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Blood and Blood Component Therapy

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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