blood products 2016
TRANSCRIPT
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BLOOD & BLOOD PRODUCTS
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GOALS
1. To know variety of blood products2. To know right time and indications to start
blood or blood products transfusion3. To know the complications of massive
transfusion
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PREGNANCY & BLOOD LOSS Pregnant women has an increased blood
volume of about 20-30% Blood volume estimation - about 100ml/kg 60kg = 6 litres of blood
As such 1.0L of blood loss in a pregnant woman is not the
same as 1.0L of blood loss in a non-pregnant woman 1.0L of blood loss in a 80kg woman is different from
a 40kg woman
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CHANGES IN VITAL SIGNS WITH BLOOD LOSS
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VITAL SIGNS When abnormal in the context of haemorrhage,
they are useful in assessing the severity of the hypovolemic shock
When normal however, they are not reliable in assessing the severity of the hypovolemic shock Remember that a drop in BP is a late sign of
hypovolaemia! Patient has lost at least 30% of her blood volume!!!
Should not rely on BP to assess volume loss!!!
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LOSS OF CIRCULATING VOLUME
Replacement with crystalloids - every ml blood loss, 3ml crystalloids needed 3 to 1 ratio
Replacement with colloids – every ml blood loss, 1.5 ml colloids needed 3 to 2 ratio
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VARIETY OF BLOOD COMPONENTS
Whole blood Red blood cells
Packed cells Platelet Fresh frozen plasma Cryoprecipitate
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VARIOUS BLOOD PRODUCTS
Blood products
Volume (ml/unit
)
Contents Effects Compatibility
Packed red cells
280 +/- 50
RBC, WBC, plasma
Increase HCT by 3%, increase HB by 1gm/dL
ABO and RH
Platelets 50 +/- 10
PLT, RBC, WBC, plasma
Increase PLT between 5-10 x 109/L
ABO and RH
Fresh Frozen plasma (FFP)
200 – 250
One IU/ml of all coagulation factors; 400mg of fibrinogen per unit
Increase fibrinogen by 10mg/dL
ABO, no need RH compatibility
Cryoprecipitate
40 +/- 10
Fibrinogen, factorsVII, III, XIII, VonWillerbrand factorFibrinogen, factor VIII, XIII, Von Willebrand factor, fibronectin
Increase fibrinogen by 10mg/dL
ABO, no need RH compatibility
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INDICATION FOR TRANSFUSION – WHOLE BLOOD
Whole blood vs Packed cells No data to suggest that the use of whole blood, even “fresh” is associated with better outcome in acute blood loss Usually used in exchange transfusion For acute blood loss
Give specific blood components as required: Packed cells Platelet concentrate FFP
Cryoprecipitate - Factor I, VIII, vWF (+ XIII, fibronectin) Cryosupernatant
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INDICATION FOR TRANSFUSION – RED CELLS
Acute blood loss Based on haemoglobin concentration
Hb > 10 g/dl – not indicated Hb < 7 g/dl – indicated Hb 7 – 10 g/dl – less clear; depends on situation and
patient Based on risk of further blood loss
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Based on estimation of blood lossCirculating volume lost
Signs Replacement
15% (750 mls)
Mild increase in PR -
15 – 30% (800 – 1500 mls)
Increase PRIncrease breathing
Use crystalloids or colloids to replace fluid loss
30 – 40%(1.5-2.0L)
Increase PRIncrease breathingFall in BP
Use crystalloids or colloids to replace fluid lossRed cells transfusion likely be required
>40%(Over 2 L)
Immediate life threatening
Blood transfusion is required immediatelyNeed rapid transfusion
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Major problem!!!!!Underestimation of blood lost often
happens!!Therefore, clinical signs of shock are
important
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Other indications Perioperative haemoglobin optimisation Chronic anaemia Anaemia in critical care
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RAPID BLOOD TRANSFUSION IN LIFE THREATENING CONDITION
BP cuff (high-pressure infusion devices) No blood filters With warmers
O-ve or O +ve blood Unmatched blood
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INDICATION FOR TRANSFUSION OF OTHER BLOOD PRODUCTS
Platelet In DIVC or at platelet transfusion trigger of 75,000/l
Fresh frozen plasma and cryoprecipitate In DIVC (evidenced clinically or from coagulation
screen) with evidence of bleeding There is no evidence for prophylactic
FFPntransfusion to prevent DIVC or to reduce transfusion
In massive transfusion FFP should be administered for every 6 units of red
cells transfusion; aim to maintain APTT < 1.5 Cryoprecipitate should be administered early in major
obstetric haemorrhage to keep fibrinogen > 1.5 g/l
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DIVC IN OBSTETRICS Consumption coagulopathy (depletion of
platelets and coagulation factors) that leads to further haemorrhage
Can be due to: Massive bleeding (e.g. APH, PPH, abruption) Sepsis Amniotic fluid embolism Eclampsia IUD
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Treat the underlying cause (sepsis, massive blood loss, severe vessel injury, toxins)
Transfuse platelet if bleeding associated with thrombocytopaenia. Aim for > 50 x 109 /L (C, IV) Platelets should not be allowed to fall <50 x 109 in
acutely bleeding patient
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If bleeding continues after large volumes red cell and platelets have been transfused, FFP and cryoprecipitate may be given (depending on protocol e.g. after 10 units of RBCs, abnormal coagulation profile, etc)
Transfuse FFP and cryoprecipitate so that the PT and APTT ratios are within 1.5 and a fibrinogen level of > 1.0 g/ L
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Adequate resuscitation from shock - most important in preventing coagulopathy
No evidence that prophylactic regimes prevents or reduce transfusion requirements
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DIVC REGIMES?? Various regimes depends on hospital protocol Need to contact Transfusionist medicine specialist
for MTP (Massive blood transfusion protocol) Depends on patient’s body weight and also clinical
situation
NO LONGER 6U FFP, 4U Platelet, 2U cryopercipitate
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THERAPEUTIC AIMS OF MANAGEMENT
FACTOR AIMS1. HB > 8 g/dL2. Platelet > 50K3. PT/ PTT ratio < 1.5 4. Fibrinogen level > 1.0 g/dL
Adapted from Malaysian CPG on blood transfussion
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MASSIVE BLOOD LOSS Replacement of total blood volume (5 L) within 24
hours Loss of 50% blood volume in less than or equal to
3 hours 150ml/ min blood loss (Loss of half the blood
volume in 20 minutes) Transfusion of more than 20 units of erythrocytes
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COMPLICATIONS OF MASSIVE TRANSFUSION
Hypothermia Acid-base disturbance – metabolic alkalosis >
acidosis Thrombocytopenia & reduced factor I,V,VIII Electrolyte imbalance
Hypokalemia > Hyperkalemia Hypocalcemia & citrate intoxication
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QUESTIONS??