fe & female workshop

21 August 201121 August 2011 Hazards of Blood TransfusionHazards of Blood Transfusion 11

Fe & Female WorkshopFe & Female Workshop

Hazards of Blood TransfusionHazards of Blood TransfusionPresented byPresented by

Dr. Ravindra S. Dr. Ravindra S. ShivdeShivde

M.D.,D.G.O.M.D.,D.G.O.

Organised by Nashik Ob/Gy Society

F.O.G.S.I.


MILESTONES:MILESTONES: Andreas Libavius- 1546-1616Andreas Libavius- 1546-1616 James Blundell- 1818James Blundell- 1818 Karl landsteiner- 1900Karl landsteiner- 1900


Blood TransfusionBlood Transfusion

General Tonic?


Risks of Blood TransfusionRisks of Blood Transfusion

Incompatible bloodIncompatible blood

Allergy, febrile reactionAllergy, febrile reaction

InfectionInfection

ImmunosuppressionImmunosuppression

Noninfectious HazardsImmunosuppressionInfection


Risks of blood transfusionRisks of blood transfusion( Per unit of blood U.S.A. )( Per unit of blood U.S.A. ) Minor allergic reactionsMinor allergic reactions 1:1001:100 Viral hepatitisViral hepatitis (A,B,C,D,G) (A,B,C,D,G)

1:50,0001:50,000 Hemolytic reactionsHemolytic reactions 1:6,0001:6,000 Fatal hemolytic reactionsFatal hemolytic reactions 1:600,0001:600,000 HIV infectionHIV infection

1:420,000*1:420,000* HTLV-I/IIHTLV-I/II 1:200,0001:200,000 Bacterial infectionsBacterial infections 1:2,5001:2,500 Acute lung injuryAcute lung injury 1:500,0001:500,000 Anaphylactic shockAnaphylactic shock 1:500,0001:500,000 Graft Vs. host diseaseGraft Vs. host disease RareRare ImmunosuppressionImmunosuppression 1:11:1


Williamson LM, et al. BMJ. 1999;319:16-9.

Serious Hazards of Serious Hazards of TransfusionTransfusion

Based on 366 spontaneously-reportedBased on 366 spontaneously-reporteddeaths/major complications between deaths/major complications between October 1996 and September 1998 October 1996 and September 1998 in the UK and Ireland.in the UK and Ireland.

Transfusion-transmitted Transfusion-transmitted infectionsinfections

Acute lung injuryAcute lung injury

Post-transfusionPost-transfusionpurpurapurpura

Graft vs hostGraft vs hostdiseasedisease

DelayedDelayedtransfusiontransfusion

reactionreaction

AcuteAcutetransfusiontransfusion

reactionreaction

Incorrect blood/Incorrect blood/componentcomponenttransfusedtransfused

3%3%

6%6%

8%2%

14%

15%

53%


HumanHumanerror aserror asa riska riskfactor?factor?


Infectious Infectious complicationscomplications

VirusesViruses HIV-1,2 …HIV-1,2 … HTLV-I,IIHTLV-I,II CytomegalovirusCytomegalovirus Epstein-Barr virusEpstein-Barr virus Parvovirus B19Parvovirus B19 Creutzfeldt-Jakob Creutzfeldt-Jakob

disease(CJD)disease(CJD) TTVTTV West NileWest Nile SpirochetesSpirochetes Treponema pallidumTreponema pallidum Borrelia burgdorferiBorrelia burgdorferi

ParasitesParasites PlasmodiaPlasmodia Babesia microltiBabesia microlti Trypanosoma criziTrypanosoma crizi Toxoplasma gondiiToxoplasma gondii Leishmania Leishmania

donovanidonovani

BacteriaBacteria Staphylococcus Staphylococcus SalmonellaSalmonella Yersinia Yersinia

enterocoliticaenterocolitica


Risks of Transfusion: Risks of Transfusion: Infectious DiseaseInfectious Disease

HIV HIV = 1 in 1.8 million= 1 in 1.8 million

HCVHCV = 1 in 1.6 million = 1 in 1.6 million

HBV HBV = 1 in 220,000= 1 in 220,000

HIV = human immunodeficiency virus.HCV = hepatitis C virus.HBV = hepatitis B virus.Busch MP, et al. JAMA. 2003;289:959-62.


Risks of Allogeneic BloodRisks of Allogeneic Blood

‘TRIM’Transfusion Related Immune

Modulation


Immune modulationImmune modulation

Allogeneic transfusion may enhance tumor Allogeneic transfusion may enhance tumor recurrence following colorectal cancer resection recurrence following colorectal cancer resection (Heiss MM, J Clin Oncol 1994)(Heiss MM, J Clin Oncol 1994)

Allogeneic transfusion is associated with Allogeneic transfusion is associated with prolonged hospital stay (Vamvakas EC, prolonged hospital stay (Vamvakas EC, Transfusion 2000)Transfusion 2000)

Allogeneic transfusion is associated with Allogeneic transfusion is associated with increased risk of bacterial infection (increased risk of bacterial infection (35%) and 35%) and pneumonia (pneumonia (52%) (Carson JL, Transfusion 52%) (Carson JL, Transfusion 1999)1999)

Length of storage of transfused RBCs was Length of storage of transfused RBCs was associated with postoperative pneumonia associated with postoperative pneumonia following CABG surgery, 5% per unit (Vamvakas following CABG surgery, 5% per unit (Vamvakas EC, Transfusion 1999)EC, Transfusion 1999)


Immune Effects of BloodImmune Effects of BloodImmunologic effects of Immunologic effects of

autologous/allogenic blood autologous/allogenic blood TxTx

Decreased T-cell proliferationDecreased T-cell proliferation Decreased CD3, CD4, CD8 T-cellsDecreased CD3, CD4, CD8 T-cells Increased soluble cytokine receptor Increased soluble cytokine receptor

sTNF-R, sIL-2RsTNF-R, sIL-2R Increased serum neopterinIncreased serum neopterin Increased cell-mediated lympholysisIncreased cell-mediated lympholysis Increased TNF-alfaIncreased TNF-alfa Increased suppressor T-cell activity Increased suppressor T-cell activity Reduced natural killer cell activityReduced natural killer cell activityMcAlister FA et al, Br J Surg 1998;85:171-8.

Innerhofer P et al, Transfusion 1999;39:1089-96.


Blood Tx Increases Risk of Blood Tx Increases Risk of Postoperative Bacterial Postoperative Bacterial

InfectionInfection 20 peer-reviewed studies, 1986-200020 peer-reviewed studies, 1986-2000 N = 13,152 (Tx 5215, No-Tx 7937)N = 13,152 (Tx 5215, No-Tx 7937) Association of Blood Tx to InfectionAssociation of Blood Tx to Infection

Common OR 3.45Common OR 3.45 (range 1.43-15.15) (range 1.43-15.15) 17 of 20 studies with p < 0.0517 of 20 studies with p < 0.05

Trauma subgroupTrauma subgroup Common OR 5.26Common OR 5.26 (range 5.03-5.43) (range 5.03-5.43) All studies with p < 0.05 (0.005 – 0.0001)All studies with p < 0.05 (0.005 – 0.0001) Blood Tx associated with greater risk in Blood Tx associated with greater risk in

trauma ptstrauma ptsHill GE, Minei JP et al. J Trauma 2003;54:908-914


5.9

15.4

2.9

0

2

4

6

8

10

12

14

16

18

Per

cen

t o

f P

atie

nts

All Patients

Transfused Patients

Non-transfusedPatients

N = 1,717 n = 416 n = 1,301

P < .05

Nosocomial Infection Rates Nosocomial Infection Rates in Critically Ill Patientsin Critically Ill Patients

Adjusted for severity of illness using MPM-0 scores, age, gender (Project IMPACT).Taylor RW et al, Crit Care Med 2002;30:2249-54.

For each unit of PRBCs given, the odds of infection is increased by a factor of 1.5


The Impact of PRBCs on The Impact of PRBCs on Nosocomial Infection Rates in Nosocomial Infection Rates in

ICUICU Retrospective database study of 1,717 patients Retrospective database study of 1,717 patients

using Project IMPACTusing Project IMPACT NI rates of 3 groups were compared: NI rates of 3 groups were compared:

Entire cohortEntire cohort Transfusion groupTransfusion group Nontransfusion groupNontransfusion group

Patients stratified for age, gender, and Patients stratified for age, gender, and probability probability of survival using Mortality Prediction Model of survival using Mortality Prediction Model (MPM-0) scores(MPM-0) scores

Taylor RW et al, Crit Care Med 2002;30:1-6.


Do Blood TransfusionsDo Blood TransfusionsImprove OutcomeImprove Outcome

in Sepsis?in Sepsis?


13.6

24

10.2

0

5

10

15

20

25

Pe

rce

nt

of

Pa

tie

nts

All Patients

Transfused Patients

Non-transfusedPatients

N = 1,717 n = 416 n = 1,301

P < .05

Taylor RW et al, Crit Care Med 2002;30:2249-54.

Mortality Rates in Mortality Rates in Critically Ill PatientsCritically Ill Patients


TRALITRALI 1:2000 transfused patients1:2000 transfused patients FDA reports as the third most prevalent FDA reports as the third most prevalent

transfusion related mortality, after transfusion related mortality, after hemolysis and sepsis hemolysis and sepsis

Associated with: whole blood, RBC, Associated with: whole blood, RBC, platelets, FFP and cryo.platelets, FFP and cryo.

CHF – ARDS, fleeting or devastatingCHF – ARDS, fleeting or devastating Two prominent theoriesTwo prominent theories

HLA class I and possible II, and monocyte HLA class I and possible II, and monocyte antigens antigens

20% of women with multiple gestations carry 20% of women with multiple gestations carry class I antigensclass I antigens

Mixture of predisposition and infusion of blood Mixture of predisposition and infusion of blood related lipid derived mediators related lipid derived mediators


Donor LeukocytesDonor Leukocytes Persistence of donor WBCs in trauma Persistence of donor WBCs in trauma

patients for up to 1.5 years after an patients for up to 1.5 years after an allogeneic blood transfusionallogeneic blood transfusion

‘‘Survival of donor leukocyte Survival of donor leukocyte subpopulations in immunocompetent subpopulations in immunocompetent

transfusion recipients: frequent long-term transfusion recipients: frequent long-term microchimerism in severe trauma patientsmicrochimerism in severe trauma patients’’

2 x 102 x 1099 WBCs WBCs in one unit of packed red in one unit of packed red blood cellsblood cells

1 x 101 x 1088 WBCs WBCs – – ccentrifuged, buffy coat entrifuged, buffy coat depleteddepleted

1–5 x 101–5 x 1066 WBCs WBCs – – lleukocyte filter, eukocyte filter, leukocyte-depletedleukocyte-depleted Lee TH et al, Blood 1999;93:3127–3139


Why is blood Why is blood transfusiontransfusion

NOT associated withNOT associated withimproved outcome?improved outcome?


Age of BloodAge of Blood


Stored RBCsStored RBCs Increased deformityIncreased deformity Decreased 2,3, DPGDecreased 2,3, DPG Metabolic acidosisMetabolic acidosis decreased oxygen carrying decreased oxygen carrying

capacitycapacity Increased red cell death with Increased red cell death with

increased age of blood (increased age of blood (~30% ~30% dead)dead)

No improvement in oxygen No improvement in oxygen utilization at the tissue levelutilization at the tissue level


Distribution of Transfused Units by Age of Blood – CRIT Study

0%

5%

10%

15%

20%

25%

30%

35%

Pe

rce

nta

ge

of

Pa

tie

nts

Oldest Age of Blood in Days

0 - 10 10 - 20 20 - 30 30 - 40 > 40

60% of Blood transfused is > 20 days old

In Trauma Subset, 68% of blood is > 20 days old


Anemia is common Anemia is common No evidence that blood tx for No evidence that blood tx for

treatment of anemia improves treatment of anemia improves outcomeoutcome

Critically ill patients can tolerate Critically ill patients can tolerate Hb levels as low as 7 mg/dLHb levels as low as 7 mg/dL

Blood should be transfused for Blood should be transfused for physiologic indicationsphysiologic indications

Guidelines for Blood Transfusion in Anemia


RBCs should be administered as RBCs should be administered as single unitssingle units for most for most operative and inpatient indications (transfuse and operative and inpatient indications (transfuse and reassess strategy) except for ongoing blood loss with reassess strategy) except for ongoing blood loss with hemodynamic instability. hemodynamic instability. 1PRBC 1.3 gm/dl1PRBC 1.3 gm/dl

Tx decisions are clinical judgments that should be Tx decisions are clinical judgments that should be based on the overall clinical assessment of the based on the overall clinical assessment of the individual patient. Transfusion decisions should not be individual patient. Transfusion decisions should not be based on laboratory parameters alone. based on laboratory parameters alone.

Routine premedication is Routine premedication is notnot advised unless the advised unless the patient has a history of previous transfusion reactions. patient has a history of previous transfusion reactions. Premedication has not been shown to reduce the risk Premedication has not been shown to reduce the risk of transfusion reactions.of transfusion reactions.

How to reduce the hazards?How to reduce the hazards?


WHATWHAT BEFORE ANY BEFORE ANY TRANSFUSION:TRANSFUSION:

W- whether required?, when?W- whether required?, when? H- how much?H- how much? A- actual component required?A- actual component required? T- time duration and technique of T- time duration and technique of

transfusion?transfusion?


W- WHETHER REQUIRED?W- WHETHER REQUIRED?

Indications:Indications: Anemia- 60%Anemia- 60% Surgery- 42%Surgery- 42% Acute hemorrhage- 26% Acute hemorrhage- 26% Pregnancy- 16%. Pregnancy- 16%.

Seventy-four per cent of adult Seventy-four per cent of adult transfusions were transfusions were inappropriate.inappropriate.

Indian Study by Tim Bray et al


W- WHAT TO W- WHAT TO TRANSFUSE?TRANSFUSE?

Use Packed red cells to correct volume & Use Packed red cells to correct volume & oxygenation.oxygenation.

Uncontrolled bleeding and laboratory Uncontrolled bleeding and laboratory evidence of coagulopathy –Add fresh evidence of coagulopathy –Add fresh frozen plasma.frozen plasma.

Bleeding continues :Consider Platelets Bleeding continues :Consider Platelets after investigations.after investigations.


THRESHOLD FOR RED CELL THRESHOLD FOR RED CELL TRANSFUSION: HISTORICAL FACTSTRANSFUSION: HISTORICAL FACTS

MAYO CLINIC in 1900 proposed a MAYO CLINIC in 1900 proposed a target value of 8-10 g/dL.target value of 8-10 g/dL.

CURRENT PRACTICE (NIH Consensus) CURRENT PRACTICE (NIH Consensus) is 7g/dL in the absence of disease is 7g/dL in the absence of disease

8-10g/dL in the presence of disease 8-10g/dL in the presence of disease (cardiovascular disease/risk (cardiovascular disease/risk factors/elderly).factors/elderly).

Rate of fall of Hb is more important Rate of fall of Hb is more important than the actual Hb valuethan the actual Hb value

Healthy individuals tolerate Hb levels Healthy individuals tolerate Hb levels as low as 5g/dLas low as 5g/dL


FFPFFP

More than 1 blood volume replaced More than 1 blood volume replaced Prothrombin time prolonged with INR >1.5 Prothrombin time prolonged with INR >1.5 and/orand/orContinued blood lossContinued blood loss

Dose:Dose: 15 ml/kg or 1 Litre (4 packs) for adult 15 ml/kg or 1 Litre (4 packs) for adult of 60 kg of 60 kg


PlateletsPlateletsPlatelet count below 50 × 10Platelet count below 50 × 1099/l (<50,000/ cmm), /l (<50,000/ cmm), in the presence of bleeding.in the presence of bleeding.Increased risk of hemorrhage in coagulopathy- <= Increased risk of hemorrhage in coagulopathy- <= 10000/mm10000/mm33.. Vaginal deliveries or operative procedures ordinarily Vaginal deliveries or operative procedures ordinarily associated with insignificant blood loss may be undertaken associated with insignificant blood loss may be undertaken in patients with platelet counts < 50,000/mmin patients with platelet counts < 50,000/mm33..Drop in Platelet below this level necessitates transfusion Drop in Platelet below this level necessitates transfusion with platelet concentrates.with platelet concentrates.DoseDose: 4-6 platelet concentrates or one unit of single donor : 4-6 platelet concentrates or one unit of single donor (apheresis) platelets(apheresis) platelets..


Cryoprecipitate Cryoprecipitate If If the fibrinogen is particularly low(<1g/l) or <100mg/dl.the fibrinogen is particularly low(<1g/l) or <100mg/dl.Factor VIII deficiencyFactor VIII deficiencyEarly use of FFP may avoid the need for cryoprecipitateEarly use of FFP may avoid the need for cryoprecipitateGive 10 units initially and repeat based on fibrinogen Give 10 units initially and repeat based on fibrinogen estimation estimation

Note: Cryoprecipitate is not available from all blood centres. Note: Cryoprecipitate is not available from all blood centres. 5 units of FFP (1000-1250 ml) contains, typically, the same 5 units of FFP (1000-1250 ml) contains, typically, the same quantity of fibrinogen as 10 units of quantity of fibrinogen as 10 units of cryoprecipitate (approximately 150-250 ml)cryoprecipitate (approximately 150-250 ml)

DoseDose: one unit/ 5 kg body weight or 10 units in the : one unit/ 5 kg body weight or 10 units in the adult.adult.


Jehovah’s Witnesses and Jehovah’s Witnesses and Associates - World Associates - World

PopulationPopulation1985 - 7,792,1091985 - 7,792,1091995 - 13,147,2011995 - 13,147,2012000 - 14,872,0862000 - 14,872,0862007 - 16,675,1132007 - 16,675,113


What is Acceptable Risk?What is Acceptable Risk?


Thank you!

fe & female workshop

Documents