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Chapter 24 - Blood Therapy

Chapter 24 - Blood Therapy. Seth Christian, MD MBA Tulane Anesthesiology. Overview of Perioperative Blood Transfusion and Adjuvant Therapies. Transfusion Medicine (T&S, T&C, Emergency transfusion, Storage) Transfusion Thresholds Blood Components (PRBC, Plt, FFP, Cryo)

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Chapter 24 - Blood Therapy

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  1. Chapter 24 - Blood Therapy • Seth Christian, MD MBA • Tulane Anesthesiology

  2. Overview of Perioperative Blood Transfusion and Adjuvant Therapies • Transfusion Medicine (T&S, T&C, Emergency transfusion, Storage) • Transfusion Thresholds • Blood Components (PRBC, Plt, FFP, Cryo) • Complications and Risks • Miscellaneous (autologous transfusion, cell-saver, normovolemic hemodilution)

  3. Practice Guidelines for Perioperative Blood Transfusions and Adjuvant Therapies

  4. Type and Screen • Type - the donor erythrocytes do not have major antigens (A, B, Rh) that will react with antibodies in the recipient blood • O negative blood - does not have any antigens, so it is the universal donor • Screen - the donor erythrocytes do not have common antigens that will react with antibodies in the recipient blood • T&S blood is recommended for procedures in which transfusion is unlikely, but possible (lap choly, TAH) • Risk of Significant Transfusion Reaction = 1 in 10,000 units transfused

  5. Type and Cross • Cross-match - donor erythrocytes are introduced to the recipient's plasma • Major cross-match checks for IgG antibodies (Duffy, Kell, Kidd) • T&C blood should be reserved for procedures in which transfusion is expected • Risk of Significant Transfusion Reaction = 1 in 1,000 units transfused

  6. Emergency Transfusion • It takes 5 minutes to perform a partial cross-match (donor erythrocytes introduced to recipient plasma, centrifuged and observed for agglutination • Once 2 units of O-negative PRBC are transfused, subsequent transfusions should continue with O-negative blood

  7. Blood Storage • Temperature - 1 to 6 deg C • ADP (adenine, dextrose, phosphate) • Adenine: fuel for ATP production/survival • "Young blood" - < 14 days is associated with better outcomes.

  8. Decision to Transfuse • BP, HR, UOP, O2, EKG, AGB, SvO2. • Hgb <= 6 almost always require transfusion • Hgb = 8 may be threshold for patients not at risk of ischemia • Hgb = 10 may be threshold for patients at risk of ischemia (COPD, CAD, rapid bleeding). • Hgb > 10 g/dl rarely require transfusion

  9. Decision to Transfuse • Transfusion greater than 10 does not substantially increase O2 delivery • "The exact Hgb value at which CO increases (compensatory) varies among individuals and is influenced by age, chronicity, and sometimes anesthesia"

  10. Decision to Transfuse • Hypotension and tachycardia are likely, but may be blunted by anesthesia or other drugs • Compensatory vasoconstriction may conceal the signs of acute blood loss until at least 10% of blood volume is lost • Healthy patients may be able to lose 20% of blood volume before signs of hypovolemia occur.

  11. PRBCs • 250 - 300 ml with Hct ~70-80 • Cell Saver - Hct usually ~ 50 • Mix with NS (not hypotonic or LR) • Ca++ may cause clotting

  12. Platelets • Probably not required unless platelet count is less than 50,000 • Consider transfusing 1 pooled unit (6 pk) for every 6 units of PRBC in large transfusions • Bacterial contamination is most likely to occur in platelet concentrates • Platelet related sepsis incidence is as high as 1 in 5000 transfusions • Desmopressin 20 mcg may be given for qualitative platelet disorders

  13. Fresh Frozen Plasma • All coagulation factors except platelets • Probably not necessary unless PT is > 1.5 times normal or INR > 2 • Warfarin reversal, heparin resistance • FFP of 10-15ml/kg will achieve 30% of most plasma factor concentrations

  14. Cryoprecipitate • The fraction of plasma that precipitates when FFP is thawed • High concentrations of Factor VIII, fibrinogen • Indicated for Hypofibrinogenemia and Hemophilia A • Consider transfusion if fibrinogen less than 100 mg/dl • Not recommended for patients with unstable coronary artery disease because ultralarge vWF multimers released by DDAVP can aggregate platelets and increase risk of infarction

  15. Complications • RIsk of fatal outcome due to blood transfusion is remote but possible.

  16. Complications • Hyperthermia, increased airway pressures, and/or change in urine output/color may be suggestive of transfusion reaction • Febrile reaction: most common (0.5-1%) as a result of recipient antibodies to donor antigens on leukocytes or platelets • Allergic reaction: also associated with pruritis and urticaria, bronchospasm • Slow the infusion and give antipyretics for febrile reaction; give antihistamines, bronchodilators, and stop infusion for allergic reaction

  17. Complications • Hemolytic reactions: typically a result of wrong blood type • Lumbar and substernal pain, fever, chills, dyspnea, and skin flushing • Free hemoglobin in plasma or urine, acute renal failure and DIC occur • Discontinue transfusion and maintain urine output with IVF, mannitol and lasix • Alkalinization of urine with bicarb and steroids are of unproven value

  18. Autologous Blood Transfusions • Predeposited autologous donation (PAD): • More expensive and not very effective at reducing allogenic blood transfusion • Patients for elective surgery with high likelihood of transfusion may donate 10ml/kg of blood every 5-7 days if Hgb > 11g/dL up to a maximum of 3 units

  19. Autologous Blood Transfusion • Infection or malignancy is a contraindication to blood intraop blood salvage (cell saver) • Normovolemic hemodilution: early intraop donation and intravascular volume replacement with crystalloids to Hct of 27-33% • Fewer RBC per millimeter of blood loss during surgery

  20. Complications • Incidence of infection from blood transfusions has markedly decreased • HCV transmission decreased from 1 in 10 to less than 1 in 1 million transfusions since 1980 • Nucleic acid technology responsible for improved viral testing • HBV, HTLV, CMV, Malaria, Creutzfeldt-Jakob

  21. TRALI • Non-cardiac exudative pulmonary edema in the absence of left atrial hypertension that occurs within 6 hours of transfusion • Exclusion of female donors and fresher blood (< 14 days) decreases risk • Stop transfusion, send off fluid from ETT, CBC, CXR, and notify blood bank so that other units may be quarantined

  22. Transfusion Related Immunomodulation • Long-term prognosis in cancer surgery is unclear, but there is a suggestion of a correlation between tumor recurrence and blood transfusions • Leukoreduction reduces incidence of nonhemolytic febrile transfusion reactions and transmission of leukocyte-associated viruses • Leukoreduction to prevent cancer recurrence is more speculative

  23. Metabolic Abnormalities • pH decreases, K increases, and 2,3-DPG decreases with duration of storage. • Metabolic acidosis and hyperkalemia rarely occur even in massive transfusions • Less 2,3-DPG increases affinity of Hgb for Oxygen, and potentially decreases tissue oxygen delivery • Citrate metabolism to bicarbonate may contribute to metabolic alkalosis • In anhepatic phase of liver transplant, citrate is not metabolized and it binds to calcium in blood causing hypocalcemia

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