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Blood Product Transfusion

Blood Product Transfusion. Rational use Complications and its management Dr Chu Po Ngai Alvin 13 Feb 2009. Take home message…. Drug Art > solid evidence Look out for complications. Blood components. Red blood cells Platelets Fresh Frozen Plasma Cryoprecipitate. Red blood cells.

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Blood Product Transfusion

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  1. Blood Product Transfusion Rational use Complications and its management Dr Chu Po Ngai Alvin 13 Feb 2009

  2. Take home message… • Drug • Art > solid evidence • Look out for complications

  3. Blood components • Red blood cells • Platelets • Fresh Frozen Plasma • Cryoprecipitate

  4. Red blood cells • Red cell transfusions increase the oxygen carrying capacity of blood by raising the Hb concentration • Avoid tissue hypoxia • 1 unit • 300ml volume • Hb concentration 18-23 g/dL • 1 unit -> ↑ Hb 1 g/dL

  5. Anaemia, eg. • Bleeding • Anaemia of critical illness (decreased EPO production with abnormal iron metabolism) • Historical indication for transfusion • Hb 10 g/dL or Hct 0.3

  6. Infection risk (eg. HIV, hepatitis, vCJD) • Adverse reactions • Limited supply

  7. Compensation for anaemia: • Acute isovolaemic anaemia to Hb 5g/dL in volunteers and patients produced no evidence of inadequate oxygenation (Weiskopf, 1998)

  8. Crit Care Med, 2004, Vol 32:1

  9. Mean Hb level at baseline was 11.0 • 44% of patients received one or more RBC units while in the ICU (mean 4.6 +/- 4.9 units) • Mean pre-transfusion Hb was 8.6 +/- 1.7 g/dL • Mean time to first ICU transfusion was 2.3 +/- 3.7 days

  10. The number of RBC transfusions a patient received during the study was independently associated with longer ICU and hospital length of stay, and an increase in mortality • Corrected for baseline Hb + severity of illness (APACHE/SOFA) • Exposure to leukocytes in transfusions trigger an immune response in the recipient, leading to: • Increased risk of infection (esp. trauma, burns, surgery) • Earlier recurrence of malignancy

  11. Hb level rather than clinical or physiologic factors drives transfusion decisions • Time to first transfusion was significantly longer in those patients who presented with a high baseline Hb • 1.8 days with baseline Hb of 8 g/dL • 6.3 days with baseline Hb of 12 g/dL • p=0.05

  12. JAMA, 2002, Vol 288:12

  13. Mean Hb (on admission) 11.3 g/dL • 29% had Hb < 10 g/dL • Transfusion rate: 37%

  14. ICU mortality rate higher in those with transfusion • (18.5% vs 10.1%, p < 0.001) • Overall mortality rate higher in those with transfusion • (29.0 vs 14.9%, p < 0.001) • For similar organ dysfunction, patients with transfusion had higher mortality rate • For matched patients, 28-day mortality was higher in those with transfusion • (22.7% vs 17.1%, p=0.02)

  15. British Committee for Standards in Haematology (BCSH), Guidelines for the clinical use of red cell transfusions • National Health and Medical Research Council (NHMRC), Clinical practice guidelines on the use of blood components • American Society of Anesthesiologists, Practice Guidelines for Blood component therapy

  16. Consideration of the patient’s condition is essential • cause of anaemia, severity, chronicity • patient’s ability to compensate (age > 65, cardiovascular / pulmonary disease) • likelihood of further blood loss • need for provision of reserve before onset of tissue hypoxia

  17. Need for transfusion based on Hb level: • Hb > 10 – no transfusion (Level I) • Hb < 7 – transfuse (Level IV) • Hb 7-10 - no clear guideline, but evidence suggests usually transfusion not justified • Lower threshold (Hb < 8) for transfusion if patient likely to tolerate anaemia poorly • eg. > 65y, cardiovascular / respiratory disease

  18. Need for transfusion based on estimation of blood loss: • 15% (750ml): no transfusion, unless preexisting anaemia or unable to compensate (severe cardiac / respiratory disease) • 15-30% (800-1500ml): IVF, no transfusion unless preexisting anaemia or unable to compensate • 30-40% (1500-2000ml): IVF, transfusion probably required • >40% (>2000ml): IVF + transfusion

  19. Similar guidelines for peri-operative patients, but importance of avoiding transfusions • Eg. Fe for Fe deficiency, stop anti-platelet drugs (Aspirin), reverse anticoagulation (Warfarin) • Importance of volume replacement, maintenance of BP and cardiac output

  20. Dose • 1 unit PC -> ↑ 1 g/dL Hb

  21. Platelets • Prevention and treatment of haemorrhage in patients with thrombocytopenia or defective platelets • 1 unit • about 5 x 1010 platelets • 150-300ml volume • Dose: 1 unit per 10kg body weight • 1 unit increases platelet count by 5-7 x 109/L • Check post-transfusion Plt count after 1 hour

  22. Transfusion, 2006, Vol 46

  23. Retrospective cohort study, single centre • 118 ICU patients with thrombocytopenia • Median APACHE II score 26 • Trauma / cardiac surgery / orthopaedic patients excluded

  24. Prophylactic (44.7%) • median transfusion trigger = 33 x 109/L • Therapeutic (31.6%): • median transfusion trigger = 51 x 109/L • Peri-procedure (23.7%): • median transfusion trigger = 46 x 109/L

  25. Platelet count response • Median platelet count increase after 1 unit = 14 x 109/L • No increase in platelet count (ineffective transfusion) was observed after 17 transfusions given to 13 (48.1%) of 27 transfused patients

  26. BCSH 03 • NHMRC 01

  27. Transfuse if: • < 10 x 109/L, w/o risk factors (bleeding, fever, antibiotics) (Level II) • < 20 x 109/L, w/ risk factors (Level II) • ≤ 50 x 109/L, undergoing surgery / invasive procedure, massive haemorrhage, massive transfusion (1.5-2.0 blood volumes, or > 10 units RBC within 24 hours) (Level IV) • ≤ 100 x 109/L, undergoing neurosurgery / eye surgery, diffuse microvascular bleeding (Level IV)

  28. No benefit from platelet transfusion, may even be harmful (Level IV) • Immune-mediated platelet destruction • TTP • HUS • Post-cardiac bypass surgery without bleeding • Drug induced thrombocytopenia without bleeding

  29. Fresh Frozen Plasma • Treatment of excessive bleeding or prevention of bleeding in patients with abnormal coagulation • Dose: 10-20ml FFP/kg body weight • 1 dose expected to increase level of coagulation factors by 15-20% immediately after transfusion (ie. 1ml FFP/kg body weight raises coagulation factors by about 1%) • Bolus • Volume: 180-400ml/unit

  30. Indications are very limited

  31. Journal of Trauma, 2008; Vol 65(2)

  32. Retrospective review, single centre (Denver Health Medical Center), 2001-2006 • Massive transfusion (> 10 units RBC in initial 6 hours)

  33. Journal of Trauma, 2007; 63:805-813

  34. Retrospective chart review, 246 patients, single centre (one US Army combat support hospital in Iraq), 2003-2005

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