1. BLOOD TRANSFUSION Ferdi Menda,M.D. Assistant Prof of Anesthesiology
Yeditepe University

2. Today’s Topics Available Blood Productsn
Current Estimates of Transfusion Risks n
Fatal Transfusion Reactions n
Transfusion Reactions n
Indications for Adult Blood Transfusions n

3. Indications for Transfusion (Adults)

4. Quality Quality Defining Defining Administering the S S Right Right
quantity S
S Right
Right
component S
S Right
Right
way S
S Right
Right
time
S Right S
Right
patient
S Right reason
with informed consent and adequate
documentation of process& outcomes

5. Packed Red Blood Cells Symptomatic Anemia:
Angina Claudication Diaphoresis
Dyspnea Fatigue TIA
Syncope Tachycardia Postural Hypotension
Asymptomatic anemia with Hgb <7 g/dl n
Pre- or Post-operative Hgb <10 g/dl or Hct <30% n
Acute blood loss >15% of estimated blood volume or n
estimated blood loss of 750 ml
Acute blood loss with evidence of inadequate oxygen n
delivery
Hgb <9 g/dl in patient ona chronic transfusion regimen n

6. Canadian Critical Care Trial Group
Study compared “restrictive” (Hgb<7) to “liberal” (Hgb<10) transfusion strategies among critically ill patients.
The “restrictive” strategy was as effective and superior to the “liberal” transfusion strategy among patients less than 55 and without cardiac disease. Patients had an overall greater decrease in mortality and less complications. They concluded that a transfusion threshold of 7 g/dl is safe in critically ill patients, including those with minimal cardiopulmonary disease.

7. Platelets Patient… Maintain platelet ct. above…
Marrow failure> 10-20,000/mm 3
Invasive procedure> 50,000/mm 3
Neurosurgical or
> 100,000/mm 3
ophthalmologic procedure
Bleeding patient> 50,000/mm 3
Bleeding with functional
50-100,000/mm above baseline 3
platelet defect
Neonates
> 100,000/mm 3

8. Fresh Frozen Plasma PTT >50 sec or INR> 1.5 (PT> 20 sec)
Diffuse microvascular bleeding in massive n
transfusion (>1 blood volume) with abnormal
parameters
Emergency reversal of Warfarin (Coumadin) n
anticoagulation when evidence of bleeding
present or emergency surgery required
Deficiency of specific factors of the n
coagulation system when virus-inactivated
concentrates not available

9. Cryoprecipitate Fibrinogen <100mg /dl Factor XIII deficiency
Diffuse microvascular bleeding and fibrinogen n
<120 mg/dl
Von Willebrand’s disease or hemophilia n
unresponsive to DDAVP and no appropriate
factor concentrates available
Uremic bleeding (if DDAVP is ineffective) n

10. Risks of Transfusion

11. The safest transfusion is the one not given
Medicine

13. Transfusion Risks: Infectious
Current Risks of Infection from “Test Negative”
Blood Components (USA)
Agent Risk
HIV-1/21 in 2.1 million
HCV1 in 1.9 million
HBV1 in 205, ,000
WNV1 in 12 million
Bacteria (cultured apheresis1 in 75,000
platelets, ARC)

14. Transfusion Risks: Non-Infectious, Early Onset
Noninfectious Risks of Transfusion, Early Onset (within hrs)
Risk
Published Rates
Febrile, nonhemolytic nonseptic reaction RBC:1 per units
Platelets: 1-1.5%
Circulatory overload (TACO)1 per 100-2,000 units
Hemolysis of incompatible RBCs1 per 13, ,000
1 per million (fatal)
Hemolysis from incompatible plasma1 per 46,000 (21% plasma
incompatible)
TRALI1 per 1,000-5,000
Allergic reaction, mild1 per 4,000 RBC, 3-5% plts
Allergic reaction, severe; anaphylactic1 per 25,000 (RBC),
1 per 2,000 plts

15. Transfusion Risks, Late Onset
Noninfectious Risks of Transfusion, Late Onset
(days to months)
Risk Published Rates
Formation red cell antibody(s)1 per 200 RBC units (9% pts)
Delayed hemolytic reaction1 per 5,000-10,000
Iron overload Essentially all chronically
transfused patients
Immune suppression All show variable suppression
Formation of HLA antibodies 7-15% if multiply transfused
Formation of anti-platelet Ab 0.85% of patients
Graft-versus-host disease<1 per1 million

16. Transfusion Reactions

17. Transfusion reactions
Timing: acute versus delayed reaction n
Severity: fatal versus non-fatal n
Cause: immunologic, infectious, n
cardiovascular overload
All reactions must be reported to the n
lab for investigation and documentation

18. Transfusion Reactions- Common
Febrile n
Allergic n
Cardiovascular Overload n

19. Transfusion Reactions- Serious
TRALI (transfusion-related acute lung injury) n
Hemolytic n
Bacterial contamination n
Anaphylactic n
Graft vs. host disease n

20. Leading Causes of Fatal Reactions: Cases Reported to FDA, FY07-08
TRALI (51%) n
Incompatible blood (23%) n
Patient mis-identification: 50-75% n
Clerical errors: 10-15% n
Technical errors: 10-15% n
Bacterial contamination (13%) n
Anaphylaxis (5%) n

21. Transfusion Fatality Update
Transfusion-Related Fatalities Reported in FY2005 thru FY2008
Source: Fatalities Reported to FDA Following Blood Collection and
Transfusion, Annual Summary for Fiscal Year 2008, March 2009

22. Transfusion Fatality Update
Transfusion-Related Fatalities Reported in FY2005 thru FY2008
Source: Fatalities Reported to FDA Following Blood Collection and
Transfusion, Annual Summary for Fiscal Year 2008, March 2009

23. Allergic Reaction Frequency: Hives or rash
RBCs:1 per 4,000, Platelets: 3-5% n
Hives or rash n
Few/localized– slow infusion rate, antihistamines Rx n
Generalized or cardiorespiratory S/Sx– D/C infusion n
Triggered by donor proteins or medications n
Can develop bronchospasm, GI symptoms n
Rx: antihistamines; steroids (severe rxns) n

24. Volume overload Frequency: Too rapid or too largea volume transfused
1 per 100-2,000 units n
Too rapid or too largea volume transfused n
Usually pre-existing history of heart or lung n
disease
Rx: slow infusion rate, diuretics n
May need to “split”a unit of blood if transfusion n
time will exceed4 hours

25. Hemolytic Reactions, Acute
Frequency n
RBCs:1 per 13, ,000 n
1 per million (fatal) n
ABO incompatibility (usually) n
Misidentified patient or clerical error n
Rx: Supportive (treat shock, DIC) n

26. Hemolytic Reactions, Delayed
Frequency–1 per 5,000-10,000 RBCs n
Patient has RBC antibodies n
Chronically transfused patients (10- 40%) n
Multiparous females n
Unexplained drop in Hgb 3-10 days n
after transfusion
Rx: Antigen negative blood n

27. Septic Transfusion Reaction
Bacterial contamination of blood product n
Frequency–1 in 75,000 n
Platelet transfusions most common cause n
Room temperature storage n
Contamination during blood collection, processing or n
pooling
Strep and Staph; gram negative bacteria n
Platelet products cultured before release by SBB n
Rx: Supportive, antibiotics n

28. Anaphylactic Reaction (Severe Allergic)
Frequency n
RBCs:1 per 25,000, Platelets:1 per 2,000 n
IgA deficient patient with anti-IgA n
antibodies
Symptoms are immediate (1-2 ml) n
Hypotension, shock, bronchospasm n
Rx: Supportive; washed RBCs/platelets n

29. TRALI: Transfusion-Related Acute Lung Injury Donor or patient has
cytotoxic
white cell n
antibodies (HLA or HNA)
Patient or donor has cognant antigen n
Symptoms within6 hours of transfusion n
Acute
injury to capillary-alveolar membrane of n
lungs
Protein-rich fluid leaks into alveolar air spaces n
Hypoxemia, fever, pulmonary edema n
All
require
O2 therapy, may require mechanical n
ventilation
Chest
x-ray:
pulmonary edema fluid without CHF n
changes

30. TRALI: Treatment& Diagnosis
Supportive care: n O
, mechanical ventilation, inotropic agents n 2
AVOID diuretics, steroids? n
Diagnosis: n
Demonstrate
HLA
and/or
HNA
antibodies
and n
matching antigen in patient and donor
Differential Diagnosis: n
congestive heart failure, acute left ventricular failure n
acute circulatory (volume) overload n
pulmonary embolism n
rapidly progressive pneumonia n
acute respiratory distress syndrome (ARDS) n

31. TRALI Prevention Frequency of TRALI related to amount of plasma in
blood product
Platelets and FFP> RBC n
Donors
with
history of
prior
pregnancies,
transfusion, n
tissue transplant at higher risk for HLA/HNA antibodies
Blood supplier (SBB) provides male-only
FFP n
Female AB
FFP
may
be provided if emergency FFP n
inventory shortage
Blood
providers
considering screening of platelet and n
FFP donors
History of
prior
pregnancies, transfusion, tissue n
transplants
HLA/HNA antibodies n

32. TRALI and Blood Products
Source: Fatalities Reported to FDA Following Blood Collection and
Transfusion, Annual Summary for 2006, March 2009

33. TRALI Edema Fluid

34. TRALI Edema Fluid

35. TRALI Chest X-Ray

36. Suspected Transfusion Reaction
STOP transfusion; Keep IV open with NS n
Promptly notify laboratory and attending MD n
Verify clerical information; n
Patient ID, bag tag and label n
Complete transfusion reaction report n
Order transfusion reaction workup in CareCast n
Send report with bag (tubing attached) to lab n
Lab will determine what samples need to be n
collected and contact pathologist on-call

37. Massive Blood Transfusion
one unit of whole blood equals 450 ml in US 37

38. Definition
Replacement by transfusion of more than 50 % of a patient's blood volume in hours
Adult patients requiring > 4 units of PRBCs in first hour of resuscitation or.
pediatric patient requiring > 20 ml/kg of PRBCs in first hour of resuscitation. 38

39. Problems in Massive Transfusion: Lethal triad
Hypothermia, acidosis, coagulopathy, usually occurs after uncontrolled bleeding often at 16 units. It exemplifies the issues associated with massive bleeding and volume and blood product replacement

40. Hypothermia
Reduces the enzymatic activity of plasma coagulation proteins
Has a greater effect by preventing the activation of platelets via traction on the glycoprotein Ib/IX/V complex by von Willebrand factor. In tests of shear-dependent platelet activation, this pathway stops functioning in 50 percent of individuals at 30º C, and is markedly diminished in most of the rest.

41. Acidosis
Interferes with the assembly of coagulation factor complexes involving calcium and negatively-charged phospholipids.
The activity of the factor Xa/Va/prothrombinase complex is reduced by 50, 70, and 90 percent at a pH of 7.2, 7.0, and 6.8, respectively.

42. COMPLICATIONS OF CITRATE INFUSION
Large amounts of citrate are given with massive blood transfusion, since blood is anticoagulated with sodium citrate and citric acid.
Metabolic alkalosis
Decline in the plasma free calcium concentration

43. Free hypocalcemia
Citrate binding of ionized calcium can lead to a clinically significant fall in the plasma free calcium concentration. This change can lead to paresthesias and/or cardiac arrhythmias in some patients

44. Goal of Massive Blood Transfusion
Maintain Hb >8 g/dl
Maintain platelet count >75 · 109 /L
Maintain PT & APTT < 1.5 · mean control
Maintain Fibrinogen > 1.0 g/L

45. The coagulation system should be frequently monitored with measurements of the PT, aPTT and platelet count, preferably after each 5 units of blood replaced.
If the PT and PTT exceed 1.5 times the control value, the patient should be transfused with 2 units of fresh frozen plasma. If the platelet count falls below 50,000/microL, 6 units of platelets should be given.

46. A blood warmer should be used whenever more than three units are transfused. Hypothermia should be either avoided or minimized.
Acid–base balance and the plasma ionized calcium and potassium levels should be periodically monitored, particularly in patients with coexistent liver or renal disease or in those with massive hemorrhage and low cardiac output