Blood Transfusion Brig Shabbir Rana

Background Human blood replacement therapy was accepted in the late nineteenth century introduction of blood grouping by Dr. Karl Landsteiner, who identified the major A, B, and O groups in 1900 In 1939 Dr. Philip Levine and Dr. Rufus Stetson followed with the concept of Rh grouping

Whole blood was considered the standard in transfusion until the late 1970s Goal-directed component therapy

Typing and Cross-Matching Serologic compatibility for A, B, O, and Rh groups is established routinely Cross-matching between donors' red blood cells and recipients' sera (the major cross-match) is performed Rh-negative recipients should receive transfusions only of Rh-negative blood

Typing and Cross-Matching Human RBC have mainly 2 types of antigen ABO and Rhesus Blood group O is universal donor and AB group is universal recipient Rh antigen is strongly antigenic present in 85% of population

Typing and Cross-Matching Rh negative group represents only 15% of the population The administration of Rh-positive blood is acceptable if Rh-negative blood is not available Rh-positive blood should not be transfused to Rh-negative females who are of childbearing age

In emergency situations, type O-negative blood may be transfused to all recipients Patient with multiple transfusions developed alloantibodies, typing and cross-matching is often difficult Sufficient time should be allotted preoperatively to accumulate blood that might be required during the operation

Autologous transfusion Up to 5 units can be collected for subsequent use during elective procedures Patients can donate blood if their hemoglobin concentration exceeds 11 g/dL or if the hematocrit is >34% The donation is performed 40 days before the planned operation and the last one is performed 3 days before the operation

Autologous transfusion Donations can be scheduled at intervals of 3 to 4 days Administration of recombinant human erythropoietin accelerates generation of red blood cells and allows for more frequent harvesting of blood

Banked Whole Blood Banked whole blood, once the gold standard, is rarely available Shelf life is now around 6 weeks At least 70% of the transfused erythrocytes remain in the circulation for 24 hours after transfusion and are viable

Changes in the red blood cells that occur during storage include reduction of intracellular ADP and 2,3-diphosphoglycerate Alters the oxygen dissociation curve of hemoglobin and results in a decrease in oxygen transport Clotting factors are relatively stable in banked blood except for factors V and VIII

Fresh Whole Blood Fresh whole blood refers to blood that is administered within 24 hours of its donation Use of fresh whole blood may improve outcomes in patients with trauma-associated coagulopathy Advantage to the use of fresh whole blood is that it provides greater coagulation activity than equal units of component therapy.

Packed Red Blood Cells Packed red blood cells are the product of choice for most clinical situations Concentrated suspensions of red blood cells can be prepared by removing most of the supernatant plasma after centrifugation This preparation reduces, but does not eliminate, reaction caused by plasma components

Packed Red Blood Cells It also reduces the amount of sodium, potassium, lactic acid, and citrate administered Each unit is approximately 330 ml and hematocrit of 50-70% stored in sag-m solution self life 5 wks at 4-6C They are used for patients who are known to have been previously sensitized

Frozen Red Blood Cells freezing red blood cells viability is theoretically improved ATP and 2,3-diphosphoglycerate concentrations are maintained

Leukocyte-Reduced /Washed Red Blood Cells Leukocyte-reduced and leukocyte-reduced/washed red blood cell products are prepared by filtration that removes approximately 99.9% of the white blood cells and most of the platelets Saline washing (leukocyte-reduced/washed red blood cells). Leukocyte reduction prevents almost all febrile, reactions

Platelet Concentrates Indications for platelet transfusion include thrombocytopenia caused by massive blood loss Thrombocytopenia caused by inadequate platelet production Qualitative platelet disorders shelf life of platelets is 120 hours from time of donation

Platelet Concentrates One unit of platelet concentrate has a volume of approximately 50 Ml Platelet preparations are capable of transmitting infectious diseases and can provoke allergic reactions Platelet are stored at 20-24C Prevention of HLA alloimmunization can be achieved by leukocyte reduction through filtration

Fresh-Frozen Plasma Fresh-frozen plasma (FFP) prepared from freshly donated blood is the usual source of the vitamin K–dependent factors only source of factor V FFP has come to the forefront with the inception of damage control resuscitation in patients with trauma-associated coagulopathy`

FFP FFP is stored at -40---- -50C Shelf life is 2 yrs Ist line treatment of hemorrhage due to coagulopathy

Human Polymerized Hemoglobin (Polyheme) Human polymerized hemoglobin (PolyHeme) is a universally compatible Immediately available, disease-free, oxygen-carrying resuscitative fluid used in massively bleeding patients Advantages of an artificial oxygen carrier include the absence of blood-type antigens (no cross-match needed)

No incidence of viral infections long-term stability, which allows prolonged periods of storage Disadvantages include shorter half-life in the bloodstream and the potential to increase cardiovascular complication

Indications for Replacement of Blood Oxygen-carrying capacity is primarily a function of the red blood cells Transfusion of red blood cells should augment oxygen-carrying capacity Hemoglobin is fundamental to arterial oxygen content and thus oxygen delivery

Indications for Replacement of Blood Acute blood loss to replace circulating volume Perioperative anaemia Symptomatic chronic anaemia without hemorrhage

Maintaining hemoglobin levels between 7 and 9 g/dL had no adverse effect on mortality Patients with acute myocardial infarctions with ST elevation may, however, benefit from receiving red blood cell transfusions for anemia

Volume Replacement Most common indication for blood transfusion in surgical patients is the replenishment of the blood volume A healthy adult can lose up to 15% of total blood volume (class I hemorrhage or up to 750 mL) with only minor effects on the circulation

Volume Replacement Loss of 15 to 30% of blood volume (class II hemorrhage or 750 to 1500 mL) is associated with tachycardia and decreased pulse pressure but, importantly, a normal blood pressure Loss of 30 to 40% (class III hemorrhage or 1500 to 2000 mL) results in tachycardia, tachypnea, hypotension, oliguria, and changes in mental status

Class IV hemorrhage is loss of >40% of blood volume and is considered life-threatening

LOSS OF BLOOD IN OR Loss of blood in the operating room can be evaluated by estimating the amount of blood in the wound and on the drapes weighing the sponges, and quantifying blood suctioned from the operative field In patients with normal preoperative values, blood loss of up to 20% of total blood volume can be replaced with crystalloid solution

Blood loss above this amount may require the addition of packed red blood cells Transfusion of platelets and/or FFP may be indicated in specific patients before or during an operative procedure

Component Therapy Administration during Massive Transfusion Fresh-frozen plasma (FFP)  As soon as the need for massive transfusion is recognized. For every 6 units of red blood cells (RBCs), give 6 units of FFP (1:1 ratio). Platelets For every 6 units of RBCs and plasma, give one 6-pack of platelets

Cryoprecipitate After first 6 units of RBCs, check fibrinogen level. If ≤100 mg/dL, give 20 units of cryoprecipitate

Complications of Transfusion Transfusion-related events are estimated to occur in approximately 10% of all transfusions <0.5% are serious Transfusion-related deaths 0.5%

Transfusion complication acute lung injury (16 to 22%), ABO hemolytic transfusion reactions (12 to 15%) Bacterial contamination of platelets (11 to 18%).

Febrile nonhemolytic reactions Defined as an increase in temperature >1°C associated with a transfusion and are fairly common Approximately 1% of all transfusions Preformed cytokines in donated blood and recipient antibodies reacting with donated antibodies are postulated causes

Febrile reactions can be greatly reduced by the use of leukocyte-reduced blood products Pretreatment with acetaminophen reduces the severity of the reaction

Bacterial contamination Bacterial contamination of infused blood is rareGram-negative organisms, especially Yersinia enterocolitica and Pseudomonas species capable of growth at 4°C Most cases, however, are associated with the administration of platelets that are stored at 20°C Bacterial contamination results in sepsis and death in up to 25% of patients

Clinical manifestations include systemic signs such as fever and chills, tachycardia Hypotension, and GI symptoms (abdominal cramps, vomiting, and diarrhea) If the diagnosis is suspected, the transfusion should be discontinued The blood is send for culture

Emergency treatment includes administration of oxygen Adrenergic blocking agents, and antibiotics Prevention includes avoidance of out-of-date platelets

Allergic Reactions Allergic reactions are relatively frequent Reactions usually are mild and consist of rash, urticaria, and fever occurring within 60 to 90 minutes of the start of the transfusion Allergic reactions are caused by the transfusion of antibodies from hypersensitive donors or the transfusion of antigens to which the recipient is hypersensitive

Treatment and prophylaxis consist of the administration of antihistamines In more serious cases, use of epinephrine or steroids may be indicated.

Respiratory Complications Respiratory compromise may be associated with transfusion-associated circulatory overload Occur with rapid infusion of blood, plasma expanders, and crystalloids, particularly in older patients with underlying heart disease Central venous pressure monitoring should be considered whenever large amounts of fluid are administered

Treatment consists of initiating diuresis Slowing the rate of blood administration Minimizing delivery of fluids while blood products are being transfused

Transfusion-related acute lung injury noncardiogenic pulmonary edema related to transfusion It can occur with the administration of any plasma-containing blood product Symptoms are similar to those of circulatory overload with dyspnea and associated hypoxemia

Accompanied by fever, rigors, and bilateral pulmonary infiltrates on chest radiograph Commonly occurs within 1 to 2 hours after the onset of transfusion, but virtually always before 6 hours Related to anti-HLA or anti–human neutrophil antigen antibodies in transfused blood that primes neutrophils in the pulmonary circulation

Treatment includes discontinuation of transfusion Provision of pulmonary support

Hemolytic Reactions Acute hemolytic reactions occur with the administration of ABO-incompatible blood and are fatal in up to 6% of cases Technical or clerical errors in the laboratory and administration of blood of the wrong blood type Hemolytic reactions are characterized by intravascular destruction of red blood cells and consequent hemoglobinemia and hemoglobinuria

DIC can be initiated activation of factor XII and complement by antibody-antigen complexes Acute renal insufficiency

Delayed hemolytic transfusion reactions occur 2 to 10 days after transfusion Individual has a low antibody titer at the time of transfusion but the titer increases after transfusion Immunoglobulin G–mediated Pain at the site of transfusion, facial flushing, and back and chest pain In anesthetized patients, diffuse bleeding and hypotension are the hallmarks

The Coombs' test usually yields a positive result Urine output should be monitored and adequate hydration maintained to prevent precipitation of hemoglobin within the tubules

Transmission of Disease malaria, Chagas' disease, brucellosis Transmission of hepatitis C virus and HIV-1 has been dramatically minimized by the introduction of better screening for these pathogens The infection rate for these pathogens is now estimated to be <1 per 1,000,000 units transfused

Hepatitis B virus transmission may still occur in about 1 in 100,000 transfusions in nonimmune recipients

Complication of massive transfusion Hypocalcemia Hyperkalamia Hypothermia coagulopathy