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Module 3: Indications for blood/ blood components

Module 3: Indications for blood/ blood components. Transfusion Training Workshop KKM 2012. Case 1 – PRBC. Cik SL, 18 year-old lady Had reconstruction of L mandible Blood loss 2 L Hb dropped from 11 to 8.5 g/dL PR 100 BP 120/70 1 unit packed red blood cell (PRBC) transfused.

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Module 3: Indications for blood/ blood components

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  1. Module 3: Indications for blood/ blood components Transfusion Training Workshop KKM 2012

  2. Case 1 – PRBC • Cik SL, 18 year-old lady • Had reconstruction of L mandible • Blood loss 2 L • Hb dropped from 11 to 8.5 g/dL • PR 100 BP 120/70 • 1 unit packed red blood cell (PRBC) transfused

  3. Case 2 – PRBC • Cik SB, 25 year-old lady • Delivered SVD 1st child • Blood loss 80 mL • Hb 7.5 g/dL MCV 65fL MCH 19 pg • Transfused 2 units PRBC

  4. Case 3 – PRBC • En SM, 35 year-old man • Admitted to ICU for multiple trauma • Hb 8.9 g/dL • Transfused 2 units PRBC

  5. Case 4 – PRBC • En AF, 56 year-old man • Admitted for hernia repair • Known DM with CKD type II • Hb 10.0 g/dL • 2 units PRBC requested

  6. Adaptive mechanisms to avoid tissue hypoxia • When Hb falls, • cardiac output increases • blood viscosity decreases • peripheral vasoconstriction occurs • To maintain O2 delivery to tissues

  7. Clinicians underestimate the effectiveness of adaptive mechanisms Over-reliance on Hb measurements Using a Hb trigger of 10 g/dL >> Leading to excessive and inappropriate use of red cell transfusions

  8. Indications for packed red cells • Factors to be considered: • Acute vs. chronic anaemia • On-going blood loss • Age of patient • Underlying medical illness

  9. Acute anaemia (due to blood loss)

  10. Acute blood loss(no on-going loss) * Except for patients who tolerate anaemia poorly eg. pre-existing anaemia, severe cardiac or respiratory disease, age >65 years BJH guidelines 2001

  11. Acute blood loss(no on-going loss) * Except for patients who tolerate anaemia poorly eg. pre-existing anaemia, severe cardiac or respiratory disease, age >65 years BJH guidelines 2001

  12. Acute blood loss(no on-going loss) BJH guidelines 2001

  13. Acute blood loss(no on-going loss) BJH guidelines 2001

  14. Acute blood loss(no on-going loss) * Except for patients who tolerate anaemia poorly eg. pre-existing anaemia, severe cardiac or respiratory disease, age >65 years BJH guidelines 2001

  15. Acute blood loss(no on-going loss) • Except for patients who tolerate anaemia poorly eg. severe cardiac or • respiratory disease, age >65 years BJH guidelines 2001

  16. Case 1 – PRBC • Acute blood loss of 2L = 40% loss of blood volume • Need for transfusion: probably • But in view of young age and Hb >8.0 with no ongoing blood loss • Decision: not to transfuse

  17. Chronic anaemia

  18. Chronic anaemia • Chronic anaemia is better tolerated • Better O2 delivery due to the increase in 2,3 DPG and a shift in the O2 dissociation curve • Cardiac output at rest does not usually increase until Hb falls <7 g/dL

  19. Chronic anaemia • The cause of anaemia should be established • Correct the anaemia eg. iron deficiency anaemia with iron Rx • Usually asymptomatic with Hb >7 g/dL • Transfuse only if life-threatening BJH guidelines 2001

  20. Case 2 – PRBC • 1st pregnancy • Minimal blood loss post-partum • Hb 7.5 g/dL • Hypochromic microcytic indices • Most likely iron deficiency anaemia • Treat with iron supplements while investigating • No indication for transfusion

  21. Anaemia in Critical Care

  22. Anaemia in critical care • Same target apply as for acute blood loss • Over-transfusion may increase mortality in this group Herbert et al, NEJM 1999

  23. 30-day mortality no worse: all patients 100 Restrictive- transfusion strategy (trigger Hb <7) 90 80 Liberal- transfusion strategy (trigger Hb <10) Survival % 70 60 P= 0.10 50 0 5 10 15 20 25 30 Days Herbert et al, NEJM 1999

  24. 30-day mortality lower in patients with APACHE II score <20 Restrictive- transfusion strategy (trigger Hb <7) 100 90 Liberal- transfusion strategy (trigger Hb <10) 80 Survival % 70 60 P= 0.02 50 0 5 10 15 20 25 30 Days Herbert et al, NEJM 1999

  25. Anaemia in critical care • Except for patients who tolerate anaemia poorly eg. severe cardiac or • respiratory disease, age >65 years BJH guidelines 2001

  26. Case 3 – PRBC • Multiple trauma • Hb 8.9 • Age 35 years • No case for transfusion

  27. Pre-operative Assessment

  28. Peri-operative transfusion • Objective is to manage the patient so that transfusion is not needed • Investigate and treat anaemia prior to op • Discontinue anti-platelet drugs or anticoagulants if possible • Consider erythropoeitin or autologous transfusion • Management of acute haemorrhage during surgery is the same approach as for acute blood loss BJH guidelines 2001

  29. Case 4 – PRBC • Hernia repair • Hb 10 g/dL • No indication for transfusion

  30. Case 1 – Whole blood • 51 year-old lady • c/o: fever x 5 days • Myalgia • Haematemesis x 1 cupful • Hb 10.7 Hct 31 Plt 42 • Dengue IgM pos (D7) • O/E: Pink • BP 115/66 PR 110 • T 37.5

  31. Case 1 – WB • Chest: dull both bases • Abd: tender RHC and ascites • Diagnosis: DHF or severe dengue • 2 pints whole blood (WB) requested

  32. Whole blood • Made into components • Contain 1 unit red cell, 1 unit plasma and 1 unit platelet • Kept at 4oC • Labile clotting factors are lost • Platelets are non-functional

  33. Case 1 – WB • Plasma in WB will leak in DHF • Higher risk of TRALI with WB • PRBC stays in vessels, less leak (indicated only if signs of occult bleeding) • Monitor clinically

  34. Indications for WB • Most indications for WB transfusion are now well managed exclusively with blood component therapy • Storage of WB precludes the production of components and is highly inefficient • WB is thus unavailable in most blood banks in the United States AABB circular 2009

  35. Case 1 – FFP • Pn SA, 60 year-old lady • h/o Hypertension and IHD • Atrial fibrillation on warfarin

  36. Case 1 – FFP • c/o severe headache • O/E: R hemiparesis GCS 12/15 • CT scan: L parietal haemorrhage • INR 9.0

  37. Case 1 – FFP • Urgent 4 units FFP requested • IV vitamin K 10 mg bolus • FFP transfused 1½ hour later (6h after admission)

  38. Case 1 – FFP • GCS deteriorated • Intubated and ventilated • Referred neurosurgical • Conservative Mx

  39. Indications for FFP 1. For warfarin reversal in a bleeding patient ONLY if prothrombin complex concentrate (PCC) is not available BJH guidelines 2001

  40. Warfarin reversal

  41. INR and discontinuation of Warfarin White 1995

  42. Reversing Warfarin Effect • Stop warfarin • Give Vitamin K • PCC or FFP

  43. Prothrombin Complex Concentrate (PCC) • Lyophilised powder • Reconstituted within 1 minute • Kept at pharmacy (like albumin and ivIg)

  44. INR reversal by PCC Yasaka 2003 7-27u/kg

  45. Reversal of Warfarin 25-30 U/kg PCC 800 mL FFP 100 100 90 90 80 80 70 70 60 60 FII 50 50 40 40 30 30 20 20 10 10 0 0 Pre Post Pre Post Median 3 17 15 65 Makris 1997

  46. Warfarin and ICH • 6x risk of hematoma expansion after admission • Expansion is associated with poor outcome • 3x mortality risk than non-warfarin ICH Flibotte 2004

  47. PCC vs FFP • PCC gives more rapid and complete correction of warfarin-induced coagulation defect than FFP • Rapid correction of INR prevents ICH enlargement • Must combine with Vitamin K for sustained reversal Fredriksson 1992 Yasaka 2003

  48. Rapid reversal of warfarin • FFP • Time to thaw • 15 mL/kg: large volume • Slow to administer • Effect on levels is small • Multiple donors, ± untreated • Blood group required • Generally available • PCC • Rapid reconstitution • Minimal volume • Rapid administration • Reliable correction • Prothrombotic risk • Pooled • Viral inactivation • Limited availability

  49. PCC • Prothrombinex • Octaplex • Beriplex

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