1 / 83

Blood Product Transfusion

Blood Product Transfusion. Rational use Complications and its management Dr Chu Po Ngai Alvin 13 Feb 2009. Take home message…. Drug Art > solid evidence Look out for complications. Blood components. Red blood cells Platelets Fresh Frozen Plasma Cryoprecipitate. Red blood cells.

susan
Télécharger la présentation

Blood Product Transfusion

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Blood Product Transfusion Rational use Complications and its management Dr Chu Po Ngai Alvin 13 Feb 2009

  2. Take home message… • Drug • Art > solid evidence • Look out for complications

  3. Blood components • Red blood cells • Platelets • Fresh Frozen Plasma • Cryoprecipitate

  4. Red blood cells • Red cell transfusions increase the oxygen carrying capacity of blood by raising the Hb concentration • Avoid tissue hypoxia • 1 unit • 300ml volume • Hb concentration 18-23 g/dL • 1 unit -> ↑ Hb 1 g/dL

  5. Anaemia, eg. • Bleeding • Anaemia of critical illness (decreased EPO production with abnormal iron metabolism) • Historical indication for transfusion • Hb 10 g/dL or Hct 0.3

  6. Infection risk (eg. HIV, hepatitis, vCJD) • Adverse reactions • Limited supply

  7. Compensation for anaemia: • Acute isovolaemic anaemia to Hb 5g/dL in volunteers and patients produced no evidence of inadequate oxygenation (Weiskopf, 1998)

  8. Crit Care Med, 2004, Vol 32:1

  9. Mean Hb level at baseline was 11.0 • 44% of patients received one or more RBC units while in the ICU (mean 4.6 +/- 4.9 units) • Mean pre-transfusion Hb was 8.6 +/- 1.7 g/dL • Mean time to first ICU transfusion was 2.3 +/- 3.7 days

  10. The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital length of stay, and an increase in mortality • Corrected for baseline Hb + severity of illness (APACHE/SOFA) • Exposure to leukocytes in transfusions trigger an immune response in the recipient, leading to: • Increased risk of infection (esp. trauma, burns, surgery) • Earlier recurrence of malignancy

  11. Hb level rather than clinical or physiologic factors drives transfusion decisions • Time to first transfusion was significantly longer in those patients who presented with a high baseline Hb • 1.8 days with baseline Hb of 8 g/dL • 6.3 days with baseline Hb of 12 g/dL • p=0.05

  12. JAMA, 2002, Vol 288:12

  13. Mean Hb (on admission) 11.3 g/dL • 29% had Hb < 10 g/dL • Transfusion rate: 37%

  14. ICU mortality rate higher in those with transfusion • (18.5% vs 10.1%, p < 0.001) • Overall mortality rate higher in those with transfusion • (29.0 vs 14.9%, p < 0.001) • For similar organ dysfunction, patients with transfusion had higher mortality rate • For matched patients, 28-day mortality was higher in those with transfusion • (22.7% vs 17.1%, p=0.02)

  15. British Committee for Standards in Haematology (BCSH), Guidelines for the clinical use of red cell transfusions • National Health and Medical Research Council (NHMRC), Clinical practice guidelines on the use of blood components • American Society of Anesthesiologists, Practice Guidelines for Blood component therapy

  16. Consideration of the patient’s condition is essential • cause of anaemia, severity, chronicity • patient’s ability to compensate (age > 65, cardiovascular / pulmonary disease) • likelihood of further blood loss • need for provision of reserve before onset of tissue hypoxia

  17. Need for transfusion based on Hb level: • Hb > 10 – no transfusion (Level I) • Hb < 7 – transfuse (Level IV) • Hb 7-10 - no clear guideline, but evidence suggests usually transfusion not justified • Lower threshold (Hb < 8) for transfusion if patient likely to tolerate anaemia poorly • eg. > 65y, cardiovascular / respiratory disease

  18. Need for transfusion based on estimation of blood loss: • 15% (750ml): no transfusion, unless preexisting anaemia or unable to compensate (severe cardiac / respiratory disease) • 15-30% (800-1500ml): IVF, no transfusion unless preexisting anaemia or unable to compensate • 30-40% (1500-2000ml): IVF, transfusion probably required • >40% (>2000ml): IVF + transfusion

  19. Similar guidelines for peri-operative patients, but importance of avoiding transfusions • Eg. Fe for Fe deficiency, stop anti-platelet drugs (Aspirin), reverse anticoagulation (Warfarin) • Importance of volume replacement, maintenance of BP and cardiac output

  20. Dose • 1 unit PC -> ↑ 1 g/dL Hb

  21. Platelets • Prevention and treatment of haemorrhage in patients with thrombocytopenia or defective platelets • 1 unit • about 5 x 1010 platelets • 150-300ml volume • Dose: 1 unit per 10kg body weight • 1 unit increases platelet count by 5-7 x 109/L • Check post-transfusion Plt count after 1 hour

  22. Transfusion, 2006, Vol 46

  23. Retrospective cohort study, single centre • 118 ICU patients with thrombocytopenia • Median APACHE II score 26 • Trauma / cardiac surgery / orthopaedic patients excluded

  24. Prophylactic (44.7%) • median transfusion trigger = 33 x 109/L • Therapeutic (31.6%): • median transfusion trigger = 51 x 109/L • Peri-procedure (23.7%): • median transfusion trigger = 46 x 109/L

  25. Platelet count response • Median platelet count increase after 1 unit = 14 x 109/L • No increase in platelet count (ineffective transfusion) was observed after 17 transfusions given to 13 (48.1%) of 27 transfused patients

  26. BCSH 03 • NHMRC 01

  27. Transfuse if: • < 10 x 109/L, w/o risk factors (bleeding, fever, antibiotics) (Level II) • < 20 x 109/L, w/ risk factors (Level II) • ≤ 50 x 109/L, undergoing surgery / invasive procedure, massive haemorrhage, massive transfusion (1.5-2.0 blood volumes, or > 10 units RBC within 24 hours) (Level IV) • ≤ 100 x 109/L, undergoing neurosurgery / eye surgery, diffuse microvascular bleeding (Level IV)

  28. No benefit from platelet transfusion, may even be harmful (Level IV) • Immune-mediated platelet destruction • TTP • HUS • Post-cardiac bypass surgery without bleeding • Drug induced thrombocytopenia without bleeding

  29. Fresh Frozen Plasma • Treatment of excessive bleeding or prevention of bleeding in patients with abnormal coagulation • Dose: 10-20ml FFP/kg body weight • 1 dose expected to increase level of coagulation factors by 15-20% immediately after transfusion (ie. 1ml FFP/kg body weight raises coagulation factors by about 1%) • Bolus • Volume: 180-400ml/unit

  30. Indications are very limited

  31. Journal of Trauma, 2008; Vol 65(2)

  32. Retrospective review, single centre (Denver Health Medical Center), 2001-2006 • Massive transfusion (> 10 units RBC in initial 6 hours)

  33. Journal of Trauma, 2007; 63:805-813

  34. Retrospective chart review, 246 patients, single centre (one US Army combat support hospital in Iraq), 2003-2005

More Related