Blood Transfusion

Introduction
• In the past “Benign intervention”
• Present “outcome to be avoided”
• Why?
Components
Indications
Complications & management
 Components
Whole
blood
Cellular components Fresh plasma

Fresh frozen plasma

Cryoprecipitate Cryosupernatant

Red cells Albumin

Factor VIII
Platelets Immunoglobulin
Fibrinogen
etc
 Packed red blood cells
• Also called
• Packed cells
• RBC’s
• Description of Components:
• Concentrated erythrocytes
• Citrate anticoagulant
• Preservative solution/s
• Hct ranges from about 50-65% (e.g., AS-1, AS-
3, AS-5) to about 65-80% (e.g., CPDA-1, CPD,
CP2D).
• 50 mL of donor plasma (range 20 mL to 150
mL),
• 42.5-80 g of hemoglobin or 128-240 mL of pure
red cells,
• hemoglobin level of the donor,
 Dosing and response
• One unit of compatible RBCs
increases the hemoglobin level in an
average sized adult by
approximately 1g/dL or Hct by 3%.
• Dose
• Packed cells (mls)
= wt (kg) x Hb rise required(g/dL) x 4
• Half life of approximately 30 days
 Packed red blood cells
• Indications
• Symptomatic deficit of oxygen-carrying capacity
• Exchange transfusion
• Hemolytic disease of new born
• Acute chest syndrome in sickle cell crisis

• Contraindications
• Anemias that can be corrected with specific
medications such as iron, vitamin B12, folic acid, or
erythropoietin
• Coagulation deficiency
• Volume expansion
• To improve oncotic pressure, wound healing and
sense of well being
 Indications
• Clinical signs & symptoms
• Exertional dyspnea,
• Chest pain,
• Lethargy,
• Hypotension,
• Pallor,
• Tachycardia,
• Impaired consciousness
• Unreliable esp
• in children
• Anaesthetised patints
 Indications
• Physiologic transfusion triggers
• Mixed Venous O2(PvO 2)
• Mixed Venous O2 SaturationSvO2
• O2 ConsumptionVO2
• Oxygen Extraction Ratio—O2ER

• Disadvantage
• Requires invasive monitoring
• May be unreliable in certain clinical situations
 ASA Task Force
Recommendations
(perioperative)
• Transfusion is rarely indicated when the
hemoglobin level is above 10 g/dL
• Almost always indicated in patients when
the hemoglobin level is below 6 g/dL;
• For hemoglobin level 6-10 g/dL
• Ongoing indication of organ ischemia,
• The rate and magnitude of any potential or
actual bleeding,
• The patient’s intravascular volume status
• Risk of complications due to inadequate
oxygenation.
 Potential Candidates
for Transfusion
• Patients undergoing
• Cardiopulmonary bypass or cardiac surgery
• Urgent or emergent procedures
• Obstetric procedures
• Organ transplantation
• Major noncardiac surgery
• Patients with pre-existing blood disorders or
acquired deficiency secondary to massive
bleeding
• Critically ill patients
American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and
Adjuvant Therapies. Anesthesiology. 2006;105:198-208.
 Critical care
• Effects of hypovolemia should be
differentiated from that of anemia
• In healthy adults
• Upto 40% loss( approximately 2L in males)
• DO2 is maintained with Hb as low as 6-7 gms
Platelets
 Platelets
• Single donor platelets >3.0 x 1011per
bag(250ml) (derived by apheresis)
• Random derived platelets >5.5 x 1010
per bag(50ml)
• 4-10 RDPs are pooled for one adult
transfusion
• Stored up to five days at 20-24°C
(room temperature).
• Continually agitated to prevent
clumping. Storage is limited to five
days due to the risk of bacterial
 Platelet Incubator

Stored with constant

agitation
 Dosage And Response
• 4-10 RDPs or 1SDP in adults
• 1unit RDP/10 Kg
• 7-10,000/ mm3 for each RDPgiven, or 30-
60,000/ mm3 for each SDP given.
• Rate @3ml/kg/hr over 2-3 hours.
• Response adversely affected by
• the presence of fever, sepsis,
• splenomegaly,
• severe bleeding,
• consumptive coagulopathy,
• HLA alloimmunization
• certain drugs (e.g.,amphotericin B).
 Transfusion of Platelets:
Indications and Contraindications
• Indications
• Bleeding due to critically decreased circulating
platelet count or functionally abnormal
platelets
• Prevention of bleeding from marrow hypoplasia
(platelet count <10,000/μL)
• Selected cases of postoperative bleeding
(platelet count <50,000/μL)
• Contraindications
• Plasma coagulation deficits
• Some conditions with rapid platelet destruction (eg,
ITP, TTP) unless life-threatening hemorrhage
 Guidelines- Perioperative

• Cardiothoracic surgery:
• Routine prophylactic transfusions are
not required in the absence of bleeding.
• When coagulation parameters are not
significantly abnormal, counts
<100,000/mm3 accompanied by major
unexpected microvascular bleeding
 Guidelines- Perioperative
• Other surgical procedures:
• Intraoperative platelet counts as a guide
• Microvascular bleeding in dilutional
thrombocytopenia may require empiric
transfusion before counts are available.
• Prophylactic preoperative transfusion
• Is rarely required for counts >100,000/mm3,
• Is usually required for counts <50,000/mm3 and is
guided by risk factors for intermediate counts.
• Procedures with insignificant blood loss or vaginal
deliveries can be performed at counts 50,000/mm3
without prophylactic transfusion.
• Neurologic or ophthalmologic procedures
require a platelet count near 100,000/mm3.
• Transfusion may be required with apparently
adequate counts when known or suspected
platelet dysfunction results in microvascular
 Guidelines- Perioperative
• Specific procedures:
• In the absence of other coagulopathy, major
invasive procedures require platelet counts of
at least 40,000 to 50,000/mm3 (including CVP
placement, paracentesis/ thoracentesis,
respiratory tract / GI biopsies, closed Liver
biopsy, lumbar puncture, sinus aspiration &
dental extraction).
• A threshold of 80,000/mm3 has been proposed
for spinal epidural anesthesia.
• Fiberoptic bronchoscopy without biopsy by an
experienced operator may be safely performed
in the presence of a platelet count
<20,000/mm3.
• GI endoscopy without biopsy may be safely
 Guidelines- Perioperative
• Platelet Function Defects:
Transfusion is
• Indicated in critical bleeding or before
major surgery regardless of the platelet
count.
• Not indicated
• When defect extrinsic to the platelet
(e.g.,uremia, certain types of von Willebrand
Disease, hyperglobulinemia)
• Antiplatelet Agents:Thienopyridine
platelet ADP receptor inhibitors and direct
glycoprotein IIb/IIIa inhibitors impair platelet
function in absence of thrombocytopenia
• But high dose therapeutic transfusion may
be required for life threatening hemorrhage
 Guidelines :Critical Care
• Massive transfusion:
• A transfusion target of >50,000/mm3 in
acutely bleeding patients and >100,000/mm3
for those with polytrauma or CNS injury.
• The platelet count may fall below 50,000/mm3
when >1.5–2 blood volumes have been
replaced with red cells.
• In the presence of microvascular bleeding,
transfusion may be appropriate when counts
are known or suspected to be <100,000/mm3.
• Disseminated/local Intravascular
coagulation (DIC/LIC) and/or sepsis
• Microvascular bleeding is treated in children
and adults with platelet counts <50,000/mm3
• Neonates<100,000/mm3.
FRESH FROZEN PLASMA
 Fresh Frozen Plasma
• Separated from whole blood and frozen
within 8 hours of collection. It can be
obtained from a whole blood donation
(approx. 250 ml) or by apheresis (approx.
500 ml).
• Frozen Plasma must be thawed, usually in
a water bath, and infused immediately or
stored at 1-6oC for up to 24 hours.
• Contains a normal concentration of
fibrinogen and the labile coagulation
factors VIII and V.
• Fresh frozen plasma contains the clotting
factors that are necessary for hemostasis.
 Frozen Plasma 24
• The plasma is separated after cold
centrifugation and processed to the frozen
state within 24 hours of collection
• Frozen plasma contains stable coagulation
factors such as Factor IX and fibrinogen in
concentrations similar to FFP, but reduced
amounts of Factor V and VIII.
• The indications and side effects are the
same as for FFP, except that FP should not
be used to treat coagulation factor
deficiencies of Factor V and Factor VIII.
 Dosing
• Multiple coagulation factor defeciency
• 10-20 ml/kg
• Isolated coagulation factor deficiencies for
which no concentrated preparation is
available (e.g., factor V, or XI)
• The half-life of the specific factor,
• The pretransfusion level of the factor,
• The desired post transfusion level
• Duration of raised levels required.
• TTP
• initially requires exchange of 1 – 1.5 plasma
volume daily
• Twice daily single plasma volume exchanges in
 Indications
• Active bleeding or risk of bleeding due to
deficiency of multiple coagulation factors,
• Severe bleeding due to warfarin therapy,
or urgent reversal of warfarin effect
• Massive transfusion with coagulopathic
bleeding.
• Bleeding or prophylaxis of bleeding for a
known single coagulation factor deficiency
for which no concentrate is available.
• Thrombotic thrombocytopenic purpura.
• Rare specific plasma protein deficiencies,
such as C1- inhibitor.
 Contra-indications
• Increasing blood volume or albumin
concentration
• Coagulopathy that can be corrected
with administration of vitamin K.
• Normalizing abnormal coagulation
screen results, in the absence of
bleeding.
Cryoprecipitate
Cryoprecipitate
 CRYOPRECIPITATE
• Cryoprecipitate is prepared by thawing fresh
frozen plasma at a temperature between 1°C
and 6°C. After centrifugation, the supernatant
plasma is removed and the insoluble
cryoprecipitate is refrozen.
• On average, each unit of cryoprecipitate
contains 80 IU or more Factor VIII (FVIII:C) and
at least 150 mg of fibrinogen in 5-15 mL of
plasma.
• Cryoprecipitate provides a source of coagulation
factors. Factor VIII, Factor XIII and von
Willebrand Factor.
• Fibrinogen and fibronectin are present.
 CRYOPRECIPITATE
• Acellular blood component.
• Compatibility testing inluding Rh type is
unnecessary.
• CMV testing and leukoreduction are not
required.
• Frozen cryoprecipitate is thawed in a
protective plastic overwrap in a waterbath
at 30-37oC up to 15 minutes.
• Kept at room temp & transfused as soon
as possible after thawing or within 6 hours
if it is a closed single unit or has been
pooled prior to freezing.
• It should be transfused within 4 hours if it
 Dosing
• Fibrinogen required (mg) =
• (desired F(mg/dL) - initial F (mg/dL)) X
plasma volume (mL) /100
• Bags of cryo required = mg fibrinogen
required
250 mg
• A typical dose for the treatment of
hypofibrinogenemia is one
cryoprecipitate unit per 7 - 10 kg of
body weight.
 Indications and Contra-
indications
• Indications
• Bleeding associated with fibrinogen
deficiencies (<100mg/dl) and Factor XIII
deficiency esp if FFP cannot be given due to
volume overload
• Indicated in hemophilia A or von Willebrand’s
disease (vWD) when appropriate Factor VIII
concentrates or Factor VIII concentrates
containing FVIII:vWF are not available.
• Fibrin Sealant
• Uremic bleeding
• Contraindications
• Do not transfuse cryoprecipitate unless
laboratory studies confirm deficiency of a
 Clotting factors
• Factor VIII
• Dose
• Loading Dose 50 u/kg
• Infusion 3u/kg/hr
• Factor IX
• Dose
• Loading dose100u/kg
• Infusion 3u/kg/hr
• Activated Factor VIIa (NovosevenTM)
• Factor XIII (13) FibrogamminTM
• ProthrombinexTM
 Complications
• Immunologic Complications,
Immediate
• Hemolytic transfusion reaction,
• Immune-mediated platelet destruction,
• Febrile nonhemolytic reaction
• Allergic reactions
• Anaphylactoid reactions
• Transfusion-related acute lung injury
(TRALI)
 Hemolytic transfusion reaction
• Pathogenesis –
• Immunologic destruction of transfused red
cells, due to antigen antibody reaction.
• Mistransfusion of ABO-incompatible blood,
resulting from identification errors
• Incompatibility unidentified during
pretransfusion testing
• Symptoms and signs
• an increase in temperature and pulse rate;
• chills,
• dyspnea, chest or back pain,
• Abnormal bleeding, or shock.
• Instability of blood pressure
• In anesthetized patients,
• Hypotension
• Evidence of disseminated intravascular coagulopathy
Hemolytic transfusion reaction
• Laboratory findings
• hemoglobinemia and/or hemoglobinuria,
• elevation of serum bilirubin;
• in less catastrophic acute hemolytic
reactions, a positive direct antiglobulin
test (DAT)
• Treatment
• transfusion must be stopped
• measures to maintain or correct arterial
blood pressure; correct coagulopathy,
• promote and maintain urine flow.
• Febrile nonhemolytic reaction
• Symptoms
• Fever Shortly after transfusion
• No tests available for diagnosis
• Treatment
• Antipyretics.
• Patients who experience repeated,severe febrile
reactions may benefit from receiving leukocyte
reduced components.
• Allergic reactions
• urticaria,
• wheezing or angioedematous reactions.
• Treatment
• antihistamines
• corticosteroids
• epinephrine.
 Anaphylactoid reactions
• Rare but dangerous
• IgA-deficient patients who have IgA antibodies of the
IgE class.
• Symptoms
• characterized by autonomic dysregulation
• severe dyspnea,
• pulmonary and/or laryngeal edema,
• bronchospasm and/or laryngospasm,
• Immediate treatment
• Corticosteroids
• epinephrine.
 Transfusion-related acute
lung injury (TRALI)
• Pathogenesis
• Passively transfused donor HLA class I/II or neutrophil
antigens
• Mixture of predisposition and infusion of blood-related lipid-
derived mediators
• acutely increased permeability of the
pulmonary microcirculation causes massive
leakage of fluids and protein into the alveolar
spaces and interstitium,
• usually within 6 hours of transfusion.
• Treatment consists of aggressive
respiratory support.
 Immunologic
Complications, Delayed
• Delayed hemolytic reaction
• Alloimunization
• Posttransfusion purpura (PTP)
• Graft-vs-host disease (GVHD)
Delayed hemolytic reaction
• Occurs in previously red-cell-
alloimmunized patients
• the usual time frame is 2 to 14 days after
transfusion.
• Signs may include
• unexplained fever,
• development of a positive DAT,
• unexplained decrease in
hemoglobin/hematocrit.
• Hemoglobinemia and hemoglobinuria are
uncommon,
• Elevation of lactic dehydrogenase (LDH) or
 Alloimmunization
• Antigens of red cells, white cells,
platelets, or plasma proteins
• Primary immunization does not
become apparent until days or weeks
asymptomatic
• Subsequent transfusions causes
accelerated removal of components
and systemic reactions
 Post Transfusion puroura
• a rare syndrome characterized by the
development of dramatic, sudden, and self-
limiting thrombocytopenia, typically 7-10
days after a blood transfusion,
• history of sensitization by either pregnancy
or transfusion.
• autologous and allogeneic platelets are
destroyed.
• Treatment In a bleeding patient, high dose
Immune Globulin Intravenous (IGIV) may
promptly correct the thrombocytopenia.
 Graft-vs-host disease
(GVHD)
• is a rare but extremely dangerous
condition
• Pathogenesis
• occurs when viable T lymphocytes in the
transfused component engraft in the recipient
and react against tissue antigens in the
recipient.
• GVHD can occur if the host does not recognize
as foreign and reject the transfused cells, and
can follow transfusionof any component that
contains even very small numbers of viable T
lymphocytes.
• Severely immunocompromised recipients are
at greatest risk conditions)
 Graft-vs-host Disease
(GVHD)
• Can occur immunologically normal
recipients heterozygous for a tissue
antigen haplotype for which the donor is
homozygous. This is most likely to occur
when the transfused component is from a
blood relative or has been selected for HLA
compatibility.
• GVHD remains a risk with leukocyte-
reduced components because they contain
sufficient residual T lymphocytes.
• Irradiation of the component renders T
lymphocytes incapable of proliferation and
is presently the only approved means to
 Nonimmunologic
Complications
• Transmission of infectious disease
• Bacterial contamination
• Circulatory overload,
• Hypothermia
• Metabolic complications
 Transmission of infectious
disease
• HIV, HTLV, • Other potential
hepatitis, and agents
syphilis,CMV • SARS
• Other potential • Influenza
agents • Bartonella spp.,
• Simian foamy virus • Borrelia spp.,
(SFV) • Brucella spp.,
• HHV-8 • Leishmania spp.,
• West Nile virus • Parvovirus spp.,
• Chagas • rickettsia,
• nCJD • Toxoplasma spp.,
• Malaria
 Bacterial contamination
• Risk of bacterial sepsis in red cells and
platelet 1:3000 units transfused
• Sepsis develops in 1:25,000 units of
platelets and 1:250,000 units of RBCs
transfused
• Symptoms and signs
• Onset of high fever (=2 C or =3.5 F rise
in temperature),
• severe chills,
• hypotension, or circulatory collapse
during or immediately after transfusion
 Bacterial contamination
• Both gram-positive and gram-negative
organisms
• Treatment
• Prompt recognition of a possible septic
reaction
• immediate discontinuation of the
transfusion
• aggressive therapy with broad-spectrum
antimicrobials
• vasopressor agents, if necessary.
• Investigations
• Prompt sampling of the patient’s blood for
cultures at several different temperatures,
 Circulatory Overload
• Excessive volume at excessive rapid rate
• In patients with chronic severe anaemia
• Transfusion of small volumes in at risk
patients
• Treatment
• Treat for pulmonary edema
• Hypothermia
• Metabolic complications
• Citrate toxicity
• Severe liver disease
• Inadequqte hepatic blood flow
• Acidosis
• Alkalosis
• Hyperkalemia
• Hypokalemia
 Miscellaneous complications
• Iron overload
• Non immunologic hemolysis
• Stored donor blood: “The Cold Storage
Lesion”
• Free hemoglobin Increased nosocomial
infection
• SIRS
 The Cold Storage Lesion
Storage Effects Consequences
Reduced to absent 2,3- Increased oxygen affinity and
diphosphoglycerate decreased oxygen unloading by
hemoglobin
Reduced to absent Erythrocyte shape changes
ATP Increased osmotic fragility
Decreased deformability
Microvesiculation and Decreased erythrocyte viability
loss of lipid membrane
Lipid peroxidation Cellular injury and early cell death –
free Hb
Offner PJ, et al. Arch Surg. 2002;137:711-717.
LossM, of
Brown NOPK. Crit Care Nurse. 2000;20(suppl):1-14.
Whalen Vasoconstriction and poor unloading
Zallen G, et al. Shock. 2000;13:29-33.
 SUMMARY
“Because of the Risks Associated With
Transfusion, Physicians Should Remain
Familiar With Currently Recognized
Alternatives to Transfusion. Autologous
Transfusion Techniques (Such As
Perioperative Collection and Preoperative
Donation) Should Be Considered, When
Indicated, to Reduce the Need for
allogeneic Transfusion With Its Attendant
Risks of Disease Transmission and
Immune Reactions.”
THANK YOU