Blood and Blood Products [Autosaved].pptx

Blood and Blood Products

1. Blood and Blood Products

2. Introduction Blood is a specialized type of connective tissue, in which living blood cells are suspended in a non-living matrix called plasma. Total blood volume – 5-6 liters ( 8% of body weight or 80ml/kg ) Specific gravity- 1050-1060 Viscosity- 4-5 times of water pH 7.4 ± 0.05 alkaline

3. Blood components

4. Functions of blood

5. History of blood transfusion 1665  The first recorded successful blood transfusion occurs in England: Physician Richard Lower keeps dogs alive by transfusion of blood from other dogs. 1818  James Blundell performs the first successful blood transfusion of human blood to treat postpartum hemorrhage. 1840  The first whole blood transfusion to treat hemophilia is successfully completed. 1900  Karl Landsteiner discovers the first three human blood groups, A, B and O . 1907  Blood typing and cross matching between donors and patients is attempted to improve the safety of transfusions. The universality of the O blood group is identified. 1914  Adolf Hustin discovers that sodium citrate can anticoagulate blood for transfusion, allowing it to be stored and later transfused safely to patients on the battlefield.

6. 1932  The first blood bank is established at Leningrad hospital. 1939-1940  The Rh blood group is discovered and recognized as the cause behind most transfusion reactions. 1960-1980s- Transfusion therapy was characterized by giving the patient only the component of blood that was needed. 1990-2000 - The focus of blood product safety towards noninfectious serious hazards of transfusion. Like hemolytic transfusion reactions, transfusion-related acute lung injury (TRALI), and transfusion-associated circulatory overload (TACO) 2010 onwards- not just correcting anemia and coagulopathy, there is advancement of Blood Management defines PBM as “the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcome.

7. Donors, testing and storage There are risks associated with both donating and receiving blood, but these can be minimized by good practice.

8. Blood Testing The blood that is collected is identified for blood type (ABO and Rh), but is also tested to minimize the risk of transmissible infections. The World Health Organization recommends four core tests as a minimum, which are: Hepatitis B Surface Antigen Antibody to Hepatitis C Antibody to HIV, usually subtypes 1 and 2 Serology for Syphilis

9. Blood grouping determined by the antigens carried on the surface of red blood cells. There are as many as 30 different blood groups, but the main ones are the ABO and rhesus groups(D)

10. Storage Short-term storage of blood – with combination of refrigeration and the addition of preservatives. Standard temperature used is 1°- 6°C, Preservatives- acid-citrate-dextrose (ACD), citrate-phosphate-dextrose (CPD) or citrate-phosphate-double dextrose (CP2D), the storage is limited to 21 days -citrate-phosphate-dextrose-adenine (CPDA1) this can be extended to 35 days. RBCs can be stored for much longer periods, even up to 10 years, by freezing (cryopreservation). This requires the cells to be incubated in a glycerol solution which acts as an intracellular "antifreeze", so protecting against damage. The units are then placed in special sterile containers and frozen to below -60°C. The exact temperature depends on the glycerol concentration used.

11. Changes seen in stored blood Despite refrigeration and the addition of preservatives, the quality of donated red blood cells deteriorate over time as predictable cellular and biochemical changes occur, that result in the ‘storage lesion’ of banked blood. Blood cells RBCs subjected to an acidic and hypotonic anticoagulant solution -damages a small proportion of them irreversibly. Their shelf life requires that at least 70% of them remain viable in the recipient’s circulation 24 hours after transfusion. Other cellular elements, Granulocytes become non-functional after 24 hours of storage, but still retain antigenic potential to cause febrile reactions. Some lymphocytes may remain viable for several weeks. Platelet function declines to zero after only 48 hours of storage

12. Blood products

13. Separation of whole blood Slow spin Fast spin Freeze @ -80 ċ Filters Thawing Freeze @ - 20 ċ Freeze @ - 70 ċ

14. Whole blood Donor blood + anticoagulant Anticoagulant- CPDA C- citrate –for anticoagulation P-phosphate- as buffer D- dextrose- A- adenine- to maintain ATP and RBC membrane integrity Rich in coagulation factors Hematocrit- 45% Stored at 2-6 ċ Shelf life- 35 days

15. Indications- ASA 2006 Guidelines 1. Transfusion is rarely indicated when Hb is greater than 10 g% and is almost always indicated when it is less than 6 g%, especially when the anemia is acute.   2. The determination of whether intermediate Hb (6 to 10 g%) justify or require RBC transfusion should be based on the patient's risk for complications of inadequate oxygenation.    3. The use of a single Hb, as “trigger” for all patients and not considering the important physiologic and surgical factors affecting oxygenation is not recommended.   4. When appropriate, measures to decrease blood loss may be beneficial.   5. The indications for transfusion of autologous RBCs may be more liberal, because of less frequent (but still significant) risks associated, than for allogeneic RBCs.

16. Packed RBC Obtained by apheresis/ prepared from anticoagulated blood, following centrifugation 1 unit- 200ml RBC, <50ml plasma, 55-60% hematocrit Shelf life- 21-42 days at 1-6 ċ Dosage- Each 2 units or 15 ml/Kg increases Hb by 2 g/dl . Transfused after 30mins of procuring till 4hrs at room temperature

17. Leukocyte poor red cells Prepared during procuring blood or at the time of transfusion by Using specially designed filters Residual WBC count < 5000 WBCs. Indications • to prevent nonhemolytic febrile reactions • to reduce HLA antigen alloimmunization • Prevent transmission of CMV and TA-GVHD.

18. Washed RBC Packed RBC obtained by centrifugation are washed with saline by: – Manual batch centrifugation – Continuous flow separation Removes ≥ 98% plasma proteins, electrolyte and antibodies Indications Hypersensitivity to plasma Pts with recurrent allergic reactions To decrease quantity of metabolic breakdown products, extracellular potassium and CMV transmission.

19. Frozen RBC After addition of cryoprotective agent (10% glycol), RBC may be stored continuously below freezing temperature – 80 C. Shelf Life : 3–5 years. Advantages Ready supply of RBC Freezing arrests biochemical changes Decreases incidence of non-hemolytic reactions, sensitization to HLA

20. Platelet preparations Apheresis platelets- SDP Platelet concentrates- RDP Lymphocyte depleted platelets Ultraviolet B irradiated platelets ABO compatible platelets should be transfused where possible . Can transmit viruses including CMV Should be transfused within 30 min. Stored at 20-24°C. Survival time is 1 to 7 days. 170mm filters should be used for transfusion.

21. RDP Prepared from whole blood by centrifugation 5.5*10 10 platelets in 50 ml plasma Stored at- 20-24 ċ under continuous agitation for 5 days 5-6 RDP= adult dose platelets 1 unit of RDP increases platelets by 7000-10000cells/mm 3 SDP From single donor by apheresis 3*10 11 platelets in 200-400 ml plasma Stored at 20-24 ċ under continuous agitation for 5 days 1SDP= 4-6RDP 1 unit of SDP increases platelets by 30000-60000 cells/ mm 3

22. Indications- ASA 2006 Guidelines Platelet count < 10, 000/mm3 in non-bleeding patients, without other abnormalities of hemostasis Platelet count 10,000 to 50,000/mm3 for: regional anesthesia, Central venous access, Endoscopy with biopsy, Vaginal delivery, Laparotomy, and to maintain same platelet count or > 50,000/mm3 during DIC with ongoing blood loss. Platelet count 75,000/mm3 : during management of massive blood loss Platelet count 1,00, 000/mm3 : Intended procedures where closed cavity bleed may be especially hazardous (neurosurgery) Microvascular bleeds due to platelet dysfunction

23. Plasma Types •FFP: When fluid portion of centrifuge is thawed within 6 to 8 hours •FP24: – Plasma frozen 24 hours after phlebotomy – Comparable to FFP except a 25% reduction in factor VIII and V levels. Manufacture • Obtained by apheresis/separation of plasma from centrifuged whole blood. • Plasma is frozen at –20 C within 6 and 8 hours of collection (FFP) or within 24 hours (FP24) •Each unit of FFP prepared from 1 unit of blood will have 200 to 250 ml. Shelf Life - 1 year frozen and 24 hours thawed

24. Contents • Factors IV, V, VII, VIII, IX • Especially rich in factors V and VIII (contains 1 IU/ml of each factor) • Protein C, S and antithrombin III • Electrolytes, albumin, immunoglobulins and complement. Indications Reversal of warfarin therapy Heparin resistance Replacement of isolated factor deficiency Massive blood transfusion

25. Dosage •10–15 ml/kg FFP to achieve minimum of 30% coagulation factor concentration: If used for clotting factor deficiency therapy • 5–8 ml/kg of FFP for reversal of warfarin therapy • 1 unit of FFP provides coagulation factors equivalent to: 4–5 units of platelet concentrates, 1 unit of apheresis platelets, 1 unit of whole blood • Fresh Frozen Plasma need not be of the same Rh type • For example, A +ve FFP can be given to A –ve patient.

26. Cryoprecipitate Prepared as cold insoluble precipitate by thawing FFP at 4 C and removing supernatant 1 unit of cryoprecipitate= 10-20ml Contents Principally factor VIII, XIII (80 IU of VIII and 40–60 IU of XIII) VWF 80 IU 100–250 mg of fibrinogen, fibronectin Trace of other plasma protein Antibodies in cryoprecipitate is very low.

27. Dosage 10 U or 1 U/5 kgs increases fibrinogen by 50 mg/dl Units are usually pooled in order to facilitate transfusion (5–10 U/pool) ABO compatible units preferred but it is not very important as concentration of antibodies in cryoprecipitate is very low Cryoprecipitate need not be group specific Should be administered through a filter as rapidly as possible, at least 200 ml/hour Infusion should be completed within 6 hours of thawing

28. Targets of resuscitation MAP of 60 to 65 mm hg Hb 7 to 9 gm/dl INR < 1.5 Fibrinogen > 1.5 to 2 gm /l Platelets > 50 thousand/ dl pH 7.35 to 7.45 Core temperature >35 ċ Base deficit <3 / lactates <2 mEq/L

29. Complications of blood transfusion

30. Hemolytic reactions Involve specific destruction of the transfused red cells by the recipient’s antibodies Transfusion of large volumes of Incompatible units of platelet concentrates, FFP, clotting factor concentrates, or cryoprecipitate may contain small amounts of plasma with anti-A or anti-B (or both) alloantibodies, which can lead to intravascular hemolysis. It may be- acute or delayed

31. Acute Hemolytic Reactions Due to ABO blood incompatibility, The most common cause being- misidentification of a patient, blood specimen, or transfusion unit These reactions are often severe, and may occur after infusion of as little as 10 to 15 mL of ABO-incompatible blood. Symptoms- awake patients- chills, fever, nausea, chest and flank pain anesthetized patients- rise in temperature, unexplained tachycardia, hypotension, hemoglobinuria, diffuse oozing in the surgical field DIC, shock, and acute kidney failure can develop rapidly severity of a reaction, depends upon the volume of incompatible blood administered

32. Management of hemolytic reactions- 1. If a hemolytic reaction is suspected, the transfusion should be stopped immediately and the blood bank should be notified. 2. The unit should be rechecked against the blood slip and the patient’s identity bracelet. 3. Blood should be drawn to identify hemoglobin in plasma, to repeat compatibility testing, and to obtain coagulation studies and a platelet count. 4. A urinary bladder catheter should be inserted, and the urine should be checked for hemoglobin. 5. Forced diuresis should be initiated with mannitol and intravenous fluids, and with a loop diuretic if necessary.

33. Delayed Hemolytic Reactions caused by antibodies to non-D antigens of the Rh system or to foreign alleles in other systems such as the Kell, Duffy, or Kidd antigens. even after cross-matching, patients have a 1-1.6% chance of forming antibodies directed against foreign antigens in these other systems. an amnestic antibody response against the foreign antigen. hemolytic reaction is delayed by 2 to 21 days after transfusion Symptoms- are generally mild like malaise, jaundice and fever. patient’s hematocrit typically fails to rise, or rises only transiently, in spite of the transfusion and in the absence of bleeding, increase in unconjugated bilirubin. Treatment - supportive

34. Non- hemolytic reactions due to sensitization of the recipient to the donor’s white cells, platelets, or plasma proteins the risk of these reactions may be minimized by the use of leukoreduced blood products. Examples - Febrile Urticarial Anaphylactic TRALI TACO

35. Febrile non-hemolytic transfusion reactions occurs in about 1% of transfusions. according to The American Association of Blood Banks, FNHTR is defined as any 1°C rise in temperature above patient’s baseline, having no medical explanation other than blood component transfusion Symptoms - fever with or without chills, rarely hypotension. Severe reactions may include hypotension, cyanosis, tachycardia, tachypnea, dyspnea, cough, limited fibrinolysis and transient leukopenia FNHTR is a diagnosis of exclusion Prevention- leukocyte-reduced blood components are indicated Many recommend documenting 2/more FNHTRs before ordering leukocyte-reduced blood components.

36. Urticarial reactions due to sensitization of the patient to transfused plasma proteins. Symptoms - local erythema (redness), pruritus and hives. - Rarely, allergic reactions can be severe with angioneurotic edema, laryngeal edema, and bronchial asthma Prevention - Allergic reactions cannot be completely prevented. For patients with suspected or documented histories of allergic reactions, the usual prevention strategies are premedication with antihistaminics. If still occurs plasma deficient blood components.

37. Anaphylactic reactions Immediate hypersensitivity type of immune system response . Anaphylaxis can range from mild urticaria (hives) and pruritus to severe shock and death (limited to 5-10% of presenting patients) Two significant features distinguish anaphylactic and anaphylactoid reactions from other types of transfusion reactions: Fever is absent Clinical signs and symptoms occur after transfusion of just a few milliliters of plasma or plasma-containing blood components

38. Pathophysiology- attributed to IgA deficiency in patients who have developed anti-IgA antibodies by sensitization from transfusion or pregnancy. Immune hypersensitivity reactions are mediated by histamines and leukotrienes. Signs and symptoms- Anaphylactic reactions are sudden in onset with pronounced symptoms that may include coughing, dyspnea, nausea , emesis, bronchospasm, hypotension, diarrhea, possible shock, and death. Anaphylactoid reactions are usually less severe and are characterized by urticaria, periorbital swelling, dyspnea, and peri laryngeal edema.

39. Treatment- Stop the transfusion, and do not restart transfusion of the blood component Keep the intravenous line open with normal saline. Give epinephrine (usually about 0.5mL of 1:1000 solution) immediately. For severe reactions, corticosteroids or aminophylline, or both, may be indicated. Airway patency must be maintained The diagnosis of is retrospective; therefore, special measures must be taken for patients with documented or suspected histories of these reactions. Two approaches may be considered for prevention : Remove all plasma from the blood component before transfusion, or Transfuse blood components from donors lacking IgA. Even a small amount of plasma found in fibrin glue preparation may cause anaphylactic reactions.

40. Transfusion related acute lung injury (TRALI) Non cardiogenic form of pulmonary edema occurring after blood product administration New acute lung injury occurring within 6 hrs. of a complete transfusion with ratio of PaO2/FiO2< 300 mm Hg or O2 saturation as measured by pulse oximetry of less than 90% when the patient is breathing room air: NHBLI definition. Associated with transfusion of all blood products:

41. Symptoms - Increasing respiratory distress shortly after transfusion of blood component volumes that usually do not produce hypervolemia. The diagnosis of TRALI is one of exclusion. Acute onset of dyspnea, severe hypoxemia, fever, chills, fluid in ET tube in intubated pts, non-cardiogenic pulmonary edema Chest x ray shows bilateral infiltrates

42. Treatment- Immediately stop blood transfusion( if ongoing) Mainly supportive hemodynamic and ventilatory support Ventilatory support- Supplement O2 Noninvasive ventilation for moderate symptoms Mechanical ventilation for severe TRALI: low tidal volume (6 – 7 ml/kg), optimal PEEP, limit plateau pressure <30 cm of water Diuretics have no role in TRALI can be tried, if TRALI cannot be differentiated from TACO IV corticosteroids have been tried to reduce complement mediated granulocyte activation Efficacy of corticosteroids however, has not been tested Prostaglandin E1 has also been tried Rapid resolution usually occurs in 96 hrs.

43. Transfusion associated circulatory overload(TACO) pulmonary edema due to administration of excessive blood volume Features: Acute respiratory distress (dyspnea, cough, orthopnea) Elevated BNP Elevated CVP Evidence of LHF Occurs within 6 hrs. of transfusion Treatment : The usual rate of transfusion is about 200 mL / hr. In patients at risk or with histories of circulatory overload, rates of 100 ml / hr. or less are appropriate. Donor units should be split into aliquots. RBCs should be used instead of whole blood.

44. TRIM( TRANSFUSION RELATED IMMUNOMODULATION) Allogenic blood transfusion exerts a nonspecific immunosuppressive action on the recipient. Some clinical studies have tried to relate allogenic blood transfusion to recurrence of resected cancers, postoperative infections, viral activation Although conclusions of these studies are contradictory

45. Bacterial contamination Seen in 1 in 1-6 million transfused units. The source can be donor blood, donor skin flora, or contaminants introduced during collection, processing, and storage. Numerous gram-positive and gram-negative organisms can occur. In order of frequency they are; Staphylococcus aureus, Klebsiella pneumoniae, Serratia marcescens, and Staphylococcus epidermidis. The patient who receives contaminated blood will rapidly experience some combination of fever, chills, tachycardia, emesis, and shock. The patient may also develop DIC and acute renal failure. If the index of suspicion is high then the blood transfusion should be stopped immediately and blood cultures taken.

46. Citrate toxicity each unit of blood contains 3gm of citrate Factors responsible for toxicity Rate of blood transfusion 1 unit every 5 mins Hypothermia Citrate binds to calcium and results in hypocalcemia Citrate also binds to magnesium and causes hypomagnesemia Clinical features – hypotension, narrow pulse pressure due to myocardial depression, ECG changes like wide QRS, flat T waves Treatment – 1gm of ca gluconate (10%) given IV for every 5 units of blood

47. HYPERKALEMIA Serum K+ is as high as 19 – 20 meq/lt in stored blood after 21 days RBCs exchange K+ ions to uptake H+ions Precipitating factors : Large amount of blood Rate of infusion( 100- 150 ml/min) Prevention: Transfuse only fresh plasma(<8days old) or washed pRBCs Hypokalemia occurs 24 hrs. after transfusion as the transfused cells correct their electrolyte composition and K+ enters cells.

48. Acid- base imbalance pH of stored blood is 7.0 because CPDA (pH 5.5) is added to it Lactic and pyruvic acid are accumulated due to RBC metabolism, pH of stored blood further reduces to 6.9 after 21 days On blood transfusion, citrate is metabolized in liver and bicarbonate is produced which neutralizes metabolic acidosis So initially metabolic acidosis with hyperkalemia later metabolic alkalosis with hypokalemia occurs

49. Hypothermia Transfusion of multiple units of refrigerated blood leads to fall in core body temperature Hypothermia reduces enzymatic activity of coagulation factors and prevents activation of platelets. Prevention of hypothermia- A high capacity commercial blood warmer should be used to warm blood components

50. Autologous blood transfusion Is the transfusion in which both donor and recipient are same Types- Preoperative autologous blood donation Intra op blood salvage Post op blood salvage Acute normovolemic hemodilution

51. Advantages Decreases chances of transfusion reactions, alloimmunization, GVHD Ready availability in rare blood groups Acceptable in Jehovahs witness patients Hemodilution increases tissue oxygenation by decreasing viscosity Disadvantages Patient may become anemic suddenly Complex procedure for blood collection Chances of bacterial contamination Chances of over transfusion

52. Complications- Risk of contracting infection during phlebotomy Vasovagal attack during blood donation Human errors in transfusing blood like transfusing wrong unit of blood Iatrogenic anemia, MI/cerebral hypoxia.

53. Contraindications Evidence of infection and risk of bacteremia Scheduled surgery to correct aortic stenosis Unstable angina Active seizure disorder Myocardial infarction or cerebrovascular accident within 6 months of donation High-grade left main coronary artery disease Cyanotic heart disease Uncontrolled hypertension

54. References Barash clinical anaesthesia 8 th edition Miller’s anaesthesia 9 th edition Stoelting pharmacology and physiology 5 th edition Morgan and Mikhail’s clinical anesthesilogy 6 th edition Various articles and internet resources

55. Blood bank equipments Blast freezer Platelet agitator and incubator

56. Plasma expressor Bag pouches

57. Refrigerated centrifuge machine Deep freezer

58. Previous year questions Strategy to conserve blood during surgery What is autologous blood transfusion Enumerate blood components and mention indications for administering them Enumerate perioperative blood conservative strategies and discuss about acute normovolemic hemodilution Prothrombin complex concentrates

59. Thank you……..