Blood and Blood Component Therapy by cuiliqing

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									  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
   Blood component therapy
   Complications of blood transfusion
   Methods to reduce blood transfusion
   Case Scenarios
Blood Grouping and
       Crossmatch
Blood Group Systems
   ABO system
   Rhesus system
   Other blood groups
       MN
       Lutheran
       Kell
       Duffy
       Kidd
     ABO Blood Groups
Blood group Red cells have           Plasma contains

     O       Neither A nor B antigen Both anti-A and
                                     anti-B Ab
     A       A antigen               Anti-B Ab
     B       B antigen               Anti-A Ab
     AB      Both A and B antigen    Neither anti-A nor
                                     anti-B Ab


   anti-A and anti-B are naturally occurring IgM
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
Compatibility testing
   Major complications
       incompatibility between donor’s red cells and
        antibodies in recipient’s plasma
   Three procedures
       Blood typing
       Antibody screen
       Cross-match
Blood grouping
   RBC
       Test with anti-A and anti-B Ab
       Test with anti-D Ab
   Serum
       Test with A and B RBC
Antibody Screening
   Recipient’s serum +
    commercially supplied RBCs
   Indirect antiglobulin test
Cross-matching
   Recipient’s serum + donor’s RBCs
       At room temp
       Incubate at 37C
       Antiglobulin serum
           Detect incomplete antibodies
Is Crossmatch Really Necessary?
                         Compatible transfusion
   ABO Rh typing              99.8%
   ABO Rh typing + Ab        99.94%
    screen
   Crossmatch                 99.95%
  Blood and blood
component therapy
  When will they be needed?
Red Cells
   Tolerance of anemia
       Maintenance of intravascular volume
       Ability to increase cardiac output
       Adaptive changes that increase oxygen delivery
           2,3 DPG
   Oxygen carrying capacity
         DO2= Cardiac Output (CO) x Oxygen Content (CaO2)
         Oxygen Content (CaO2): - (Hgb x 1.39) x O2 saturation +
          PaO2(0.003)
Oxygen dissociation curve and
2,3 DPG
   Transfusion trigger
    Hb level at which transfusion is necessary
         ? 10g/dL
         ? 8g/dL
         ? 6g/dL
         ? 4g/dL
   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
   Hb >10g/dL
       Generally not required transfusion
   Hb 7-10g/dL
       Acute/chronic blood loss, ongoing blood loss
       Age, cardiorespiratory status, intravascular volume
       Signs of inadequate perfusion
       Risks of transfusion
   Hb < 7g/dL
       Usually required transfusion
   Hb < 5g/dL
       Transfusion essential
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
Fresh Frozen Plasma
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
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)
   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
Platelets
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
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)
   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
   prophylactic platelet transfusion is
    ineffective and not indicated
       ITP
       TTP
       Heparin-induced thrombocytopenia
   Use only when these are assoicated with
    haemorrhage
   1 unit of platelets increases platelet count
    5000-10000 mm3 in 70kg adult
   1 unit / 10kg BW
   Complete transfusion in 4 hours
Cryoprecipitate
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
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
Selection of plasma products
     Recipient   ABO blood group of plasma for
    ABO blood
      group
                 transfusion
   Unknown       AB (if required urgently)

        O        O or A or B or AB

        A        A or AB

        B        B or AB

       AB        AB
Safe Administration of Blood
   Correct patient identity
       Blood taking
       Blood processing
       Before transfusion
   Check the package
   Correct method of storage
   0.9% NaCl or gelofuscine 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
Administration of Blood Products
   170-260 m filter
 Complications of
Blood Transfusion
Infections
    Bacterial contamination
    CMV, Hepatitis B, Hepatitis C, HIV, HTLV
    Malaria
    Syphilis
    Human Parvovirus B19
    ? vCJD
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 Hb
            Organ support – BP, renal blood flow, rx of DIC,
             coagulopathy
   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
   Febrile non hemolytic transfusion reactions
    (FNHTR)
       1:100
       Ig against donor WCC and platelets
       Fever, chills
       Mx
           Rule out Acute hemolytic reactions
           Anti-pyretics
           Use leukocyte-reduced blood products
   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
   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
   Anaphylaxis
       Congenital IgA deficiency, high titre of Ig to IgA
       Urticaria, bronchospasm, hypotension
       Mx:
           ABC, organ support
           Adrenaline, steroid, organ support
   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
Crit Care Med 2006 Vol. 34, No. 5 (Suppl.)
Biochemical Changes of Stored Blood
Metabolic Complications
    Fluid overload
    Citrate toxicity
    Metabolic acidosis
    Hyperkalemia, hypocalcemia
    Hypothermia
    Impaired O2 delivery
    Dilutional coagulopathy, thromocytopenia
Serious Acute Transfusion Rx
   TRALI
   Acute hemolytic transfusion reaction
   Sepsis
   Anaphylaxis
Case Scenarios
   Chronic                    Simple operation
   Asymptomatic               Expected blood loss
   Capability of further       low
    increase in cardiac
    output
   Bleeding tendency?
Case 1
   35/F
   Chronic menorrhagia due to uterine polyp
   Plan for hysteroscopic polypectomy
   Pre-operative assessment
       Hb 7, on Fe supplement
       Otherwise healthy and asymptomatic
   Would you transfuse her for the operation?
Case 2
   40/M
   RTA victim with polytrauma
   BP 90/50 HR 140 after 4L of crystalloid, Hb 5
   Will you transfuse?
   What type of blood products?
   When XM is available, will you give
    compatible blood products?
   Unmatched blood
       Group O neg
       Group O pos if O neg blood is not available
   Packed cells preferable to whole blood
       Significant Anti-A and Anti-B in Group O plasma
Goal of therapy during blood loss
   Maintenance of intravascular volume
   Maintenance of oxygen carrying capacity
   Maintenance of coagulation
   Maintenance of other functions
   Principle of fluid therapy
       Replenish intravascular volume
           Crystalloids : NS, LR (3:1 ratio)
           Colloids: gelofusin, haemacel, hetastarch
Massive Transfusion
   Transfusion of > 1 total blood volume within
    24 hours
       Consider metabolic complications
           Hypocalcemia
           Hypothermia
           Hyperkalemia
       Dilutional thrombocytopenia
       Dilutional coagulopathy
   When you are about to transfuse
       Wife declares that patient is a Jehovah witness
       He wears a JW bracelet
   Will you transfuse him?
Case 3
   70/M
   Bleeding DU, post endoscopic hemostatsis
   Hb 6, transfusion is in progress
   He develops fever and chills during
    transfusion of the second unit of blood
   What are the differential diagnosis?
   DDx
       FNHTR
       Allergic reaction
       Bacterial contamination
       TRALI
       HTR
       Anaphylaxis
   Stop transfusion
   Assess the patient
   Symptoms and vital signs
       Rash, chills, SOB, fever, urine, BP/P, SaO2
   Investigations
   Treatment
       Supportive treatment
       anti-pyretics, anti-histamines, steriods
The End

								
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