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Blood and Blood Component Therapy

Blood and Blood Component Therapy. Dr Andrea Yu Department of Anesthesia and Intensive Care. Basic Knowledge …. Components of blood Functions of blood and blood components Blood groups Screening of pathogens in blood. Topics to be covered …. Blood grouping and cross-matching

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Blood and Blood Component Therapy

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  1. Blood and Blood Component Therapy Dr Andrea Yu Department of Anesthesia and Intensive Care

  2. Basic Knowledge … • Components of blood • Functions of blood and blood components • Blood groups • Screening of pathogens in blood

  3. Topics to be covered … • Blood grouping and cross-matching • Blood component therapy • Complications of blood transfusion • Methods to reduce blood transfusion • Case Scenarios

  4. Blood Grouping and Crossmatch

  5. Blood Group Systems • ABO system • Rhesus system • Other blood groups • MN • Lutheran • Kell • Duffy • Kidd

  6. ABO Blood Groups • anti-A and anti-B are naturally occurring IgM

  7. Rhesus system • Many types of Rhesus antigen identified • RhD Ag is the most antigenic • Rh positive • RBC having D antigen • Rh negative • RBC without D antigen • Anti RhD Ab are IgG

  8. Compatibility testing • Major complications • incompatibility between donor’s red cells and antibodies in recipient’s plasma • Three procedures • Blood typing • Antibody screen • Cross-match

  9. Blood grouping • RBC • Test with anti-A and anti-B Ab • Test with anti-D Ab • Serum • Test with A and B RBC

  10. Antibody Screening • Recipient’s serum + commercially supplied RBCs • Indirect antiglobulin test

  11. Cross-matching • Recipient’s serum + donor’s RBCs • At room temp • Incubate at 37C • Antiglobulin serum • Detect incomplete antibodies

  12. ABO Rh typing ABO Rh typing + Ab screen Crossmatch Compatible transfusion 99.8% 99.94% 99.95% Is Crossmatch Really Necessary?

  13. Blood Component Therapy Whole blood/packed red cells

  14. Function of Blood • Intravascular volume • Oxygen carrying capacity • DO2= Cardiac Output (CO) x Oxygen Content (CaO2) • Oxygen Content (CaO2): - (Hgb x 1.39) x O2 saturation + PaO2(0.003)

  15. Tolerance of blood loss • Maintenance of intravascular volume • Ability to increase cardiac output • Age, co-morbidities • Increase in oxygen delivery by 2,3-DPG • Acute/chronic, rate of loss of blood

  16. Oxygen dissociation curve and 2,3 DPG

  17. Principle of fluid therapy • Replenish intravascular volume • Crystalloids : NS, LR (3:1 ratio) • Colloids: gelofusin, haemacel, hetastarch • Restore oxygen carrying capacity

  18. Transfusion trigger • Hb level at which transfusion is necessary • ? 10g/dL • ? 8g/dL • ? 6g/dL • ? 4g/dL

  19. Restrictive transfusion • Hb 7-9 g/dL • Liberal transfusion • Hb 10-12 g/dL • 30-day mortality • 18.7 % vs 23.3% (P= 0.11) • significant cardiac disease 20.5% vs 22.9% (P=0.69) NEJM 340(6):409-417

  20. Hb >10g/dL • Generally not required transfusion • Hb 7-10g/dL • Consider acute/chronic blood loss, ongoing blood loss • Age, cardiorespiratory status, intravascular volume • Risks of transfusion • Hb < 7g/dL • Usually required transfusion • Hb < 5g/dL • Transfusion essential

  21. How much to give? • Packed cells • 4-5ml/kg to raise Hb 1g/dL • Whole blood • 8-10ml/kg to raise Hb 1g/dL • Complete transfusion in 4 hours

  22. Blood Component Therapy FFP, platelets, cryoprecipitate

  23. FFP • Separated and frozen within 18hrs after collection of whole blood • Contains all coagulation factors • Including labile factors V & VIII • Volume: 200-250 ml • Shelf life: 12 months at -25°C • ABO compatibility essential

  24. Indication for FFP transfusion • Urgent reversal of warfarin effect • DIC with bleeding • Microvascular bleeding in the presence of elevated (>1.5 times normal) PT or APTT • Coagulopathy after massive transfusion • Coagulation factor deficiency (when specific concentrates are unavailable)

  25. Dose: 10-15ml/kg • Thawed before administration • Once thawed • Infuse immediately, or • Stored at 2-6°C for up to 24 hours • Complete infusion in 4 hours

  26. Platelet Concentrates • Platelets separated from a single unit of whole blood • suspended in a small amount of the original plasma • Volume: 40-60ml • Shelf life: 5 days at 20-24°C • Agitated gently and continously on a platelet shaker during storage • ABO compatible platelets preferable

  27. Indications for Platelet Tranfusion • actively bleeding • Platelet count <20,000/mm3 • Platelet count <50,000/mm3 in the setting of additional risk factors (sepsis, concurrent antibiotic use, uraemia)

  28. absence of active bleeding: • Platelet count <5,000/mm3 • Platelet count <20,000/mm3 + a high risk of bleeding or in children undergoing a lumbar puncture • Platelet count <50,000/mm3 in a patient to undergo any invasive procedure • Platelet count <100,000/mm3 if procedure involves the CNS or eye

  29. prophylactic platelet transfusion is ineffective and not indicated • ITP • TTP • Heparin-induced thrombocytopenia • Use only when these are assoicated with haemorrhage

  30. 1 unit of platelets increases platelet count 5000-10000 mm3 in 70kg adult • 1 unit / 10kg BW • Complete transfusion in 4 hours

  31. Cryoprecipitate • Prepared by: • Thawing fresh frozen plasma between 1-6°C • Recovery the precipitate • The precipitate is then refrozen • Factor VIII, Factor XIII, vwF, fibrinogen and fibronectin • Volume: 10-40ml • Shelf life: 12 months at -25°C • ABO compatibility preferred

  32. Indications for Cryoprecipitate Transfusion • Bleeding due to hypofibrinogenemia or dysfibrinogenemia • DIC with fibrinogen and FVIII depletion • Prophylaxis or treatment of significant FXIII deficiency • 1-1.5u / 10kg BW

  33. Selection of plasma products

  34. Safe Administration of Blood • Correct patient identity • Blood taking • Blood processing • Before transfusion • Check the package • Correct method of storage

  35. Administration of Blood Products • 170-260 m filter

  36. 0.9% NaCl can be infused with blood • Most other commonly used solutions are not compatible with blood • D5 • Haemolysis due to hypontonicity • Lactated ringers/Haemaccel • Calcium leads to clotting

  37. Complications of Blood Transfusion

  38. Infections • Bacterial contamination • CMV, Hepatitis B, Hepatitis C, HIV, HTLV • Malaria • Syphilis • Human Parvovirus B19 • ? vCJD

  39. Immune-mediated Complications • Acute hemolytic reaction • 1:12,000-77,000 • ABO incompatibility, mediated by IgM • Fever, chills, SOB, hemolysis, hemoglobinuria, MODS, DIC, death • Mx • Stop further transfusion • Send the remaining blood to blood bank • CBP, RFT, clotting, LDH, haptoglobin, urine Mb • Organ support – BP, renal blood flow, rx of DIC, coagulopathy

  40. Delayed hemolytic reaction • 1:4,000-9,000 • Previously sensitized patients with low IgG titre • Rh and Kidd systems • Hemolysis a few days after blood transfusion • Mx: • Type and screen • Transfusion with compatible blood

  41. Febrile non hemolytic transfusion reactions (FNHTR) • 1:100 • IgG against donor WCC and platelets • Fever, chills • Mx • Rule out Acute hemolytic reactions • Anti-pyretics • Use leukocyte-reduced blood products

  42. Allergic reactions • Very common, 1-3% of plasma transfusion • Donor plasma proteins react with recipient’s mast cells • Urticaria, itching, laryngeal edema • Mx • Rule out anaphylaxis • Anti-histamine, +/- steroid • Saline–washed RBCs, slower infusion rate

  43. Anaphylaxis • Congenital IgA deficiency, high titre of IgG to IgA • Urticaria, bronchospasm, hypotension • Mx: • ABC, organ support • Adrenaline, steroid, organ support

  44. Transfusion-related acute lung injury • 1:5000 – 1:10000 plasma containing blood products • Donor anti-leucocyte Ab reacts with recipient WCC in pulmonary vasculature • Acute respiratory distress < 6 hours after transfusion • Hypoxemia, bilateral lung infiltrates, hypotension, fever • 80% improve rapidly within 48h, 5-10% mortality • Mx • Organ support

  45. TAGvHD • transfused immunocompetent lymphocytes directed against an immunocompromised host • Mx • Irradiated RBC and platelets • Immunomodulatory effect • Increase risk of recurrence of cancers • Increase risk of post-operative infection

  46. Alloimmunisation • Blood products exposes patient to: • Red cells • White cells • Platelet antigens • Plasma proteins • Patients may develop antibodies in response to foreign antigen exposure

  47. Biochemical Changes of Stored Blood

  48. Metabolic Complications • Fluid overload • Citrate toxicity • Metabolic acidosis • Hyperkalemia, hypocalcemia • Hypothermia • Impaired O2 delivery • Dilutional coagulopathy, thromocytopenia

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