Blood Transfusion (Principles and procedure)

A PowerPoint presentation outlining the physiology of blood transfusion, and clinical precautions to take in preventing and managing blood transfusion reactions.

1. BLOOD TRANSFUSION Dr. Boluwatife Afolabi (BDS, Ibadan)

2. OUTLINE Introduction Definition Historical Background Blood Components Blood Groups The Rhesus Factor Blood Group Compatibility Classification of Blood Transfusion Fractions of Blood in Use Blood D onation and Donor Selection Storage Blood T ransfusion Order Principles of Blood Transfusion Complications of Blood Transfusion Conclusion References Dr. Boluwatife Afolabi 2

3. INTRODUCTION The adult human has about 4-6 litres of blood in circulation throughout the body. Among several other functions, the primary role of blood is to transport oxygen to various parts of the body. Blood is made up of several cells which float around in a liquid called plasma . Dr. Boluwatife Afolabi 3

4. DEFINITION Blood transfusion is the transfer of whole blood or blood components intravenously into one’s circulatory system. The person receiving blood is known as the recipient while the person donating blood is known as the donor. Dr. Boluwatife Afolabi 4

5. HISTORICAL BACKGROUND 1492 : Pope Innocent VII received the first recorded blood transfusion in history, it was unsuccessful. 1628 : William Harvey (a British physician) is credited with the discovery of blood circulation. 1665 : Richard Lower performed the first successful blood transfusion (animal-to-animal) 1818 : James Blundell human-to-human blood transfusion for a man with gastric carcinoma. 1901 : Karl Landsteiner discovered blood groups A, B, C now known as blood groups A, B, O. 1907 : Reuben Ottenberg and Schultz conducted the first blood grouping and cross-matching. 1914-1918 : Oswald Hope Robertson established the first blood depot (blood bank) Dr. Boluwatife Afolabi 5

6. BLOOD COMPONENTS Dr. Boluwatife Afolabi 6

7. BLOOD COMPONENTS Dr. Boluwatife Afolabi 7

8. BLOOD GROUPS Classification of blood is based on the presence or absence of inherited antigenic substances on the surface of red blood cells (RBCs). These antigens may be proteins, carbohydrates, glycoproteins or glycolipids, depending on the blood group system. The ABO blood group system is the most important blood group system in human blood transfusion. Based on the presence or absence of antigen A and antigen B, blood is divided into four groups: A B AB O Dr. Boluwatife Afolabi 8

9. BLOOD GROUPS Blood with antigen A belongs to ‘A’ group. This blood has β -antibody in the serum. Blood with antigen B and α -antibody belongs to ‘B’ group. If both the antigens are present, the blood group is called ‘AB’ group and the serum of this group does not contain any antibody. If both antigens are absent, the blood group is called ‘O’ and both α and β antibodies are present in the serum. Dr. Boluwatife Afolabi 9

10. BLOOD GROUPS Dr. Boluwatife Afolabi 10

11. THE RHESUS FACTOR The rhesus blood type (named after the rhesus monkey) was first discovered in 1937 by Karl Landsteiner and Alexander S. Wiener. When red blood cells containing Rh factor are injected into a person whose blood does not contain the Rh factor, anti-Rh agglutinins develop slowly, reaching maximum concentration of agglutinins about 2-4 months later. If a Rh-negative person has never before been exposed to Rh-positive blood and is now transfused with Rh-positive blood, the following may occur: No immediate reaction. anti-Rh antibodies develop in sufficient quantities slowly over time. Subsequent transfusion of Rh-positive blood into the same person who is now already sensitized may result in a severe transfusion reaction. Dr. Boluwatife Afolabi 11

12. THE RHESUS FACTOR Dr. Boluwatife Afolabi 12

13. BLOOD GROUP COMPATIBILITY Dr. Boluwatife Afolabi 13

14. CLASSIFICATION OF BLOOD TRANSFUSION Homologous ( allogenic ) blood transfusion: Blood transfusion with blood donated from another compatible donor of the same specie. Autologous blood transfusion: Blood transfusion with blood gotten from the same person. Types of autologous blood transfusion: Preoperative Autologous B lood D onation (PABD) Acute I sovolemic H emodilution (AIVH) Intraoperative Blood Salvage Postoperative Blood S alvage Dr. Boluwatife Afolabi 14

15. FRACTIONS OF BLOOD IN USE Whole blood: Indications To restore blood volume in cases of sudden loss of 25% or more of blood volume. Patient undergoing exchange blood transfusion (EBT). Patients who continue to bleed after receiving 4 units of packed red blood cells. Patients requiring cardio-pulmonary bypass. *Its use is now limited except in hospitals and areas where facilities for producing blood fractions are not available . Dr. Boluwatife Afolabi 15

16. FRACTIONS OF BLOOD IN USE Red Cell Concentrates : Whole blood is centrifuged at 3000 revs/min and the supernatant plasma is removed. Indications Chronic Anaemia Cardiac Failure Washed Red Blood Cells : This is obtained by continuous flow washing. Indications Severe allergies Patients awaiting transplantation Patients with repeated febrile transfusion reaction Dr. Boluwatife Afolabi 16

17. FRACTIONS OF BLOOD IN USE Platelet Concentrate : It is the precipitate obtained when platelet rich plasma is centrifuged at 3000rev/min. Platelet rich plasma is the supernatant plasma after whole blood is centrifuged at 1000rev/min. Indications Severe thrombocytopaenia Fresh Frozen Plasma : It is the supernatant liquid portion that is separated and rapidly frozen by immersion in a mixture of carbon-dioxide and ethyl alcohol within 8 hours of collection when fresh blood is centrifuged at 3000rev/min. Indications Deficiencies in coagulation factors Emergency treatment of warfarin overdose and Vitamin K deficiencies. Treatment of thrombotic thrombocytopaenic purpura Treatment of disseminated intravascular coagulation Dr. Boluwatife Afolabi 17

18. FRACTIONS OF BLOOD IN USE Cryoprecipitate : The precipitate formed when fresh frozen plasma is allowed to thaw at 4°C and the supernatant plasma removed. It is rich in factors VIII, factor XIII, fibrinogen and Von Willebrand Factor. Indications Haemophilia Von Willebrand disease Disseminated intravascular coagulation Dr. Boluwatife Afolabi 18

19. BLOOD DONATION AND DONOR SELECTION Measures to protect the donor All donors should be healthy adults between 18-65years . Weight should be above 50kg . Hb should be >13g/dl for Men . Hb should be >12g/dl for Women. Minimum donation interval of 12 weeks. Maximum of 3 donations per year. Pregnant and lactating women are excluded. Dr. Boluwatife Afolabi 19

20. BLOOD DONATION AND DONOR SELECTION Measures to protect the recipient Careful donor selection Donor deferral/exclusion Screening for: HbsAg HCV Syphilis Chagas disease Malaria Dr. Boluwatife Afolabi 20

21. BLOOD DONATION AND DONOR SELECTION Indefinite deferral History of Hepatitis B/C infection History of IV drug abuse History of Chagas disease Dr. Boluwatife Afolabi 21

22. BLOOD DONATION AND DONOR SELECTION 12 months deferral History of syphilis or gonorrhea History of recent tattoo Hepatitis B immunoglobin prophylaxis Potential donors who have undergone ear piercing/acupuncture Rabies vaccination Dr. Boluwatife Afolabi 22

23. STORAGE Standard blood bag contains 450±45 mls blood with 60 mls of anticoagulant preservative. Blood is stored at 2-6°C Anticoagulants include: Heparin- 24 hours Acid-Citrate-Dextrose (ACD)- 21 days Citrate-Phosphate-Dextrose (CPD)- 28 days Citrate-Phosphate-Dextrose-Adenine (CPDA)- 35 days Saline-Adenine-Glucose- Mannitol (SAGM)- 42 *Note: Leucocytes and platelets not viable after 24 hours of storage. Dr. Boluwatife Afolabi 23

24. BLOOD TRANSFUSION ORDER Dr. Boluwatife Afolabi 24

25. COMPLICATIONS OF BLOOD TRANSFUSION Immediate/Delayed reactions Immune/Non-immune complications Dr. Boluwatife Afolabi 25

26. Immediate Reactions Febrile non haemolytic transfusion reaction : It is quite common and most times it is due to incompatibility between antigens on the donor’s white cells and antibodies in the recipient’s plasma leading to the release of pyrogens . It may also be due to endotoxins and pyrogens in the transfusion set or blood. Clinical Features •Rigor and fever •Nausea and vomiting •Flushing •Tachycardia Management •Stop transfusion temporarily •Exclude haemolytic reactions, septicaemia or malaria •Give Paracetamol/Aspirin to bring down the temperature Prevention •Future transfusion should be with leukocyte depleted blood products Dr. Boluwatife Afolabi 26

27. Immediate Reactions Allergic reactions : It occurs in 2% of transfusions. It is common in patients receiving repeated transfusion. It is due to allergens, usually plasma protein in the donor plasma and so is less likely to occur with packed red cells. Clinical features • Urticaria •Myalgia/Arthralgia •Bronchospasm • Oedema of the face and larynx •Chest pain •Hypotension •Abdominal cramps • Diarrhoea •Shock . •Pyrexia Dr. Boluwatife Afolabi 27

28. Immediate Reactions Management •Stop the transfusion •Give steroid and anti-histamine •If symptoms are severe, adrenaline should be administered intravenously . Prevention •During future transfusion, patient should have pre-medication with antihistamines before transfusion or be given plasma free components e.g. washed packed RBC for treatment of anaemia Dr. Boluwatife Afolabi 28

29. Immediate Reactions Haemolytic Reactions : This is the most serious complication of blood transfusion and it is usually due to ABO incompatibility. Clinical Features •Pain along the vein being used for transfusion •Headache •Rigors and fever • Dyspnoea •Pain in the loin •Jaundice •Shock • Haemoglobinuria Dr. Boluwatife Afolabi 29

30. Immediate Reactions Management •Blood transfusion should be stopped and a sample is taken from the remainder and the patient’s blood for further grouping and cross matching. Besides, clerical checks should also be done. •Some blood should be taken for culture as bacterial contamination may be the cause of the symptoms. •Diuresis should be established to flush the renal tubules of haemoglobin and prevent blockage. Dr. Boluwatife Afolabi 30

31. Immediate Reactions Circulation Overload : It usually occurs in patients with congestive cardiac failure , chronic anaemia or renal disease. Clinical Features • Dyspnoea , orthopnoea •Cyanosis •Cough , frothy sputum •Raised JVP •Rapid and weak pulse Management •Transfusion is stopped and patient is propped up •IV Frusemide is administered to remove the excess fluid •Emergency phlebotomy is done to remove excess blood Dr. Boluwatife Afolabi 31

32. Delayed Reactions Thrombophlebitis : It follows •Injury to the vein by the needle or cannula •Spasm of the vein caused by cold blood. •Prolonged use of the same vein •Leakage of blood around the vein •Sepsis Clinical Features •Pain , redness, tenderness, thickening of the vein •Pyrexia Management •Analgesics are administered for the pain •The affected limb is rested •A sample is taken form the tip of the needle or cannula for culture and sensitivity Dr. Boluwatife Afolabi 32

33. Delayed Reactions Delayed Haemolysis : This delayed red cell haemolysis follows stimulation and production of antibodies which at the time of cross matching were too low in concentration to be detected. Platelet antibodies : Usually occurs 7-14 days after transfusion. It is due to formation of antibodies to the transfused platelets. Clinical Features • Petechiae haemorrhage •Bleeding from mucus membranes Management There is usually spontaneous recovery •In severe cases give prednisolone or IV immunoglobulin •You may need to do a plasmaphoresis Dr. Boluwatife Afolabi 33

34. Delayed Reactions Transfusion of diseases : Viral hepatitis ( B,C,D), Malaria, Syphilis, Cytomegalovirus infection, Human Immunodeficiency virus, Trypanosomiasis , Toxoplasmosis(protozoan), Infectious mononucleosis, Brucellosis(bacterial). Micro aggregates : Degeneration of leukocytes and platelets form aggregates, which may cause pulmonary micro embolism, with resulting pulmonary insufficiency. It occurs more commonly after massive transfusion. The use of micro-filters reduces the incidence. Immunosuppresion : Natural Killer cells and T lymphocytes’ blastogenic activities are reduced while suppressor T lymphocytes activity is enhanced. Transfusion Haemosiderosis Dr. Boluwatife Afolabi 34

35. CONCLUSION Blood is a powerful and important therapeutic agent in surgery, especially maxillofacial surgery. It’s important to have a sound knowledge on the rational use of blood (and blood components) in patients. Dr. Boluwatife Afolabi 35

36. Dr. Boluwatife Afolabi 36

37. REFERENCES Badoe E.A; Principles and Practice of Surgery, 4 th edition Ganong W.F; In Review of Medical Physiology https:// www.slideshare.net/Drkabiru2012/blood-transfusion-in-surgery https:// www.slideshare.net/rosesrred90/blood-transfusion-16397094 https:// www.slideshare.net/UthamalingamMurali/blood-transfusion-42999457 Dr. Boluwatife Afolabi 37