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Blood and blood products Indications for transfusion

Blood and blood products Indications for transfusion. Janusz Andres. What is inside the package?. Whole blood: polivinylochloride bag with antykoagulants and conservants (100 ml in 450 ml) Adenine (50-ties) Today: citric-phosphorate-dextrose. Whole blood.

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Blood and blood products Indications for transfusion

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  1. Blood and blood productsIndications for transfusion Janusz Andres

  2. What is inside the package? • Whole blood: polivinylochloride bag with antykoagulants and conservants (100 ml in 450 ml) • Adenine (50-ties) • Today: citric-phosphorate-dextrose

  3. Whole blood • Additional volume: 1.4-2.5 ml/10 ml blood • Acids (from 3 do 8 g/l) and glucose (ok. 45 g per 100 ml) • Besides anticoagulants there are some adjuvants: , phosphate, adenin, guanosin, glukose, mannitol

  4. Whole blood • Changes in blood during storing (40C): Na-K pump, K+ may reach 40 mEq/L lub 80 mEq/L after 3-4 weeks of storing (after 42 days 100 mEq/L), pH and ATP/ADP decreases, xantine and hipoxantine increases (reperfusion injury), adeniny – metabolism, citrate - hipotensja

  5. Whole Blood • Leukocytes even after antyleukocytes filters. Leukocytes are alive and induce immunosupression (recipient DNA seen even after year), old blood – increases of: Il6, Il8, TNF alpha (in 28 day level may increase 50 times), bradykinin, C3a, C5a, serotonin

  6. Whole Blood • 70% erythrocytes must be alive (FDA) after 42 days, but after 24-48 h formation of eichinocytes i and shistocytes (after 30 days 80%) – „reanimated” 24 h after administration • Microagregates (from 30 RBC) may induce flow disturbances • Decrease in 2,3DPG needs 24 h for Hb to be normal in oxygen delivery

  7. Risk factors in 90-ties Infections Viral Frequency/unit death/milion Hepatitis A 1 / 1 000 000 0 Hepatitis B 1 / 50 000 – 1/170 000 0,14 Hepatitis C 1 / 30 – 1 / 150 000 <0.5 HIV 1 / 200 000 – 1/2 000 000 <0,5 Parvovirus B19 1/10 000 0

  8. Current frequency of risk HIV - 1: 1 400 000 HBV – 1: 31 000 HCV – 1 : 135 000 Bakterie – 1 : 4 000 000 vCJD – published

  9. Risk factors Immunological complications • Linear increase in infection rate in gastrointestinal, cardiac- and thoracic surgery • Increase lenght of stay in ICU • Cost increase • Cancer disease

  10. Risk factors Immunological complications Hemolytic reactions 1 / 250 000 Delayed hemolytic reaction 1 / 1 000 TRALI ? Transfusion-related acute lung injury

  11. T R A L I Transfusion-related acute lung injury Signs after 2-4 h Dyspnea Hipotention Increase in temperature Pulmonary oedema 1 / 5 000 Unit transfused Antyleucocytes antibody Predisposing factors: infections surgery massive transfusions

  12. FFP • No erythrocytes, no metabolism • 1 U FFP (200 ml): 400 mg fibrynogen and 1 UA/ml clothing factors • V,VII most unstable • Very complicated scanning system for viruses • Crioprecypitat: 180 mg fibrynogen (20 ml), factor VIII 80-120 U

  13. Indications for FFP transfusion • Massive blood transfusion > 1 blood volume or > 10 U./24 godz. + hemorrage + increase in  PT, INR or aPTT • DIC active hemorrage +  PT, INR lub aPTT

  14. FFP transfusions (2) • Vit. K deficiency • Anticoagulant therapy • Liver injury + PT, INR, aPTT > 1,5x + Serious bleeding Surgery Invasive diagnostic procedures

  15. Contraindication for FFP transfusions • Volume replacement • Hypoalbuminemia and/or nutrition problem • Hypogammaglobulinemia • Hemofilia and/or von Willebrandta Syndrome • Genetic disorders (clothing factor deficiency)

  16. Platelets • 1 U consists with 5.5 x 1010 platelets w 50 ml of plasma (1 U „aphoresis” 30 x 1010) • Storage in 22oC 5 days (in 4 0C plts dying) • Only 40-60% platelets are active (no nucleus, apoptosis) • Interactions with leukocytes and cytokines (stroke)

  17. Indications for platelets infusion • < 30-50 x 10 9/L with active bleeding and/or risk of bleeding • < 10 x 10 9/L always • Expected effect: 5 x 10 9/L increase for 1 Unit transfused. • HIT

  18. Posttransfusion reactions • Shock and hemolysis • Delayed hemolysis • Fever • Allergy • Volume overload • Pulmonary oedema • Sepsis • Thrombocytopenia • „Graft versus host reaction”

  19. Conclusion 1 There is a risk asssocieted with blood and blood products transfusion

  20. When we have to transfuse? • Hemodynamic instability • Lost of blood • Hemoglobin level

  21. Clinical scenario Injury (bleeding?) Diagnosis of bleeding Tachycardia Low blood pressure Bad peripheral perfusion Low diuresis TRANSFUSION: what? Hypovolemia Stress reaction – catecholamin overshoot Oxygen transport disturbances

  22. Compensations mechanisms in DO2in anaemia •  Blood viscosity *  SVR *  venous return •  CO (up to Ht 30% no additional work for the heart) * tachycardia *  contactility •  tissue O2 extraction * right shift of the Hb oxygenation curve *  level of 2,3-diphosphogliceride in erythrocytes

  23. Goal Directed Therapy Rivers 2001 • ScvO2 > 70% increses survival in sepsis • Do we have GDT in blood transfusion? • What kind of goals? ScvO2, lactate, DO2?

  24. Physiology and pathology • DO2 = CI x Hb x Sa02 x 13.9 (ml/min/m2) • Norma = 3 x 12 x 0.96 x 13.9 = 500 • Anemia = 6x 6 x 0.96 x 13.9 = 500 • Hipoksemia= 6 x 12 x 0.48 x 13.6 = 500 • Low output syndrome = 1.5 x 12 x 0.96 x 13.6 = 250

  25. Oxygenation/Saturation exercise CO SvcO2=SaO2 – (VO2/CI x Hb x 13.9) hipoxaemia anaemia

  26. Physiology and pathology V02=CI x Hg x (Sa02 – Sv02) x 13.9 norma=3 x 12 x (0.96-0.72) x 13.9=125 anemia=4.5x 6 x (096-0.63) x 13.9=125 hipoksemia=6x 12 x (0.48-0.36)x13.9=125 low output=1.5x 12 x (0.96-0.63)x13.9=125 exercises=4.5x12x (0.96-0.63)x13.9=250

  27. Do we need blood for critical care pts? Napolitano LM, Crit Care M, 2004 • Are there signs of oxygenation improvement? • Do transfusions really decrease mortality? • What about the age of blood? • When transfusions cause increase in mortality?

  28. Conclusion 2 The clinical scenario and individual patient conditions are decision making factors not the Hb level

  29. Viele MK, Weiskopf RB., Transfusion 1994;43:396-401. • 54 publications, 134 patients • Hb 5 – 8 g% no mortality due to anaemia • Hb < 5 g% - mortality rate 37%

  30. Hebert PC. et al., JAMA 1999; 340: 409-417 • Group I - transfusion restriction (n=418) Hb 7 - 9 g% mortality: 77 pts (18%) • Grupa II – liberal strategy (n=420) Hb 10 – 12 g% mortality: 101 pts (24%) • APACHE II < 20 p. and pts < 55 years old – mortality decreases about 50% in gr.I

  31. Criteria TRICC (Canada) Hebert P.C. et. al. TATM 2002,2,15 • Hb 8.5 g/l versus 10.5 g/l in two groups • Cardiac diseases (278 pts) and artificial ventilation (714 pts) • Eccept pts with MI and unstable CAD transfusion trigger Hb 7 g% is save in both groups

  32. Increase risk of hypoxaemia • Age (> 65 lat) • Cardiovascular and pulmonary diseases • Cerebrovascular diseases

  33. Pts > 65 year with MI treated nonivasively • Wu W.C. et al.NEJM 2001,345,1230-36 • 79 000 pts: • Low Ht at admission– increase mortality • Ht 30-33% + transfusion = better outcome • Ht > 36% +transfusion = higher mortality rate

  34. Rao JAMA 2004, 1555-1562 PTS with MI and acute coronary syndrome • Blood transfusion in pts with Ht > 33% increases mortality • The best results of transfusion in pts with Hg 8 – 9 g%

  35. ICU pts blood transfusion indications: Marcucci C. 2005 Yearbook of IC 1. Except 2,3,4: Hg 6g%, PvO2<32mmHg, Ex02>50% 2. Pts > 80 age: Hg 7g% 3. CAD: Hg 8g% 4. CNS, fever: Hg 7g%

  36. ASA Guidelines • Rare indications with Hb > 10 g% and almost always with Hb < 6 g% • Hb 6 - 10 g% decision make upon: • Risk of inadequate oxygenation • Rate of bleeding • Cardiopulmonary status of the patient • Oxygen consumption/ requirements

  37. When? • Hb < 6 g% yes • Hb > 10 g% no • Hb 6 – 10 g% ?

  38. Conclusion 3 Patients with advanced age and cardio-pulmonary deseases, fever, unstable or critical state require individual assesments indications for blood transfusions

  39. Thanks for your attention

  40. Wniosek końcowy (Hebert 2005) • Przetaczamy krew od poziomu Hg 7g% (70 g/L) • Pacjenci w stanach krytycznych powinni mieć poziom Hg 7 – 9 g% (70 -90 g/L)

  41. Jak leczyć ostrą utratę krwi w kardiochirurgii? • „Protamine” • „Prolene” • „Platelets” • „Plasma” • rFVIIa (NovoSeven) • „Prayer”

  42. Fakty fizjologiczne • Anemia: wpływa na krzywą dysocjacji, wzrost CO, SV, HR, wzrost aktywności układu współczulnego, obniżenie oporów obwodowych, redystrybucja przepływu, wzrost przepływu mózgowego i wieńcowego, obniżenie kurczliwości m. sercowego u chorego z chorobą wieńcową

  43. Farmakologiczne metody • Aprotynina (Trascolan) • Kwas epsilon-aminokapronowy • Kwas tranexamowy • Operacje serca, wątroby, ortopedyczne,

  44. Hebert PC NEJM 1999, 340,409-417 Opcja restrykcyjna ? Cel: Poziom hemoglobiny 7-9 g/dl (8,5+-0,7) Przetoczono 2,6 (+-4) j kkcz Uniknięto transfuzji u 33 % chorych Opcja liberalna ? Cel: Poziom hemoglobiny 10-12 g/dl (11,2+-0,7) Przetoczono 5,6 (+-5,3) j kkcz Nie uniknięto transfuzji 900 chorych

  45. Wskaźniki transportu tlenu • PvO2 • SvO2 < 55% Paone G. Silverman N.A.; Circulation 1997; 96(suppl 9): II 205-208 • VO2 • O2 ER (CaO2 – CvO2)/CaO2 > 50%  stęż. mleczanów

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