb is < 10 gm / dl
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Indications contd….
Perioperative period - < 8 gm / dl without significant Heart, Lung, Vascular, Renal or Neural disease - < 10 gm / dl with significant underlying diseases
Patients of chronic Anemia - Hb < 8 gm / dl with evidence of CHF, Angina or Hypovolemia
Patients of marrow failure - Hb < 10 gm / dl with Leukemia, Lymphoma , Aplastic anemia
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Clinical Indications Of PRBCs Transfusion
SBP < 90 mm Hg Fall in SBP > 40 mm Hg within 4 hrs DBP < 40 mm Hg within 4 hrs Fall in DBP > 40 mm Hg within 4 hrs Heart rate > 100 bpm SpO2 < 90 mm Hg & PaO2 < 70 mm Hg
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Leucocyte Reduced Blood Components
WHY REQUIRED? Average unit of RBC’S contain 1 – 2 million WBC’s Average unit of platelets contain 50 million WBC’s Febrile and inflammatory reactions largely due to WBC’s
METHODS FOR REDUCTION Washing of RBC’s( Average life 24 hrs ) Leucocytes reduction filters
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Fresh Frozen Plasma (FFP)
Primary source of coagulation factors Most common blood component to be used irrationally in today’s
practice 1 unit of FFP = 200 – 250 ml plasma Expiry date 365 days Use – Thaw at 37 ºC for about 20 – 30 mins Once thawed , can be again stored for upto 24 hrs at 1- 6 ºC
SHOULD BE ABO COMPATIBLE OR IDENTICAL
CROSS MATCHING NOT REQUIRED
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Indications
Congenital coagulation factor deficiencies except VII ,VIII, IX or Von Willebrand disease
Acquired coagulation problems like liver disease, Vit. K deficiency
In massive blood transfusion to provide clotting factors Treatment of TTP Dose = 10 – 20 ml / kg 1 unit of FFP = ↑ in factor levels by 3 -5 %
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Cryoprecipitate
1 bag of cryoprecipitate = 250 mg of fibrinogen
15 – 20 ml plasma
Von Willebrand factor (IX)
80 – 130 units of factor VIII
Fibronectin
Factor XIII 20 -30 % Expiry date= 365 days Once thawed , use in 4 hrs
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Indications
Congenital / Acquired Hypofibrinogenemia
Congenital / Acquired Factor VIII deficiency
Secondary choice in Uraemia
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Platelets
CERTAIN FACTS Aphretic platelets collected from a single donor contains platelets
equivalent to 6 - 8 whole blood derived platelet concentrates Storage – 20 – 24 ºC ( Never refrigerate) Expiry – 5 - 7 days Use Platelet filters and not routine blood filters
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Indications
Blood platelet count < 50,000 /μl and evidence of significant active bleeding
Thrombocytopenia DIC Dengue Platelet count <10,000 /μlt without evidence of bleeding Bone marrow failure Functional platelet defect & bleeding Dose – 1 unit = ↑ 5000 – 10000 platelets in patient 5 -6 unit = 1 aphretic unit
NO CROSS MATCHING REQUIRED
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Transfusion Triggers
The RBC , transfusion triggers is a term used to describe, the set of circumstances under which transfusion is reasonable and for which no further justification is needed.
WHY the word TRIGGER ?
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Transfusion Triggers contd…Two type of Physiological Triggers
1) Invasive Triggers
2) Non invasive Triggers
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Invasive Triggers1. Mixed venous O2 (PVO2) The rate of a fall is more important
2. Mixed venous O2 saturation ( SVO2) Declines rapidly when haematocrit falls below 20 %
3. Oxygen uptake VO2 In sepsis and low perfusion not a true indicator as DO2 is normal but due to low pressure VO2 is reduced. Will transfusion benefit here?
4. Oxygen extraction ratio O2 ER If it is > 50% , decompensation is imminent . Usually happens at H’crit of 10%
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Non invasive Triggers
DO remember1. Minimum Hb reqd to have adequate DO2 for
isolated tissue is 3-5 gm/dl.2. In healthy people, acute normovoluemic
hemodilution can be safely tolerated upto 5 gm /dl.
3. Transfusion is reqd usually at Hb < 7 gm/dl.4. Transfusion is unjustified at Hb >10 gm /dl.5. Duration of Anemia.
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ASA Guidelines for Blood Component Therapy
RBC’s-Rarely for Hb>10 g/dl Usually for Hb<6g/dl Decision based on risk for complications related to inadequate oxygenation
Platelets-Rarely for PLT>100,000 Usually for PLT<50,000 For PLT between 50,000 and 100,000 decision based on assessment of risk
FFP-Microvascular bleeding present and PT or PTT is 1.5 times normal .Condemns use for volume replacement
Cryoprecipitate- Consider for fibrinogen levels < 80 mg/dL orwhen levels can not be rapidly obtained
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Maximum Surgical Blood Ordering Schedule (MSBOS)
List of procedures performed in a hospital together with recommended quantity of RBC units to cross match , based upon the utilization data specific to that hospital
CROSS MATCH : TRANSFUSION ( C:T) ratio Should not exceed 2 :1
GROUP AND SAVE Procedure where transfusion is not reqd
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Blood Sparing Strategies
Transfusion is either
Autologous or Homologous ( Allogenic )
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Sparing Strategies in Preoperative Period
Diagnosing and effective treatment of preexisting ailments like Iron deficiency anemia, bleeding disorders.
Review of Anticoagulant therapy
Adoption of MSBOS
Utilizing Cell salvage.
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Sparing Strategies in Intraoperative Period
Careful positing to reduce venous congestion To maintain Normothermia If possible controlled Hypotension Appropriate use of Diathermy , laser Utilizing cell salvage Following Transfusion Triggers
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Autologous Blood Harvesting
A) Predeposit Autologous Blood Donation( PABD)
B) Acute Normovoluemic Hemodilution (ANH)
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PABD Patients visit 6 weeks in advance to
donate blood Blood donation 1 per week Blood donation stops 3 weeks before
surgery Iron therapy is integral to PABD No PABD 72 hrs before surgery Usually 2 units sufficient
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Contraindications to PABD
1) If HB < 11 gm /dl2) More than 6 units reqd3) Comorbidity e.g cardiac disease 4) Patient having infectious disease markers
Since maximum allowed storage interval for RBC is 6 weeks , hence PABD is executed 6 weeks in advance.
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ANH Removal of whole blood , replacement
with acellular fluid shortly before anticipated blood loss
Done after Induction of Anesthesia and before start of surgery
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Advantages of ANH
1) Reduced Absolute RBC loss2) Unit with patient ; no wrong transfusion3) No microbiological testing reqd4) No risk of hemolytic reaction
Caution: Should be restricted to patients with sufficiently high Hb, who can withstand 1 lt of whole blood to be taken out and in whom low target Hb is deemed appropriate
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Cell Salvage
INTRAOPERATIVE / POSTOPERATIVE Shed surgical blood is suctioned under low pressure into a reservoir
filled with saline Then washed & filtered & returned to patient Can be given upto 6 hrs at room temperature Cost effective if loss is > 1000 ml
CONTRAINDICATIONS Malignancy Leakage of bowel contents in surgical field
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Pharmacological Blood Sparing Strategies
ERYTHROPOIETIN- 300 U /kg x14 days
or 600 U / kg thrice a week
APROTININ ( Serine protease inhibitor) – 2 million loading
0.5 million units / hr
High risk of Anaphylaxis to reexposure
TRANEXAMIC ACID – 10 – 15 mg / kg prior to release of tourniquet
DESMOPRESSIN – Mainly for Haemophilia, Von Willebrand disease
FIBRINOGEN – ( Combination of bovine thrombin & human fibrinogen)
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Adverse Transfusion Events
Classified into
Immediate
Delayed
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Immediate Further divided into A – Immunological1) Haemolytic transfusion reaction
2) Febrile nonhemolytic transfusion reaction
3) Allergic reactions
4) Anaphylaxis
5) TRALI
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ImmediateB - Non Immunological1) Bacterial contamination
2) Circulatory overload
3) Metabolic complications
4) Non immune haemolysis
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DelayedA – Immunological1) Delayed haemolytic tranfusion reaction2) TAGVHD3) Post transfusion Purpura (PTP)4) Alloimmunization
B - Non Immunological1) Iron overload2) Transfusion transmitted diseases
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Acute Haemolytic Transfusion Reactions
1) Intravascular Haemolysis
2) Extravascular Haemolysis
3) DIC
4) Renal failure
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Intravascular Haemolysis (IVH)
Mediated by classical pathway of Complement system
Signs Sudden drop in B.P
Haemoglobinuria
Haemoglobinaemia
No rise in haematocrit
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Extravascular Haemolysis (EVH)
Antibody mediated or Complement mediated cell destruction in RE system
Generally life threateningSigns Falling Haematocrit Increased unconjugated bilirubin Abnormal peripheral smear a ) Polychromasis b) Spherocytes May lead to I/V heamolysis
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Extravascular Haemolysis (EVH)CAUSE Exposure to patient through previous - Pregnancy - Transplant - Transfusion Generation of antibodies in response to incompatible Antigens
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Febrile Nonhemolytic Transfusion Reaction
Most common Adverse effects Increase in temperature of > 10c over base line during
transfusionCause1) Formation of Antibodies in recipients against donor WBCs
and Platelets2) Release of bioactive substances like Interleukins,
Cytokines in the blood
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Transfusion Related Acute Lung Injury ( TRALI)
Rapid onset of respiratory distress, noncardiogenic pulmonary edema and hypoxia occuring during or soon after transfusion
CAUSEDue to the presence of A) Anti HLA antibody in the plasma of donor B) Antigranulocyte antibody in the plasma of donor
leads to complement activation and increased pulmonary vascular permeability
Agent - Any plasma containing blood product
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TRALIDefinitionNew acute lung injury occurring during or within 6 hours post transfusion with a clear temporal relationship to the transfusionNorth American European Consensus Conference Criteria Acute Hypoxemia PaO2/ fiO2 ≤ 300 mm Hg B/L infilterates in the absence of circulatory overload Edema fluid to plasma protein ratio > 0.6
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Limitations
1) Not possible to differentiate between ALI and TRALI2) No specific lab tests3) Limit of 6 hrs may exclude cases developing later
TreatmentOn the lines of ARDS
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Anaphylactic Reactions
More commonly observed in Patients of hereditary IgA deficiencyPatients having IgG antibodies to infused
allergens
RemedySaline washed RBCs for future transfusions
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Immediate Immunological Reactions
CLINICAL PRESENTATION Chills with fever, nausea, chest tightness Pain at I/V site, abdomen, joints Tachycardia, tachypnea Hypotension, diffuse bleeding Shock, renal failure
CLINICAL PRESENTATION UNDER ANAESTEHSIA Hypotension Dark urine Generalized ooze
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Immediate Immunological Reactions
Lab Diagnosis Send blood back for repeat typing and cross
match
Rising serum bilirubin
Urine for heamoglobinuria
Chest X ray if TRALI is suspected
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Immediate Immunological Reactions
Management Oxygen by face mask/ Intubation (TRALI) Catheterization Continuous vital monitoring Furosemide (if BP normal) Epinepherine/ corticoids if anaphylaxis suspected Maintain urine output between 30-100ml/hr
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Aquired Diseases
Incidence getting less due to effective screening HIV 1 & 2 Hepatitis B & C Syphilis CMV Lyme Malaria Filaria
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TA GVHD
Due to transfused immunocompetent lymphocytes against immunocompromised host
Rapid course Average mortality- 90 % Treatment – Gamma irradiated blood products by
exposing WBC’s to 1500 rad to 5000 rad Not much effect on RBC’s Platelet survival decreases by 30 % at higher doses
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Metabolic Complications Clinically significant depletion of coagulation
proteins & platelets occur in stored blood leading on to
- Hypothermia - Hyperkalaemia - Hypocalcemia - DIC 8 – 10 units of red cells infused in a patient may
lead to fall in the level of coagulation proteins to 25 % of normal
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Delayed Hemolytic Transfusion Reactions
Occuring > than 24 hrs post transfusion Previous transfusion primes the patientSigns & Symptoms Within 4 – 14 days of transfusion Progressive unexplained fall in hemoglobin Low grade fever Unconjugated hyperbilirubinemiaTreatment Self limiting till clearing of all RBC’s
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Post Transfusion Purpura More in females 5 – 9 days post transfusion Due to platelet specific alloantibodiesTreatment High dose IV IgG( 2 gm/ kg over 5 days) Platelet transfusion though not effective may be
required for bleeding Steroids ? Plasma exchange?
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Massive Blood Transfusion(MBT)
Replacement of one blood mass in a period of 24 hrs Transfusion of 4 or more red cell concenterates with
in 1 hr Replacement of 50% of total blood volume with in 3
hrs Rate of infusion > 1 unit in 10 minutesIndication Hypovolemic shock secondary to blood loss
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Complications Of MBTPhysical Hypothermia Hemodilution Metabolic - Hyperkalemia –Plasma K+ levels in the stored blood increased by 1 mEq/ l /day - Citrate toxicity(3 gm / unit) - Acidosis - Alkalosis( 1 ml citrate = 3 mEq HCO3)
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Complications Of MBT
Physiological Left shift of ODC
Decrease of labile coagulation factors
Dilutional Thromocytopenia
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Citrate Toxicity
May lead to Hypocalcaemia
Look for total calcium : ionized calcium ratio (Normal 2:1)
If low give 10 – 20 ml 10 % calcium gluconate
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Thank you