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Learn about best practices for transfusion, including component types, thresholds, alternatives, and safety measures. Understand when and how to transfuse blood effectively.
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Clinical Use of Blood Components Salwa Hindawi Director of Blood Transfusion Services KAUH, Jeddah KSA SITMS 24th March 2004
Donor Patient The risks associated with transfusion can be reduced by: - Effective blood donor selection. - Screening for TTI in the blood donor population. high quality blood grouping, compatibility testing. - Component separation and storage. - Appropriate clinical use of blood and blood products. - Quality assurance
Blood Products Any therapeutic substance prepared from human blood: Whole blood 1-Blood components Red Cell Concentrate and suspension Platelet Concentrate Plasma – FFP Cryoprecipitate Cryosupernatent
2- Plasma Derivatives Human plasma proteins prepared from plasma under Pharmaceutical Manufacturing Conditions • Albumin • Coagulation factors concentrates • Immunoglobulins
Principles of Clinical Transfusion Practices • Avoid blood transfusion • Transfusion is only one part of the patient’s management. • Prevention and early diagnosis and treatment of Anemia & underlying condition • Use of alternative to transfusion. eg. IV fluids • Good anesthetic and surgical management to minimized blood loss.
* Prescribing should be based on national guidelines on the clinical use of blood taking individual patient needs into account. * Hb level should not be the sole deciding Factor Clinical evaluation is important
* The clinician should record the reason for transfusion clearly. * A trained person should monitor the transfused patient and if any adverse effects occur respond immediately.
WHEN WE SHOULD TRANSFUSE BLOOD ?&WHAT BLOOD COMPONENT SHOULD BE TRANSFUSED ?
Unnecessary transfusion can: • Expose the patient to unnecessary risks • Cause a shortage of blood products for patients in real need. Blood is an expensive, scarce resource.
Triggers of Component Transfusion • The lowest threshold for transfusion of components are: • Hb level of 6-7g/dl. Clinical judgment • FFP threshold PT & PTT 1.5 times the upper limit of the normal range. • Platelet threshold of: 10 000/µl- 20 000/µl for prophylactic transfusion
Invasive or surgical procedures: • 20 000/µl for BMA and Biopsy • 50 000/µl for surgery, massive transfusion, Liver cirrhosis. 100 000/µl for surgery to brain or eye. American Society of clinical Oncology guidline,1996&2001. Williamson LM. Transfusion Trigger in the UK. Vox sang 2002. AABB Technical Manual 14th ed, 2002.
Evidence based medicine through randomized controled trials and or clinical practice The use of a 7g/dl Hb threshold in critical care patients with maintenance of Hb of 7-9g/dl resulted in a 54%decrease in the number of transfused red cells and decrease exposure to any red cell by 33%. Hebert ,et al. N Engl J Med 1999
255 patients with acute myeloid leukemia Evaluated prospectively: • 135 patients were assigned to 10 000/mm3 threshold group • 120 were assigned to 20 000/mm3 • The risk of major bleeding was similar • Platelet use reduced by 21.5% in the lower threshold group Rebulla et al.N Engl J Med 1997.
The Appropriate Use of Blood and Blood Products • Safe Product (Supply safe accessible at reasonable cost, adequate) • Weight the risk against benefit
ALTERNATIVES TO BLOOD TRANSFUSION • CRYSTALLOID SOLUTIONS • COLLOID SLOUTIONS • DRUGS • BLOOD SUBSTITUTES
Guidelines on: • Ordering Blood • Indications • Compatibility policy differ from center to another • Collecting blood products prior to transfusion • Administration • Monitoring the transfusion • Adverse effect of transfusion
Transfusion committee • Surgery • Infection Control • Transfusion specialist or Haematologist • Pediatrics • Obstetrics • Anesthesia • Medicine • Nurse • QA
The committee shall be responsible for: • Developing the guidelines for transfusion • Reviewing of the use of blood and its components • Reviewing structure, process , outcomes and utilization Indicators.
Reviewing all reports regarding transfusion reaction & Incident reports • Promote education and training of all clinical and support Staff involved in blood transfusion. • Have the authority to modify and implement the existing Blood transfusion protocols
Maximum Surgical Blood Ordering Schedule (MSOS) • MSOS is a table of elective surgical procedures that lists the number of units of blood routinely cross-matched pre-operative. • The ideal value for cross matched to transfused blood, C:T ratio is 1:1 . • An acceptable value is 3:1 - 2:1 which corresponds to a blood usage of 30-50%.
A checklist for cliniciansAlways ask yourself the following questions before prescribing blood or blood products for a patient • What improvement in the patient's clinical condition am I aiming to achieve? • Can I minimize blood loss to reduce this patient's need for transfusion • Are there any other treatments I should give before making the decision to transfuse, such as intravenous replacement fluids or oxygen?
What are the specific clinical or laboratory indications for transfusion for this patient? • What are the risks of transmitting HIV, hepatitis, syphilis or other • Infectious agents through the blood products that are available
What other options are there if no blood is available in time? • Will a trained person monitor this patient and respond immediately if any acute transfusion reactions occur? • Have I recorded my decision and reasons for transfusion on the patient's chart and the blood request form?
Finally, if in doubt, ask yourself the following question. • If this blood was for myself or my child, would I accept the transfusion in these circumstances?
Conclusions 1 • Availability of safe blood Evidence-based clinical guidelines for usage of blood &blood products. • Correct management of blood inventory to prevent blood units wastage & outdating. • Promotion of blood component therapy.
Conclusions2 • Hospital transfusion committee. • Training & education for laboratory staff , students & treating physician. • Availability and accessibility of blood substitutes. • Auditing
References • The Clinical use of Blood Handbook, WHO Blood Transfusion safety, Geneva • AABB technical Manual 14th Edition 2002. • Handbook of transfusion Medicine 3rd edition