blood trasnsusion-2007

BLOOD TRANSFUSION –CLINICAL IMPLICATIONS

DR.BADER SHAHEEN

07-03-2007

BLOOD TRANSFUSION –CLINICAL IMPLICATIONS

Introduction

Blood grouping

Compatibility tests

Emergency Transfusion

ASA – 2005 guidelines

Storage of blood

Efficacy – blood transfusion

Complications

Jehovah’s Witnesses

GIVE BLOOD, MAKE DIFFERENCE

• SAVE LIFE

• ENDAGER LIFE

“ ANESTHESIOLOGIST ADMINISTER

OVER HALF OF ALL BLOOD GIVEN TO

PATIENTS”

( Survey conducted by the committee of American Society of Anesthesiologist on blood & blood products )

BLOOD GROUPS

ABO System

Rhesus System

Other System

LewisMNS

Kidd

Duffy

BLOOD GROUPS ( Contd . )

ABO System

Lansteiner ( 1901 )

RELATIVE FREQUENCIES OF ABO GROUPS IN DIFFERENT POPULATIONS

Blood Group Naturally occuring UK Bengalese Vietnamese

antibodies ( IgM) ( % ) ( % ) ( % )

O Anti-A anti-B 47 22 45

A Anti-B 42 24 21

B Anti-A 08 38 29

AB None 03 16 05

BLOOD GROUPS ( Contd . )

Rhesus System

Lansteiner & Weiner (1940 )

Antigens- D, C , c, E, e ø d-antigen

Rh (D ) Antigen

Rh (D) positive 85 %

IgG Antibodies upon sensitizatiionHemolytic disease of Newborns

Rh (D) Negative 15 %

The probability of developing Anti-D Ab. Upon single exposure to Rh (D) antigen is 50-70%

COMPATIBILTY TESTS

ABO- Rh type

Cross match

Antobody screen

COMPATIBILTY TESTS (Contd.)

ABO groupingIncompatitility – Most severe acute heomolytic transfusion

IgM Ab Intravascular heomolysisComplement system

Test ( 2 steps )

I

Serum ( Anti-A Ab)

Patients’s RBC

Serum ( Anti-B Ab)

Heamolysis( A , AB)

NoHeamolysis

( O, B)Heamolysis NoHeamolysis( B, AB) ( O, A)

II Pt’s Serum +RBC (Known Ag ) Confirm blood type

Rh typing: Anti-D Antibodies

COMPATIBILTY TESTS (Contd.)Cross matching

Trial transfusion in a test tube

( Donor RBC + Recipient Serum )45 – 60 minutes

Three phases

A Immediate phase ( 1-5 minutes )ABO incompatibility

Ab against MN,P Lewis systemsB Incubation phase ( 30-45 minutes )

Detects incomplete Ab

Primary Ab in Rh-system

C Antiglobulin phase Detects low titer Ab.

Antiglobulin + Test tube AgglutinationSerum

A & B –Prime importance in preventing serious hemolytic reactions


Antibody ScreenIndirect Coomb’s test

Antibodies in serum Non-ABO hemolytic transfusion reactions

Trial transfusion in a test tube

Commercial RBC + Patients’s ( Known Antigen ) Serum

Ab-coated RBC

+ Anti-globulin

RBC Agglutinations

Routinely done on all donor blood

antibodies


Incidence of compatible transfusion

ABO- Rh typing ABO- Rh typing ABO- Rh typing

99.8 %

+Antibody Screen

+Antibody Screen

99.94 %+Cross match

99.95 %ABO- Rh compatibleNegative Ab. Screen

NO Cross match

Chance of hemolytic reaction < 1%


Changes in traditional transfusion practice

ONLY type & Screen

Incidence of transfusion for the procedure <10%

Exceptions--anemiaCoagulation disorder

Type & Cross match

ONLY for elective Sx with high probability of transfusionNO ROUTINE Pre-op cross match

Blood Not available for others X 24-48 hrs

∴ Chance of outdating

Certain Elective surgeries

Cross matched Transfused unitsunits

∴ High C T ratio


Changes in traditional transfusion practice

Acceptable C T ratio < 2.5:1

High C T ratio indicates

Blood bank burdened with keeping large blood inventory

Use of excessive personnel time

High incidence of outdated units

(Contd.)

Emergency Transfusion

Order

of

Preference

① Type-specific, partially cross matched Blood

② Type-specific,uncross matched Blood

③ Type-O, Rh negative, uncross matched Blood

Emergency Transfusion ( Contd.)

Type-specific, Partially Cross matched BloodPatient Blood type known

Immediate phase cross match (1-5 minutes )

Eliminate serious hemolytic reactions-ABO Incompatibility

Type-specific, Uncross matched Blood

Current hospitalisation result of ABO-Rh grouping

Results—records,relatives,other hospital

No H/o previous blood transfusion (most successful )

Previous Exposure to foreign RBC antigen (hazardous )

Unexpected Antibodies detected during cross match 1 in every 100 individuals ]

caution – no indiscriminate use


Type-O, Rh negative Uncross matched Blood

Universal Donor

NO A and B antigens

Hemolysis of donor red blood cells

Anti-A & Anti-B Antibodies present in serumHigh titers destruction of recipient red cells,Non-Type-O

Preferrable – Uncross matched O-ve PRBC


Type-O, Rh negative Uncross matched Blood

Once Patient correct blood type determinedTransfused > 2 U Uncross matched O-ve whole blood

Ø switch to patients’s own blood type ( A,B,AB )

High titers of transfused Anti-A & Anti-B Antibodies

Intravascular hemolysis of donor cells

Continued use of O-ve blood

Minor hemolysis of recipient RBC

Hyperbilirubinemia (ONLY complication )

Type-specific Blood transfusion permissible

Transfused anti-A, anti-B antibody tiers to safe level

( Contd.)

Practice Guideline- Perioperative Blood transfusion

(American Society of Anesthesiologist )

Last amended on October 25,2005

Provide basic recommendations by analysis of current literature

Not intended as standards or abosolute requirement

Cannot guarantee any specific outcome

Apply to both Inpatient and Outpatient surgical settings

Directly applicable to care administered by anaesthesiologist

Excluded

Neonates

InfantsChildren < 35kg

Non-Surgical patients

ASA guidelines: Peri-Op Blood transfusion

Pre operative Evaluation

Pre operative Preparation

Intra operative management of Blood loss

ASA guidelines: Peri-Op Blood transfusion(Contd.)

Pre-operative Evaluation

Focused History Laboratory test Informed consent

Congenital or acquired blood disorders Hemophilia

Sickle cell diseaseITPLiver disease

Cardio respiratory disease

risk of organ ischemia

Influence transfusion on trigger for RBC ( Hb-level )

Previous blood transfusion

Previous exposure to aprotininRe-exposure severe anaphylaxix

Intake of Drugs affecting coagulationInfluence transfusion of Non-RBC components


Pre-operative Evaluation (Contd.)

Drug affecting coagulation

Anticoagulants

Warfarin

Clopidogrel

NSAIDVitamins Herbal

supplementsAspirin Vit.K

Vit.E

Decrease platelet aggregations Inhibit clottingGarlic, Ginger, Gingkobiloba

Grape seed extract, Feverfew, Fish oil

Chamomile,Dandelion root

Dong quoi,Horse chestnut


Pre-operative Evaluation (Contd.)

Laboratory results

Hemoblobin or hematocrit

Coagulation profile

PT aPTT INR TEG

Informed consent

Risk Vs benefits blood transfusion

Note preferences in the file


Pre operative patient preparation

To prevent blood loss

To prevent or reduce allogenic transfusion requirements


Pre operative patient preparation ( Contd.)

Interventions to prevent Blood loss

Discontinuation or modification of anit-coagulant therapy

( Thrombosis Vs bleeding )

Delay surgery until dissipation of drug effects

Clopidogrel ( 1 wk )

Aspirin ( 7 – 10 days )

Warfarin ( several days )

Patients’ response

Use of reversal agentsVit.K, FFP, rVIIa ,PTcomplex


Pre operative patient preparation ( Contd.)

Prevention or Reduction of Allogenic blood transfusion

Drugs to prevent or reduce peri-operative anemiaErythropoietin

Vit.K

Autologous Blood collection

Drugs to promote coagulation and minimize blood loss

Aprotinin

Epsilon aminocaproic acid (EACA )

Tranexamic acid


Intra operative management of Blood loss

Monitoring for Blood loss ( O.R.)

Monitoring for inadequate perfusion and oxygenation of vital organs

Monitoring for transfusion indicators


Intra operative management of Blood loss (Contd.)

Monitoring for Blood loss

Assessment of Excessive micro vascular bleeding

Period visual assessment of surgical field

Communication with the surgical team

Quantitative measurement of Blood loss

Weighing soaked surgical sponges & swabs

Checking suction canister & surgical drains

(1ml blood ≃ 1gm )


(Contd.)Intra operative management of Blood loss

Monitoring for Inadequate perfusion of vital organs

Conventional methods

Special monitoring

ECG , B.P.,H.R.,SPO2 ,Urine output

Echo cardiography

Mixed venous oxygen saturation

Blood gases


Intra operative management of Blood loss (Contd.)

Monitoring for transfusion Indicators

Measure Hb or HctSubstantial blood loss

Sign of organ ischemia

Hb < 6mg /dl

RBC should usually be administered

Hb 6-10gm/dl Hb >10gm/dl

RBC transfusion usually unnecessary

Basis of RBC transfusion• Any on going indication of organ ischemia

• Potential or actual on going bleeding

• Patient’s intravascular volume status(rate & magnitude )

• Risk factors for inadequate osygenationLow Cardiopulm.reserve

High oxygen consumption

Storage of Blood

Preservative Shelf life

1 A C D 14 days

2 CPDA-1 35 days

3 AS-1 (Adsol) 42 days

4 AS-3 (Nutrice ) 42 days

5 Frozen RBC upto 10 years 6 Heparin 24-48 hours

(RBC+glycerol )

Adsol Adenine, glucose, Nacl, Mannitol

Nutrice Adenine, glucose, Nacl, Citrate,Phosphate

Storage of Blood (Contd.)

Biochemical Changes “ Storage Lesions”

1. Glucose Lactate H+ accumulation

Plasma PH

2. Osmotic fragility RBC lysis

Plasma Hb

3. Storage temperate stimulate Na-K pump RBC lose K , gain Na

Plasma K

4. RBC 2 ,3DPG

3 & 4 Left shift of O-D Curve

(Contd.)Storage of Blood

Properties of Stored Blood in CPDA

Parameters 0 daysWhole Blood

35 days

PRBC

35 days

1. PH 7.55 6.98 6.71

2.Plasma Hb (mg/dl) 8.20 46.1 246.0* 3.Plasma K (meq/L) 4.20 27.3 76.0*

4.2,3DPG (MM/ml) 13.20 < 1 < 1

5.Percent survival --- 76 71*

Efficacy---Allogenic RBC Transfusion

Increasing the O2 carrying Capacity of Blood

( only REAL indication )

RBC mass O2 uptake tissue at lungs O2 delivery

Tissue O2

needs

Aerobic cell respiration*

Efficacy---Allogenic RBC Transfusion (Contd.)

Oxygen delivery to tissues DO2 = CO CaO2

CaO2 = (SaO2 K1 Hb ) + ( K2 PaO2 )

Breathing Room air > 98% < 2%

Hyperoxic ventilation ( 100% O2 )

Hemodilution----------

( plasma volume )

At Hb 3gm %,dissolved O2 contribute to 74%VO2

Hyperoxic ventilation-additional method to RBC transfusion

(Contd.)Efficacy---Allogenic RBC Transfusion

Oxygen consumption at tissue levelDO2 = 800 – 1200 ml /min

VO2 = 200 – 300 ml /min

O2 ER = VO2

DO2

= 20 – 30%

DO2 = CO ( Hb bound O2 + O2 dissolved in plasma )

Isolated

( Safety margin 70-80 % )Below critical threshold of Hb-- DO2 , VO2

Hct18% - healthy individuals

24% - well compensated systemic disease30% - sysmptomatic cardiac disease

DO2 > VO2 - 4

Efficacy---Allogenic RBC Transfusion (Contd.)

Relationship between VO2 & DO2

VO2 Constant

DO2 Crit

( VO2 independent of DO2 )

( VO2 – DO2 dependency )

VO2 decrease tissue hypoxia

RBC transfusion DO2 , VO2

DO2 , VO2 ( goal)

Efficacy---Allogenic blood Transfusion

Lacking in VO2 upon RBC transfusion

Absence of VO2 – DO2 dependency before transfusion(Experimental: Needs extreme hemo dilution with lactic acidosis )

Storage related alterations in RBC

deformability – impede capillary bed access

2 ,3 DPG levels – impede oxygenation in micro circulation

? Pre transfusion predictor of VO2 after transfusion

Efficacy---Allogenic blood Transfusion ( Contd.)

Clinical Consequences of anemia and red cell transfusion in the critically ill. Cri care clin 2004;20:225-35

Herbert and Colleagues 18 studies

Effect of RBC transfusions on oxygenation variables

• Hb All studies

• DO2 4 studies

• DO2 ( 14 studies )

VO2 ( 5 )

VO2 ( 9 ) ( absence of O2 prior to transfusion)

Efficacy---Allogenic blood Transfusion ( Contd.)

Factors influencing the individual effects of blood transfusion on DO2 and VO2

( Crit care Med 1999;27:2194-200 )

Cassutt et al67 adult cardia Sx patients170 Blood transfusions

M

M 5hrs

5hrs

Post transfusion

CI 1

Pre-CI, DO2I,VO2I

DO2 I 1

Pre-DO2 I

VO2 I 1

Pre-VO2 I

NOT related Age

Pre-transfusion Hb

Pre-Op EF

DO2 & VO2 variable better predictors than patient characteristics

Complications of Blood transfusion

Immunological

Non-Immunological

Infections

Complications of Blood transfusion (Contd.)

Immunological

Red cells

Hemolytic transfusion reactions

white cellsFebrile reactions ( 1-3 % )TRALI

Platelets Post transfusion purpura

Plasma proteins Urticaria ( 1 % )

Anaphylaxix ( 1 in 150,000 )


Immunological (Contd.)

Other Interactions

Change in response

Improved survival of transplanted kidney

? Post – Operative infections

? Cancer recurrence


Non-Immunological

Vasocactive substances ( prekallikrcin )Hypotension , Nausea

Citrate Intoxication ( Hypocalcemia )

Cold Blood

Hypotermia,ventricular irritability cardiac arrest

B.P., P.P., LVEDP., CVP

Ⓝ individual only when > 1units/ 5 min

Routine calcium administrationSeen in liver disease , hypothermia , hyperventilation


Non-Immunological (Contd.)Hyperkalemia

Potassium transfused / unit < 4meq /L

Stored blood acidic

T > 100 ml / min S.K level

( regardless of age of blood )Acid-Base abnormalities

Lactate , Pyruvate

High PCO2Adequate ventilation - PCo2

Citrate metabolism metabolic acidosisNo routine NaHCo3

Most consistent abnormality post transfusion is Metabolic alkalosis

Micro embolismCell aggregates


Infections

Viral Parasitic Bacterial Prions• HCV

• HBV

• HIV

• CMV

• HTLV-1

• HTLV-2

• Malaria

• Toxoplasmosis

• Chagas disease

• Spirochaetas VCJD(2 cases reported)


Mistransfusion

Blood transfused to other than the intended recipient

Incidence

1 : 14000 –1: 18000 transfusions


Transfusion Reactions

• Hemolytic reactions

Specific destruction of donor RBC by recipient Ab

Acute

Chronic

• Non-Hemolytic reactions

Sensitization of patient to transfused plasma proteins

Febrile

Allergic

Complications of Blood transfusion (Contd.)Acute hemolytic transfusion reaction

• Intravascular hemolysis

• ABO incompatitility

• Incidence

1 : 4000 – 1 : 6000

1 : 100000 ( fatal )

• Can occur from infusion of as little as 10ml blood

• Misidentification

patientBlood specimen

Transfusion unit(commonest cause )


Acute hemolytic transfusion reaction (Contd.)Signs and symptoms

Awake Patient

° Chills ° Fever° Chest and flank pain

° Nausea

Anesthetized patient

° Rise in temperature ° Unexplained tachycardia

° Hemoglobinuria ° Diffuse oozing from

the surgical field

° Hypotension

DIC , shock and renal shunt can develop rapidly


Acute hemolytic transfusion reaction (Contd.)

Treatment

1. STOP THE TRANSFUSION IMMEDIATELY

2. Maintain urine out put atleast 75-100ml /hr

(a) Generously administer IV fluids

(b)Mannitol

( c ) IV Frusemide3. Alkalinize the urine

( a ) Raise urine PH-8

( b )NaHCo3 40 –70 meq /70kg( c ) Additional dose – repeating urine PH


Treatment -Acute hemolytic transfusion reaction (Contd.)

4. Assay urine and plasma Hb. Concentration

7. Send patient sample to blood bank

5. Determinplatelet count, PTT ,S.fibrinogen

Antibody screen

Direct antiglobulin test

6. Return unused blood to Blood bank – re-cross match

8. Prevent hypotension


Delayed hemolytic transfusion reaction

Ab to Non-D antigen Rh-system or alleles other systms

Extra vascular hemolysis

2 to 21 days post transfusion

Incidence 1 : 2500 – 1 : 1500

Presentation

Malaise , jaundice ,fever

Supportive ℞

No rise in Hct post – transfusion

(Contd.)


Febrile reaction • Most common adverse reaction

• 1 – 3 % transfusions

• White cell and platelet sensitization • Symptoms

ChillsFever

NauseaMyalgiaHeadacheNonproductive cough

• PreventionLeuco reduced blood transfusionMicro filter ( < 40 μm )

Jehovah’s Witnesses - Blood

Jehovah’s Witnesses - Blood

“ Their drink offering of blood I will not offer nor take up their

names into lips”( Psalm 16 verse 4 )

“ To keep abstaining from Blood ” ( Acts 15 : 28 – 29 )

Jehovah’s Witnesses - BloodWatch tower Blood Policy

DO NOT ACCEPT

• Allogenic whole blood

• Major blood components

( Red cells, whitecells platelets, plasma )

• Hemoglobin preparation

GRAY AREA

• Albumin • Immuno globulins

• Fibrinogen , clotting factors

Jehovah’s Witnesses - BloodRole of Autologous Blood

“You should pour it out upon the ground as water”

( Deuteronomy 12 :24 )

“Any blood removed from the body should be

discarded ant not stored ”

Pre-op Autologous blood collection NOT acceptable

Jehovah’s Witnesses - BloodIntra operative blood salvaging

Acceptable to some believers

PROVIDED

“Their blood maintains continuity with their circulatory system at all times”

Jehovah’s Witnesses - BloodMethods to minimize blood loss

Pre operative

Full investigation of anemia

Consider pre-op erythropeietin or Iron

Jehovah’s Witnesses - BloodMethods to minimize blood loss ( Contd.)

Intra operativeStage procedures

Tourniquet

Bloodless surgical techniques

Hypotensive anesthesia

Normovolemic hemodilution

Use of vasoconstrictor

Drugs to affect coagulation( desmopressin,Tranexamic acid , aprotinin)

Balloon Occlusion / ligation of arteries supplyingbleeding area

Jehovah’s Witnesses - BloodMethods to minimize blood loss ( Contd.)

Post-operative • Measures to reduce O2 consumptions

Elective ventilations

NM blockers

Hyperthermia

Hyperbaric O2 therapy

• Mninimise phlebotomyUse of pediatric tubes

• Hormonal suppression of menstrual bleeding

• GI bleeding prophysaxis

• Erythropoietin

blood trasnsusion-2007

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