transfusion medicine

transfusion medicine

1. Ten Peaks, Banff 09/27/15 CANADA Transfusion Medicine Shoichi Inaba MD January19, 2016

2. 1 ． Supplement of Oxygen carrying capacity (Red Blood Cells; RBCs)   2 ． Supplement of coagulation factors a) Fresh Frozen Plasma (FFP) Mainly supplement of Fibrinogen b) Platelets (PCs) 3 ． Supplement of Blood Volume (Albumin, RBCs) Transfusion is not a cure therapy, it’s only a supplement therapy Indication of transfusion therapy

3. Body change due to blood loss Hypotension Vaso-spasms 　 　　 to maintain blood pressure due to decrease vasucular space tachycaridia 　　　 increase cardiac output Acidosis 　　　 increase oxgen release 30% of blood loss is life-threatning (limit is 2ℓ at adult) Shock means insufficient peripheral circulation

4. 　　 Vital signs 　　 Blood gas analyses 　　 Cell blood count 　　 Coagulation tests 　　 Patient prognosis Age (young patients should endure and elder is loose ） Evidencies for decision making of transfusion therapy

5. Body Water Distribution Dry weight 40%

6. Distribution of Body water Kanto-Koshinnetsu Block Blood Center ISF 15% of Body weight ISF 30% of Body weight Plasma 5% of Body weight Rather obesity Middle Obesity Thin Long life Body Fluid (% body weight) Child Adult (male) Adult (female) Thin 80 65 55 Middle 70 60 50 Obesity 65 55 45

7. Body fluid movement at acute blood loss （５０ｋｇ BW 　 adult) Bleeding Plasma ECF Body fluid loss Within 20% of blood loss is to ｌ erable

8. Composition of blood components Plasma 1.025 ～ 1.029 Platelet 1.040 RBC 1.095 (40 ～ 50%) (50 ～ 60%) (< 0.25%)

9. Blood components has different distribution in the body ＊ each component has different distribution in the body Differencies of blood component distribution Intra-vascular Extra Celllular Fruid Spleen RBCs ≒ 100% PCs 70% 30% Albumin 40% 60%

10. Production rate of blood components ＊ each component has different life span & production rate Intra-vascular reserve Extra-vascular reserve Life span Production rate ( /day) RBCs ≒ 100% 1.5% 120days 0.83% PC 70 ％ 30% 10days 12.8% Granulocytes 10-30 ％ 70 ～ 90% 14Hrs － Albumin 40 ％ 60% 40Day 3.75% Fibrinogen 100% － 1day 100% Distribution

11. Conponent transfusion is common in Japan 血液製剤調査機構作成 Direct use of whole blood decreased to almost zero 2013 2012 2011 2010 2009 2008 2007 2006 2005 2003 2004 2002 2013 2012 2011 2010 2007 2008 2009 Million Thousand RBC FFP PC No. of whole blood usage 0.9/5,000,000 (0.02%) About 3.5million of whole blood donors per year

12. Basic guideline of the blood transfusion therapy for the surgical bleeding Lundsgaard-Hansen (1980) Blood loss (%)

13. Oxygen dissociation curve PCO 2 , 　 right shift pH , Body temperature 2,3DPG （動脈血） （静脈血） PaO 2 Bohr’s Effect Arterial blood Venous blood (%) Oxygen saturation Metbolic acidosis happen by PaCO 2 increase at shock

14. 　 Supply of oxgen carrying capacity 1g Hemoglobin (Hb) increment increase 70ml/dl O2 carrying capacity 400ml whole blood derived RBCs has same effect Oxygen required at basal metabolism is 150ml/min Purpose of RBC transfusion

15. Relation between Oxygen consumption and Oxgen Carrying Capacity O 2 Carrying Capacity dependent phase Independent phase critical point ≒ Hb5g/dl （ trigger ） O 2 Consumption

16. 50kgBW adult needs 750kcal/day (15kcal/kg/day), and 1ml O 2 produce 3.5cal O 2 consumption require 150ml/min (3ml/kg/min) Available O 2 = O 2 Carrying capacity (DO 2 ) X O 2 Extraction rate (ER) = 1.35 X Hb(Hemoglobin) X Cardiac output (CO) X ER Body limitations ER should bt within 30% for safety CO should be within 10L/min for safety (CO = one beat volume X pulse rate) PR should be within 160/minfor safety Hb7.0g/dl can carry 500ml O 2 at PR 84/min Oxygen (O 2 ) consumption at basal metabolism

17. C: additive preserved (Day 42) B: ACD-A preserved (Day 21) A: fresh blood Morphology of additive preserved RBC Additive preserved RBCs has alomost same shape of fresh blood Aditive solution contains Mannitol, Adenine,Glucose

18. O 2 O 2 O 2 O 2 Hemoglobin molecule Trigger value of RBC transfusion Trigger value decreased 10/30 （ Hb/Hct) 7/20 Hb level: 8 ～ 10g/dl 　 (limited transfusion) is better than Hb level ＞ 12g/dl (moderate transfusion) ICU survival rate was high  

19. 1g Hb increment needs 250g RBCs (400ml whole blood derived) in 50kgBW adult RBCs administration and Hb increment

20. Emergency Cases Traffic injury Obstetrics bleeding Gunshot wound (GSW) Rupture of esophagus varix Rupture of aortic aneurysm etc. Indication of type O blood (no need of cross mating test) Transfusion against Oligemia Bleeding without BLS (basic life support)

21. 2. Bleeding under BLS General anesthesia, infusion rouite are accomplished If there is enough of blood, the bleeding of dozens of liters can support. Cases Heart or big vessel surgery ( thrachic aorta or abdominal aorta) Hepatectomy including liver transplant surgery etc. Level-1 RIS: rapid infusion system

22. Long preserved RBC has worsen prognosis of cardiac surgery? Preserved within 2 weeks has better prognosis than preserved > 4 weeks RBC transfusion Ambiguous indication NEJM 358:1229-1239, 2008

23. Surgical indication 　　 less than 50,000/ul 　　 effective for hemostat at cardiac surgery b) Indication for bone marrow suppression 　　 less than 20,000/ul Mainly due to chemotherapy 　　 contribution of safety Indication of PCs transfusion

24. Pletelet recovery rate Estimation method of PC transfusion effect: 1.Prospected pLT increment 　　　　 0.6×transfused PLT number÷blood volume 2.CCI(corrected count increment ） 　　　 PLT increment （ / μl ） ×body mass aria （㎡） 　＝ 　　　　　　　　 transfused PLT number

25. Increment of PCs transfusion 1Bag PC contains 2 ～ 3X10 11 platelets Increment of PLT count 3 ～ 5x10 4 / ul

26. Standard of PC administration Indication: Decrease of number or mal-functions Disease standard (thousand / uL ) Active bleeding less than 50 Invasive examinations less than 50 Pre- ope for difficult hemastasis ope . 70 ～ 100 PLT decrease at intra and post ope . less than 30 C-P bypass less than 30 Massive bleeding depend on bleeding volume Chemotherapy less than 20 DIC 50 APLA ・ MDS 0.5 ～ 10

27. Ambiguous indication Trigger value 10,X10 4 /ul or 20X10 4 /ul is not clear 2010年 2 月の NEJM 報告

28. Abnormal coagulation Lab. Data Measurement of PT, APTT, Fibrinogen PT>16” 、 APTT>45” 、 Fibrinogen ＜ 100mg/dl   to avoid FFP transfusion without Lab. data FFP transfusion at PT<14” is meaningless Indication of FFP transfusion

29. 　 No correction effect of PT (PT 14 ～ 17 sec) PT does not shorten by dose of FFP Transfusion Volume 46, Issue 8, August 2006, Pages: 1279 –1285 Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities

30. Indication of FFP is not clear (big difference of usage between university hospitals) FFP/Bed Public or National Private

31. 1:1 RBC/FFP transfusion recommend to emergency patients J Trauma 2009; 66: 693-7. Vox Sang 2008; 95: 112-9

32. minimum requirement 2) Zero risk is impossible at transfusion therapy 3) Transfusion therapy is thought to be necessary evil Transfusion without Lab. test is not desirable Reasonable transfusion therapy

33. 　 Risks of transfusion therapy FTR (severe) 　 　 700/ year TRALI ・ TACO　　 < 80 / year ABO mismatch 　 < 20/ year TTI 　　　　 　 < 　20/ year total 　　　　　 < 1,000 /year Recipients in japan 　　 ≒　 1million Severe complications 　 ≒ 　1/1,000 Fetal rate 　　　　　　 ≒ 　1/100,000

34. （ 44.8% ） （ 44.3% ） （ 40.2% ） （ 43.0% ） Allergic reactions Severe FTR ( feblire transfusion reactions)

35. Informed consent Dr. should explain the risks of transfusion therapy Necessity of transfusion Adverse reactions of transfusion National insurance covered TTI

36. Risk management cooperation with patient Call patient’s name by himself To avoid ABO mismatch transfusion

37. Problems of transfusion teaching stuffs Like to teach cats (each doctor has a different opinion without evidence) To reqiue enthusiastic zeal and efforts To teach reasonable transfusion therapy to many doctors have a lot of difficulties

38. Thank you for your attention! Mt.Fuji from Shonan bay Big Budda at Kamakura