blood transfusion-190607161205 powepoint

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1. BLOOD TRANSFUSION & IT’S COMPLICATION

2. INTRODUCTION Human blood replacement therapy was accepted in the late 19 th Century. This was followed by the introduction of blood grouping by Landsteiner who identified the major blood groups A, B and O in 1900. Levine and Stetson introduced the concept of Rh Typing in 1939. Whole blood was considered the standard in transfusion until the late 70’s when component therapy began to take prominence.

3. REPLACEMENT THERAPY TYPING AND CROSS-MATCHING: Serologic compatibility for A, B, O, and Rh groups is established routinely. Cross matching between donor’s RBC and recipient’s sera is performed. Rh negative blood which accounts for 15% of the population, should only be transfused to Rh negative blood group only.

4. In emergency situations, type O-negative blood may be transfused to all recipients. Problems are associated with the administration of four or more units, because there is a significant increase in risk of hemolysis. Nowadays, the use of autologus transfusion is growing. Upto 5 units can be collected for subsequent use during elective procedures. (If Hb exceeds 11gm/ dL or hematocrit >34%)

5. BANKED WHOLE BLOOD: Once the gold standard, rarely available in western countries now. With sequential changes in storage solutions, the shelf life of RBC’s is now 42 days. During storage of RBC’s reduction of intracellular ADP and 2,3 DPG occurs, which alters oxygen dissociation curve of Hb , resulting in decrease oxygen transport. Stored RBC’s progressively becomes acidodic with elevated levels of lactate, potassium & ammonia.

6. RBC’s & FROZEN RBC’s: They are the product of choice for most clinical situations. It can be prepared by removing most of the supernatant plasma after centrifugation. This preparation reduces but does not eliminate reactions caused by plasma components. Whereas, in frozen RBC’s viability is improved and ATP & 2,3 DPG concentrations are maintained. Frozen RBC’s are not available for use in emergencies.

7. LEUCOCYTE-REDUCED AND LEUKOCYTE-REDUCED/WASHED RED BLOOD CELLS: These products are prepared by filtration that removes about 99.9% of the WBC’s and most of the platelets and if necessary, by additional saline washing. This leucocyte reduction prevents nonhemolytic transfusion reaction (fever and/or rigors), alloimmunization to HLA class I antigens, platelet transfusion refractoriness & CMV transmission. In most western nations it is standard RBC transfusion.

8. PLATELET CONCENTRATES: Indications for platelet transfusion include thrombocytopenia caused by massive blood loss, inadequate platelet production or qualitative platelet disorders. Shelf life is 120 days. 1 unit of platelet concentrate has a volume of approx. 50ml. Recent evidences suggests that earlier use of platelets may improve outcomes in bleeding patients. Patients who become alloimmunized through previous transmission , HLA-matched platelets can be used.

9. FRESH FROZEN PLASMA: Prepared from freshly donated blood. Usual source of vitamin K-dependent factors & the only source of factor V. Carries similar infectious risk as other component therapies. FFP can be thawed and stored for up to 5 days. Nowadays, lyophilized plasma is being tested – to increased the shelf life and avoid refrigeration.

10. CONCENTRATES AND RECOMBINANT DNA TECHNOLOGY: Technologic advancements have made the majority of clotting factors and albumin readily available as concentrates. These products are readily available and carry none of the inherent infectious risks as other component therapies.

11. INDICATIONS IMPROVEMENT IN OXYGEN CARRYING CAPACITY TREATMENT OF ANAEMIA VOLUME REPLACEMENT NEW CONCEPTS IN RESUSCITATION – DCR

12. IMPROVEMENT IN OXYGEN CARRYING CAPACITY: Oxygen carrying capacity is primarily a function of the RBC’s & thus transfusion of RBC’s should augment oxygen carrying capacity. Hb is fundamental to arterial oxygen content and it’s delivery. There is little evidence that actually supports the premise that transfusion of RBC’s equates with enhanced cellular delivery & utilization. This happens due to changes that occurs with storage of blood - in 2,3-DPG & P50 impair oxygen offloading, and deformation of RBC’s impairs microcirculatory perfusion.

13. TREATMENT OF ANAEMIA: A 1988 NIHC Report challenged the dictum that a Hb value of less than 10gm/ dL or Hct level less than 30% indicates a need for preoperative RBC transfusion. This was verified in a prospective RCT in critically ill patients and demonstrated that maintaining Hb level between 7 & 9 gm / dL had no adverse effect on mortality. One unresolved issue related to transfusion triggers is the safety of maintaining a Hb of 7 gm / dL in a patient with Ischaemic Heart Disease.

14. “The recommendation assigns two tiers of hemoglobin level transfusion triggers: 7 g/ dL for hemodynamically stable adults, even those in critical care & 8 g/ dL for patients with preexisting cardiovascular disease or those undergoing cardiac or orthopedic surgery. The current hemoglobin threshold was 10 g/ dL ”. RECENT RECOMMENDATION IN BLOOD TRANSFUSION: (Published in JAMA, October 2016 by AABB )

15. VOLUME REPLACEMENT: The most common indication for blood transfusion in surgical patients. Deficit is difficult to evaluate. Measurement of Hb & Hct can be misleading in the face of acute loss. Amount & rate of bleeding are more important factors. Loss of blood in OR can be roughly evaluated by amount of blood in the wound and drapes, weighing the sponges & quantifying the blood suctioned from the operating field. Loss of 20% of total blood volume can be replaced with crystalloid / colloid solutions. More than this may require addition of balanced resuscitation, eg . PRBC, FFP & Platelets.

16. Volume in the suction bottle x Suction PCV Blood loss = Patient PCV In acute haemorrhage , the immediate Hct may may not actually reflect the blood loss. Total amount of blood loss= Total difference in swab weight x 1.5, or Total difference in swab weight x 2 (for larger operations) Source: Canadian Journal Of Anesthesia Estimation of blood loss in Operating Room:

17. Maximum capacity of swab: 1. Small (10 x10cm)  60ml 2. Medium (30 x 30cm)  140ml 3. Large(45 x 45cm)  350ml Floor spill: 1. 50cm diameter  500ml 2. 75cm diameter  1000ml 3. 100cm diameter  1500ml

18. NEW CONCEPTS IN RESUSCITATION – DCR: Damage Control Resuscitation (DCR) strategy, aimed at halting and/or preventing rather than treating the lethal triad of Coagulopathy , Acidosis , and Hypothermia , has challenged traditional thinking on early resuscitation strategies. Standard advanced trauma life support guidelines start resuscitation with crystalloid, followed by PRBC. Because of the known early coagulopathy of trauma, the current approach to managing the exsanguinating patient involves early implementation of DCR.

19. DCR is actually composed of 3 basic components: 1. Permissive hypotension 2. Minimizing crystalloid based resuscitation 3. Administration of predefined blood products (RBC’s, plasma and platelet) in ratios similar to those of whole blood. During recent time, in Iraq & Afghanistan, DCR practices are demonstrating unprecedented success with improved overall survival.

20. A multicenter retrospective study of modern transfusion practice showed that Plasma:Platelet:RBC ratios varied from 1:1:1 to 0.3:0.1:1 , with corresponding survival rates ranging from 71% to 41%. Similarly, in a prospective observational study evaluating current transfusion practice documented the wide variability in practice and improved outcomes with earlier use of increased ratios of plasma and platelets. Patients receiving ratios less than 1:2 were four times more likely to die than patients with ratios of 1:1 or higher.

21. Several authors have shown that a well developed massive transfusion protocol is associated with improved outcomes independent of the ratios chosen – And this should begin prior to any laboratory defined anemia or coagulopathy. Adult Massive Transfusion Guidelines (MTG) specify the early use of component therapy.

22. Specific recommendations for the administration of component therapy during a massive transfusion:

23. COMPLICATIONS Primarily related to blood induced proinflammatory responses. Occur in approximately 10% of all transfusions, but less than 0.5% are serious in nature. Death occur rarely and are primarily related to TRALI (16%-22%), ABO hemolytic transfusion reactions(12%-15%), and bacterial contamination of platelets (11%-18%).

24. NON HEMOLYTIC TRANSFUSION REACTION ( NHTR ) TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD ( TACO ) TRANSFUSION RELATED ACUTE LUNG INJURY ( TRALI ) HEMOLYTIC REACTION TRANSMISSION OF DISEASES

25. NON HEMOLYTIC TRANSFUSION REACTION ( NHTR ) Increase in temperature (>1 ° c) associated with transfusion and are fairly common. Occurs 0.5-1.5% of all transfusions. Etiology - Preformed cytokines in donated blood and recipient Ab reacting with donated Ab Prevention – Leukocyte reduced blood products, store platelets <5days. Pretreatment with acetaminophen reduces the severity of the reaction.

26. Bacterial contamination of infused blood is rare. High fever, chills, Hemodynamic changes, DIC, Emesis, Diarrhoea , Hemoglobinuria . Bacterial contamination can result in sepsis & death in up 25% of patients. <<0.05% of blood & 0.05% of platelets. Etiology – Gram negative Bacteria Emergency treatment includes Oxygen, Adrenergic blocking agents, and antibiotics

27. Allergic reactions are relatively frequent, occurs in about 1% of all transfusions. Rash, Urticaria & Flushing. (Rarely Anaphylactic shock) Caused by transfusion of antibodies from hypersensitive donors or transfusion of antigens to which the the recipient is hypersensitive. Commonly associated with FFP and Platelets. Administration of antihistamine prophylaxis.

28. TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD ( TACO ) Respiratory compromise due to pulmonary edema. Occur with rapid infusion of blood, plasma expanders, and crystalloids, particularly in older patients with underlying heart disease. Can be avoided by slowing the rate of blood transfusion, administration of diuretics and minimizing fluids

29. TRANSFUSION RELATED ACUTE LUNG INJURY ( TRALI ) Defined as noncardiogenic pulmonary edema related to transfusion. Symptoms are Acute Hypoxemia, Bilateral pulmonary infiltrates, Tachycardia, Hypotension. Occurs 1-2hrs of transfusion, but virtually always before 6hrs. Etiology – Anti-HLA or Anti-HNA antibodies in transfused blood attacks circulatory and pulmonary leukocytes. In a recent study by TOY et al reported decrease in incidence of TRALI with the reduction transfusion of plasma from female donors.

30. HEMOLYTIC REACTION This can be classified as either Acute or Delayed . Occur due to administration of ABO incompatible blood. Contributing factors are errors in the laboratory of a technical or clerical nature or the administration of wrong blood type. Causes immediate hemolytic reactions are characterized by intravascular destruction of RBC’s & consequent hemoglobinemia and hemoglobinuria – and finally ARF. Most common symptoms are pain at the site of transfusion, facial flushing and back & chest pain.

31. Delayed hemolytic reaction occur 2-10 days after transfusion. Characterized by extravascular hemolysis, mild anemia and indirect (unconjugated) hyperbilirubinemia . Etiology – Reactions to non-ABO antigens involve immunoglobulinG mediated clearance by the reticuloendothelial system.

32. TRANSMISSION OF DISEASES Malaria, Chagas disease, Brucellosis, and very rarely Syphillis are among the diseases that have been transmitted by transfusion. The most common species is Plasmodium Malariae . Initial manifestations are Shaking chills and spiking fevers. Transmission of Hep C and HIV-1 has been dramatically minimized by the introduction of better antibody and Nucleic acid screening for these pathogens.

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