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Blood Component Therapy

Blood Component Therapy. Anthony Ho MSc, MD, FRCPC, FCCP, FHKCA, FHKAM (Anaesth) Professor and Honorary Consultant Department of Anaesthesia & Intensive Care CUHK and The Prince of Wales Hospital. 1 g/dL of Hb ≈ 3% of Hct. i.v. bore, the larger the better. Make sure the joints are tight.

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Blood Component Therapy

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  1. Blood Component Therapy Anthony Ho MSc, MD, FRCPC, FCCP, FHKCA, FHKAM (Anaesth) Professor and Honorary Consultant Department of Anaesthesia & Intensive Care CUHK and The Prince of Wales Hospital

  2. 1 g/dL of Hb ≈ 3% of Hct

  3. i.v. bore, the larger the better • Make sure the joints are tight

  4. Blood volume • 70-75 mL/kg (child and adult) • 80-90 mL/kg (term baby) • 90-100 mL/kg (premature baby) • 45% of the volume is blood cells, mainly RBC • 55% of the volume is plasma • Normal Hb: 13-18 g/dL for adult males 11.5-15.5 g/dL for adult females • Normal Hct: 38-50% for adult males 36-45% for adult females

  5. ABO Rh antigens on RBC • ABO Rh-incompatibility can be fatal (haemolysis) • Group A people have anti-B antibodies • Group B people have anti-A antibodies • Gp O people have anti-A, anti-B antibodies • Group AB people have no anti-A, B antibodies • Group Rh-D +ve people have no anti-Rh antibodies • Group Rh-D –ve people have no anti-Rh antibodies, but can develop them (50% chance) through exposure • Antibodies are present from 6 months of life onwards

  6. Rh-D • 99% of Chinese are Rh-D +ve • 92% of Blacks are Rh-D +ve • 85% of Caucasians are Rh-D +ve

  7. Cross-Match and antibody screening • One 10-mL laboratory clot tube (no anticoagulant) is enough to X-match at least 6 units of blood

  8. Handling of whole blood and PRBC • Stored at 2-6°C in the blood bank • Colder, one risks haemolysis, warmer, one risks bacterial growth • Keep at 2-6°C after receiving them from blood bank, leave them in the frig • Blood that has been outside of the frig for 30 min or longer cannot be returned to blood bank • Blood that has been outside of the frig for 4 hours should be discarded

  9. RBC transfusion • Should be administered via a set with a 170-260 micron filter • Should be warmed

  10. PRBC or whole blood transfusion • O-ve, un-X-matched 5 min, 0.2-.6% of population has RC antibody • Type specific, un-X-matched 15 min, chance of incompatible transfusion 0.2% • Type specific, antibody screen 30 min, chance of incompatible transfusion 0.06% • Type specific, X-matched 45 min, chance of incompatible transfusion 0.05% • Type specific, X-matched in a pt with RC AB 90 min to several h

  11. Red Blood Cells • Comes usually in the form of packed red blood cells (a practice that started in the late 1980’s) • PRBC: 150-200 mL, hct 55-75% • 1 unit will increase Hb by 1 mg/dL in a 70 kg person • The increase in hct = ml/kg of PRBC (e.g., 30 kg person given 150 mL of PRBC, hct goes up by 5%) • Contains citrate (outside anticoagulant, inside not) to keep it from coagulating • May contain K+ if old • Must be ABO compatible

  12. Whole blood • Not the most efficient use of a scarce resource • Better in cases of massive transfusion, indeed in all surgeries, including cardiac • Contains high concentrations of all factors except V and VIII (0-15% and 0-50% of normal, respectively, after 21 days at 4°C) • Only 5-20% of V and 30% of VIII are required for adequate haemostasis during surgery

  13. Craig V, et al. Blood administration in perioperative settings. AORN J 1997;66:133-43

  14. Craig V, et al. Blood administration in perioperative settings. AORN J 1997;66:133-43

  15. When PRBC or whole blood are stored in blood banks for intervals >15 days, the capability of Hb to transport O2 and the capability of RBCs to deform such as to easily pass through capillaries are essentially lost. Accordingly, only adverse effects of the transfused blood remain. Fitzgerald RD, et al: Transfusing red blood cells stored in citrate phosphate dextrose adenine-1 for 28 days fails to improve tissue oxygenation in rats. Crit Care Med 1997;25:726–32 Marik PE, et al. Effect of stored-blood transfusion on oxygen delivery in patients with sepsis. JAMA 1993;269:3024–9

  16. Reconsititution of PRBC • Dilution of PRBC is not usually required • Should only use normal saline • Ringer’s lactate contains calcium (chelates citrate), should not be used • Dextrose solutions are hypotonic, and can cause haemolysis, excessive free water, and hyperglcaemia

  17. http://emu0.emu.uct.ac.za/gallery/blood2.gif

  18. FFP– how and when?

  19. Fresh Frozen Plasma • Stored at -25°C at the blood bank for up to 1 yr • Contains all the plasma factors at 1 unit of activity/mL, and fibrinogen 400 mg/unit • Contains citrate 20 mmol/L, lactate 3 mmol/L, Na+ 170 mmol/L, K+ 4 mmol/L, gluc 22 mmol/L • Should be ABO compatible, but X-match not required • Should be used within 24 h once thawed and stored at 1-4°C to reduce factor loss and bacterial growth) • To replenish missing coagulation factors and to reverse the effect of warfarin in a hurry • To provide anti-thrombin III in heparin resistance • Should be warmed

  20. Platelets • Stored at room temperature (20-24°C), not in the frig • Shelf life is 5 days (>70% of viability) • If received pooled, transfuse within 4 h because of contamination and growth • Needs constant gentile agitation • Each unit/10 kg should increase the platelet count by 1 x 109/L • ABO compatibility is preferred because of the presence of traces of RBC, but not required • Rh-ve patients should receive Rh-ve donor-platelets • Transfuse through a filter • 5-6 units of platelets contain 1 unit of FFP (most factors are at 75-80% of activity, except VIII), a bit of rbc and white cells

  21. Cryoprecipitate • Prepared from single units of donor plasma by freezing the plasma at –80°C and then thawing the frozen plasma at 4°C, most of the coag factors except fibrinogen, VIII re-dissolve, the precipitate is taken off and stored at –25°C for up to 1 yr • Each unit (15 ml) contains fibrinogen 150-180 mg, factor VIII 100 units, von Willebrand factor 100 units – use for treating DIC, haemophilia A, von Willebrand disease, reversal of thrombolytic therapy • Give 1 U/7 kg • Must be thawed and is often pooled by the blood bank (takes 20-60 min) • administer through a filter • No need to be ABO compatible, although that would be nice • Carries the usual infectious risks • Must be infused within 6 hours of thawing

  22. Squares stand for males, circles stand for females Storry J. Human Blood Groups: Inheritance and Importance in Transfusion Medicine. J Inf Nursing 2003;26:367-72

  23. Transfusion Error (Goodnough LT. Risks of blood transfusion Crit Care Med 2003; 31(12) Suppl:S678-86) • 1 in 14,000 units in the US • 1 in 18,000 in the UK • 1 in 17,000 in Canada • ½ of the errors occur in the clinical arena (incorrect identification of the recipient of the blood unit, phlebotomy errors, failure to recognize a transfusion reaction) • 30% of errors occur in the laboratory • 1 in 33,000 units are ABO incompatible because of error, ½ of those are associated with a transfusion reaction, and 10% are fatal • The frequency of fatality due to ABO error is 1 per 800,000 blood units, compared with approximately one per 2,000,000 transfusions for transmission of HIV.

  24. Regan F. Blood transfusion medicine. BMJ 2002;325:143-7

  25. Arm band • Often taken off for cardiac surgery because of the need for lines and the arms are tucked in • Often taken off during paediatric and neonatal surgery because of the need for lines

  26. Adverse Transfusion Reaction • Acute hemolytic transfusion reaction • Delayed hemolytic transfusion reactions • Nonimmune hemolytic transfusion reactions • Febrile Nonhemolytic transfusion reactions • Allergic reactions • Transfusion related acute lung injury (TRALI) • Circulatory overload • HyperK, hypoK • Citrate toxicity • Bacterial contamination • Hypothermia • Acic-base disturbances • Viral disease • Immunosuppression

  27. Fig 3 1 in 5000 units

  28. Acute Hemolytic Transfusion Reaction • Incidence 1/25,000 • ABO incompatibility in the majority of cases • Immediate manifestation • Manifests as fever, haemolysis, shock, DIC, multiorgan failure, failure of the Hb to rise, +ve Coombs test • Withdraw transfusion, send samples to lab • Supportive: fluids, adrenaline, steroids, etc. • Mortality rate 1.5-10%

  29. Delayed haemolytic transfusion reactions • Occurs 5-10 days later in patients who have been previously sensitized by transfusion or pregnancy • Rarely life-threatening • Manifests as drop in Hb, fever, raised unconjugated bilirubin, haematuria • Transfuse with compatible blood if required • Other treatment seldom required WHO. The Clinical Use of Blood, 2001, Geneva

  30. Post-transfusion purpura • Rare, usually in females • 5-10 days post-transfusion • Thrombocytopenia caused by the presence of antibodies in donor products against recipient’s platelets • Increased bleeding tendency • Treat with high dose corticosteroid, high dose i.v. immune globulin 2 g/kg or 0.4 g/kg for 5 days, plasma-exchange • If platelets are required, give ABO-compatible platelets and platelets without the platelet specific antigens • Recovers after 2-4 wks WHO. The Clinical Use of Blood, 2001, Geneva

  31. Graft-vs-host disease • Rare • 10-12 days post-transfusion in recipients of bone-marrow transplant, immunocompromised patients, or in normal patients receiving blood from a relative or someone with whom they have a compatible HLA • Fever, skin rash, desquamation, diarrhoea, hepatitis, pancytopenia • Supportive care, no specific Rx, usually fatal • Prevented by g-irradiation of cellular blood products to kill the lymphocytes WHO. The Clinical Use of Blood, 2001, Geneva

  32. Klein HG. Immunomodulatory Aspects of Transfusion: A Once and Future Risk? Anesthesiology 1999; 91(3):861 Fate of transfused lymphocytes. Th = T helper; IFNg = interferon-g; GM-CSF = granulocyte-macrophage colony-stimulating factor; IL = interleukin; TNF = tumor necrosis factor; TGFb = transforming growth factor-b

  33. Febrile non-haemolytic transfusion reactions • The most common: incidence 1/200 units • Self-limiting febrile reaction caused by reaction to transfused leukocytes and platelets • Rule out other causes of fever (diagnosis of exclusion) • Can be avoided by using leukocyte-poor blood • Antipyretics as required

  34. Nonimmune hemolytic transfusion reactions • Overheating, over-warmed saline mixed with blood • Freezing • Use of incompatible i.v. solution • Trauma to blood (suction, pumps, CPB, etc.), too much shaking

  35. Allergic reactions • Simple allergic reactions are the second most common type of transfusion reaction; 1/200 units • Patient’s IgE acting against certain antigens in donor blood • Manifests as hives, urticaria, itching, rarely, laryngeal edema • Treat with antihistamine (diphenhydramine 0.5-1 mg/kg)

  36. Anaphylactic reactions • Rarely, congenital IgA deficiency and IgG antibody against IgA (IgA deficiency present in 1/700 general population, 20% of IgA deficient people develop antibodies, and of these, only 20% have clinically significant reaction: 1/17,500 of the general population) • Sudden onset of flushing, hypotension, edema, respiratory distress • Adrenaline, fluids • Use saline-washed RBC or frozen-thawed RBC; blood from IgA-deficient donor

  37. Pathogen contamination • More commonly associated with platelet transfusion because of room temperature storage • Suspected if patient has rigors and chills • Syphilis, Chagas disease, Malaria, toxoplasmosis, Lymes’ disease, brucellosis • Hepatitis B, C, delta, HIV, CMV, EBV, human parvovirus, infectious mononucleosis

  38. Figure 1. Sequence of chest X-rays taken of a patient with TRALI. Left: normal chest X-ray prior to transfusion; centre: chest X-ray, 2 h after transfusion, showing pulmonary infiltrates consistent with pulmonary edema; right: chest X-ray, 48 h after transfusion, showing clearing of pulmonary infiltrates. (Popovsky, et al. Diagnostic and pathogenetic considerations in transfusion-related acute lung injury. Transfusion 1985; 25:573-7) Most commonly attributable to leukocyte-agglutination anti-bodies in donor plasma that react with recipient leukocytes in the pulmonary microvasculature. Manifests by acute onset of respiratory distress, dyspnea, cyanosis, fever, and chills. Treatment is supportive. Recovery within 72 h. Mortality 5%

  39. Microaggregates • Shock lung-ARDS • Prevented by the use of buffy-coat depleted blood

  40. Transfusion reaction type by presenting symptom or sign • Fever or chills (hemolytic transfusion reaction, acute or delayed; bacterial contamination of blood product; febrile nonhemolytic reaction) • Hemolysis (acute hemolytic transfusion reaction; bacterial contamination of blood product) • Dyspnea (anaphylactic reaction; TRALI; CHF) • Urticaria (Urticarial transfusion reaction)

  41. Immunosuppression • 680 patients undergoing ORIF hip #, incidence of postop infection 27% in those who had received transfusion vs. 15% in those who had not (Koval et al. J Orthop Trauma 1997;11:260-5) • ~700 patients undergoing colorectal cancer resection, incidence of infection 39% in those who had received transfusion vs. 24% in those who had not (Houbiers et al. Transfusion 1997; 37:126-34) • 5-fold increase in infection in spine surgical patients (Triulzi et al. Transfusion 1992;32:517)

  42. Transfusion and lung cancer recurrence and prognosis • Nosotti M, et al. Correlation Between Perioperative Blood Transfusion and Prognosis of Patients Subjected to Surgery for Stage I Lung Cancer. Chest 2003;124:102-7 • Gascon P, et al. Immunologic abnormalities in patients receiving multiple blood transfusion. Ann Intern Med 1984;100:173-7 • Tartter PI, et al. Perioperative blood transfusion adversely affects prognosis after resection of stage I (subset N0) non-oat cell lung cancer. J Thorac Cardiovasc Surg 1984;88,659-62 • Hyman NH, et al Blood transfusion and survival after lung cancer resection. Am J Surg 1985;149,502-7 • Pastorino U, et al Perioperative blood transfusion and prognosis of resected stage Ia lung cancer. Eur J Clin Oncol 1986;22,1375-8 • Keller SM, et al Blood transfusion and lung cancer recurrence. Cancer 1988;62,606-10 • Moores DWO, et al. Effect of perioperative blood transfusion on outcome in patients with surgically resected lung cancer. Ann Thorac Surg 1989;47,346-51 • Little A, et al Perioperative blood transfusion adversely affects prognosis of patients with stage I non-small cell lung cancer. Am J Surg 1990;160,630-3 • Pena CM, et al Significance of perioperative blood transfusion in patients undergoing resection of stage I and II non-small-cell lung cancer. Chest 1992;102,84-8 • Piantadosi S, et al. The adverse effect of perioperative blood transfusion in lung cancer. Chest 1994;106(suppl),382-4 • Blajchman MA. Allogeneic blood transfusion, immunomodulation and postoperative bacterial infection: do we have the answers yet? Transfusion 1997;37,121-5

  43. Cancer recurrence and transfusion • Liver cancer • Colorectal cancer

  44. Leal-Noval SM,et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac Surgery* CHEST 2001;Vol 119: 1461-1468

  45. Leal-Noval SM,et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac Surgery* CHEST 2001;Vol 119: 1461-1468

  46. Leal-Noval SM,et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac Surgery* CHEST 2001;Vol 119: 1461-1468 Relationship between the units of blood products transfused and the percentage of infections

  47. Hypothermia • At 35ºC, it is as if you have 80% of your factors • At 33ºC, it is as if you have 40% of your factors • At 31ºC, it is as if you have 20% of your factors • Not reflected in PT, INR, PTT because samples are prewarmed to 37°C • Platelets stick poorly & become sequestrated in the splanchnic circulation and spleen • Compound other haemostatic problems • Patient wakes up shivering, hypertensive, tachycardic, and uses more O2 and produces more CO2 • All fluids and blood products should be warmed • Warming mattress, especially for OPCAB, and Bair Hugger

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