Transfusion Trends In Surgical Patients Dr. Hanan AL-Awadhi (FRCPc) Hematology Unit Farwaniya Hospital

Lecture Overview Compatibility testing. Selecting compatible RBCs. RBCs transfusion triggers. Platelet transfusion. Transfusion of plasma and components.

Compatibility Testing Group and screen. Cross-match.

Compatibility Testing..Grouping Determination of recipient blood group ABO and RhD Use recipient RBC (forward testing) Use recipient plasma (reverse)

Compatibility Red cell type Antibodies present Recipient Compatibility Approximate frequency Group O (no ABO antigens) Anti-A, anti-B All ABO groups 46% Group A Anti-B Groups A & AB 42% Group B Anti-A Groups B & AB 9% Group AB Neither present 3% Rhesus group D positive Normally none Should be RhD identical, RhD -ve acceptable 85% Rhesus group D negative Should be RhD identical 15%

Compatibility Testing…Screening The recipient plasma is tested for unexpected red cell antibodies using screening cells Antibodies due to prior transfusion or previous pregnancy

Selecting Compatible Red Cells Identical ABO and RhD type preferred Red cells of non-identical ABO type may be used. RhD +ve blood to RhD -ve recipient should be avoided wherever possible

Selecting Compatible Red Cells RhD –ve females with child-bearing potential should NEVER receive any RhD +ve red cells unless…. Patients with an unexpected antibody should receive only red cells lacking the corresponding blood group antigen

Compatibility Testing…X-Match X-match between the selected unit and the recipient plasma The bag is labeled for the particular recipient and ready for transfusion. Needs 45-60 mints needed for full x-match.

Emergency Blood Release The clinician must weigh the risk of transfusing uncrossed matched or partially X-matched blood against the risk of delaying transfusion.

Degree Of Urgency Desperate blood release Blood needed immediately as life saving measure. Blood will be issued without X-match. Group O –ve uncross-matched blood Blood sample before administering the blood is needed for subsequent testing

Degree Of Urgency Blood needed in 10-30 minutes The blood will be group specific not fully X-matched Provided the patient blood sample is delivered

Degree Of Urgency Blood needed with in 45 minutes Fully matched blood will be provided Please note that delay can occur if: Antibodies are detected Problems in X-match Blood is not available in local BB

Transfusion Of RBCs

Indications For Red Cell Transfusion Acute blood loss Anemia in the critically ill Perioperative transfusion Chronic anemia

Transfusion in Acute Blood Loss Maintain Hb over 70 g/L during active bleeding Anticipate need when Hb drops to 80 g/L

Transfusion in Acute Blood Loss Consider maintaining higher level (80-100 g/L) with: Impaired pulmonary function Unstable coronary disease Atherosclerosis Uncontrolled bleeding Patients with levels above 100 g/L are unlikely to benefit

Transfusion in the Critically Ill Patients needs immediate requirement for any form of organ support (intubation, ventilation, inotropes). Hemoglobin trigger recommended for transfusion is < 70g/L.

Transfusion in the Critically Ill No general benefit (& possible harm) until hemoglobin falls to 70 g/L. Consider higher levels (100 g/L) in patients with unstable angina or acute myocardial infarction.

Randomized Controlled Trials Hebert et al.(1999) (1) assigned 418 critically ill euvolemic patients to a "restrictive" transfusion strategy (ie, transfusion for Hgb concentration <7 g/dL and Hgb maintained at 7 to 9 g/dL) and 420 patients to a "liberal" strategy (transfusion for Hgb <10 g/dL and Hgb maintained at 10 to 12 g/dL) Mortality significantly lower with the restrictive strategy (but not among patients with clinically significant cardiac disease) Conclusion: restrictive strategy of red cell transfusion is at least as effective as, and possibly superior to, a liberal transfusion

CRIT study 2004(3) RBCs transfusion and outcome were prospectively collected on 4892 patients from 284 ICUs in 213 US hospitals showed that transfused patients had longer ICU stay, more severe organ failure and higher mortality rates at every admitting Hgb level compared with non-transfused patients. Conclusion: the number of RBC units transfused is an independent predictor of worse clinical outcome.

Transfusion In The Perioperative Patient Pre-operatively Consider alternatives in advance (at least 5 weeks) of surgery to allow planning Intra-operatively Meticulous attention to surgical technique Post-operatively Adhere to good transfusion practice, minimize blood taking for laboratory tests

Transfusion and Chronic Anemia Consider alternatives and adjuncts to transfusion Ensure adequate stores of iron, B12 & folate Erythropoietin Treat underlying disease Only transfuse when there is no effective alternative Maintain hemoglobin at a level avoid symptoms of anemia Monitor long-term transfusion dependant patients for iron overload

Platelet Transfusion

Platelets Platelets for transfusion come in 2 forms: Random donor, from single donation, contains > 55x109platelets; given in pools of 6, volume 300mL Apheresis (single donor) platelets; pack contains 300x109 platelets,volume300ml

Platelets – Storage & Transfusion Shelf life 5 days Stored at 20-24 Co with constant mixing Longer storage increases risk of septic reaction Recommended infusion time 60 minutes One apheresis product is equivalent to 6 to 8 random donor platelet concentrates  increases the platelet count by 30,000/uL to 40,000/uL in a 70 kg patient. Check post-transfusion platelet count within 1 hour of transfusion to determine response and detect refractoriness

Platelets and Blood Group ABO/RhD identical preferred ABO/RhD non-identical are acceptable RhD –ve females of child-bearing potential receiving RhD +ve platelets require Rh-immunoglobulin prophylaxis

When To Give Platelets?

ITP A consensus reached by experts from the American Society of Hematology concluded that platelet transfusion was only justified in the presence of:  A platelet count less than 10x10 9 /L AND serious bleeding.

Non-Immune Thrombocytopenia Platelet transfusion support is required when the platelet count falls below 10x109/L.

Non-immune Thrombocytopenia AND Fever Greater than 38 Non-immune Thrombocytopenia AND Fever Greater than 38.5°C and/or Coagulopathy Platelet transfusion is recommended in the presence of Platelet count less than 20x10 9 /L AND Fever = or > 38.5 AND/OR INR > 1.5

Procedures Not Associated with Significant Blood Loss Platelets count less than 20x109/L Transfuse single donor platelets immediately prior to procedure. Platelets count 20-50x109/L Platelets "on hold" Transfuse only if significant unexpected bleeding occurs.

Procedures Associated with Major Blood Loss or Major Surgery Anticipated blood loss greater than 500 mL aim at platelet count above 50x109/L. Platelet count less than 50x109/L, transfuse platelets immediately prior to procedure.

Platelet Dysfunction and Marked Bleeding Marked microvascular (non-surgical) bleeding due to severe platelet dysfunction may require platelet transfusion. Example NSAIDs. Transfusion may be required regardless of the platelet count.

Fresh Frozen Plasma

Fresh Frozen Plasma Frozen Plasma is a source of clotting factors, with half lives in vivo of between 6 hours & 3 days. 30 minutes required for thawing

FFP Dose is 10-15 mL/Kg, or 4-6 units Infusion time 30-120 minutes Should be ABO compatible (Rh not important) Check INR/APTT after infusion to confirm outcome

Reversal of Warfarin Anticoagulant Effect FFP for the emergency reversal of warfarin anticoagulant effect: Patients with insufficient time (less than 6 hours) for reversal by vitamin K AND Patient about to undergo an emergency operative procedure OR With potentially life-threatening bleeding.

Think of Alternatives  The warfarin effect should be reversed with vitamin K in a dose of 10 mg administered intravenously.  This will produce partial reversal within 2 hours and normalization is usual in 24-48 hours.

Bleeding Patient With Impaired Coagulation Function Actively bleeding and INR/PTT greater than 1.5x normal Frozen plasma in a dose of 10-15mL/Kg (750-1000mL) for an average sized adult should correct the INR/PTT to 1.5x normal or less Failure to achieve the expected response should lead to review of the cause/diagnosis of impaired coagulation function

Microvascular Bleeding/Massive Transfusion Massive rapid transfusion and/or microvascular bleeding

Use of Cryoprecipitate

Clinical Use of Cryoprecipitate Must be ABO compatible, Rh not important. Treatment of massive or microvascular bleeding with Fibrinogen < 1.0 g/L

Cryoprecipitate Hereditary Disorders of Hemostasis For bleeding in von Willebrand’s syndrome patients ONLY if factor concentrate is unavailable and DDAVP is ineffective For the emergency management of factor VIII deficiency ONLY if manufactured factor VIII is unavailable

Cryoprecipitate Dose 1 unit per 10 kg of body weight (i.e. 8 to 12 units per dose). • Small adult: 8 units • Large adult: 12 units Each dose will increase the fibrinogen by 0.5 g/L. Recommended infusion time is 10-30 minutes per dose (maximum infusion time 4 hours). Half-life of fibrinogen is about 7 days.

Final Thought… As beneficial as transfusion may seem to have zero transfusion risks is impossible.

Thank you…