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2 AUTHORS:
Clare M Knottenbelt
Andrew Mackin
University of Glasgow
SEE PROFILE
SEE PROFILE
INDICATIONS
Anaemia is the major indication for blood transfusion in
veterinary practice (see box). In particular, patients with
blood loss or non-regenerative anaemia will benefit from
transfusion. In non-regenerative anaemia transfused red
blood cells can have a normal lifespan (approximately
120 days in dogs, 70 days in cats). Transfusion may
therefore stabilise the patient for two to three months,
allowing further diagnostic tests or treatment to be instituted. In haemolytic anaemia, blood transfusions are
generally of transient benefit only, as transfused cells,
like the patient's own cells, will often be destroyed by
the haemolytic process and transfusion may arguably be
'adding fuel to the fire'. However, in patients with signs
of severe anaemia such as dyspnoea, weakness or neurological disturbances a blood transfusion may be lifesaving and allow time for more specific therapy for the
underlying cause of the haemolysis to be commenced.
Since patients with haemolytic and non-regenerative
anaemia are normovolaemic at the time of transfusion,
packed red cell transfusions, if available, are more
appropriate than whole blood (see later). In contrast,
whole blood is usually the treatment of choice in patients
with hypovolaemia secondary to blood loss anaemia.
Animals with congenital and acquired coagulopathies
will benefit from the administration of fresh blood, fresh
plasma or fresh frozen plasma to replenish clotting factors. Patients with severe thrombocytopenia may require
transfusions of fresh blood or platelet-rich plasma in
order to prevent life-threatening blood loss. In particular
circumstances patients benefit from the use of specific
plasma components such as albumin to maintain oncotic
pressure, or antithrombin III as part of the management
of disseminated intravascular coagulation.
InPractice i APRIL 1998
Clare Knottenbelt
graduated from
Bristol in 1994. She is
currently the Clinical
Studies Trust Fund
(Petsavers) resident in
small animal internal
medicine at the Royal
(Dick) School of
Veterinary Studies,
Edinburgh. She
gained the certificate
in small animal
medicine in 1997.
Her interests include
feline blood types,
transfusion medicine
and haematology.
* Anaemia
- Blood loss
- Haemolysis
- Non-regenerative anaemia
* Disorders of haemostasis
* Deficiencies of specific plasma components
WHEN TO TRANSFUSE?
The most important factor in determining the need for
transfusion is the clinical condition of the patient.
Transfusion is always indicated in an anaemic patient
that is exhibiting signs of clinical compromise such as
weakness, dyspnoea and ataxia. However, many patients
with quite severe anaemia will exhibit minimal associated clinical signs and often can survive for long periods
of time without transfusion. Many authors have recommended that transfusion automatically be performed
whenever a patient's packed cell volume (PCV) drops
below 20 per cent (Pichler and Turnwald 1985). Cats,
however, are known to tolerate anaemia well; they may
show only mild lethargy at a PCV of 10 to 15 per cent
and, provided they remain unstressed, can survive at a
very low PCV for a number of days. Dogs are somewhat
more sensitive to the effects of anaemia, which is often
detected earlier due to poor exercise tolerance, a clinical
sign rarely recorded in cats. Chronic anaemia in dogs
and cats tends to be much better tolerated than acute
anaemia.
191
Andrew Mackin is
a 1983 graduate of
Murdoch University.
He has worked at
veterinary schools in
Australia, Canada and
the UK, and has
obtained specialist
level qualifications in
small animal medicine
in North America,
Australia and the UK.
He recently left the
'Dick' to take up the
post of assistant
professor in small
animal internal
medicine at
Mississippi State
University.
t (.
'U"
4ok-
t(K1
Microhaematocrit tube
revealing icteric serum. The
presence of serum icterus
indicates that an underlying
haemolytic process may be
the cause of the anaemia
BLOOD ADMINISTRATION
Examples
* A cat weighing 4 kg, with a PCV of 10 per cent, receiving donated blood with
a PCV of 35 per cent, requires 75 ml of blood to reach a target PCV of 20 per
cent, while a cat with a PCV of 5 per cent would require 113 ml of blood (which
would need to be collected from two cats or a very heavy donor!)
* A 15 kg dog with a PCV of 10 per cent, receiving donated blood with a PCV of
40 per cent, would require at least 500 ml of blood to reach a target PCV of
25 per cent
NB. Since the volume of blood required by the recipient is heavily dependent on
the donor's PCV, it is important, whenever possible, to choose donors with a PCV
within the top half of the normal range.
ROUTE OF ADMINISTRATION
Ideally, blood should be given into a cephalic or jugular
vein via an intravenous catheter. In severely hypotensive
or paediatric patients, the blood can be given into the
proximal femur using an 18 to 20 gauge intravenous
needle or a spinal needle placed in the trochanteric fossa.
Extraction of blood from the marrow cavity into the
bloodstream is highly efficient and marrow transfusion is
therefore almost as effective as direct intravenous infusion. Blood is absorbed from the marrow at a rate of one
drop per minute, but may be administered at a faster rate
by using an infusion pump.
Intraperitoneal administration of blood is an inefficient method of administration, achieving only a 40 per
cent extraction rate (Turnwald and Pichler 1985)
WIOIM
t t,.
%
I
METHOD OF ADMINISTRATION
Blood should be administered through a filtered giving
set specifically designed for blood products, to reduce
the risk of cellular aggregates and microthrombi entering
the circulation and leading to pulmonary capillary damage and pulmonary oedema. This is particularly important when blood has been stored following collection.
The filters present in standard giving sets are too small
and will tend to clog when blood is administered through
194
BLOOD PRODUCTS
PLATELETS
PLASMA
Plasma can be decanted from centrifuged or sedimented
whole blood and stored in a freezer for several months.
In order to decant plasma from whole blood, blood bags
(dogs) or syringes (cats) of fresh whole blood may be
placed upright in a refrigerator for six to 12 hours. In
some patients, sedimentation of fresh red cells allows
extraction of a usable volume of supernatant plasma.
Plasmalred cell separation via sedimentation, however,
is never as consistent or as complete as that obtained by
using a blood bank centrifuge. Although such centrifuges are not usually available in general practice, they
may on occasion be available for use at local human
transfusion centres.
Fresh plasma contains albumin, clotting factors and
immunoglobulins and, as such, its administration is
beneficial in animals with hypoalbuminaemia or clotting
disorders (including disseminated intravascular coagulation), or in those in which transfer of passive immunity
has failed. Plasma is indicated in situations such as
hypovolaemia or hypoalbuminaemia as it maintains the
oncotic pressure of the blood. Patients with severe
hypoproteinaemia will benefit from a plasma transfusion
prior to and during anaesthesia for diagnostic and therapeutic procedures.
Plasma should be given in preference to whole blood
to patients with clotting defects unless the clotting disorder has resulted in a major bleed and subsequent blood
loss anaemia. Since clotting factors are amenable to
freezing, plasma can be stored for prolonged periods
provided it is freshly harvested from whole blood and
frozen within six hours of collection. Frozen plasma harvested from whole blood more than six hours after collection may contain minimal amounts of many clotting
factors and is therefore not appropriate for the treatment
of conditions where transfusion of clotting factors is
indicated, such as haemophilia A. In patients with von
Willebrand' s disease, plasma transfusions should be
administered prior to and during surgery. The subcutaneous administration of desmopressin (1 pg/kg)
to the donor 30 to 60 minutes before blood collection
may increase von Willebrand' s factor levels within
the collected blood (Nichols and Hohenhaus 1994).
InPractice * APRIL 1998
TRANSFUSION REACTIONS
Provided a matched transfusion is given and blood has
been stored and administered appropriately, transfusion
reactions should be rare. Patients receiving blood or
blood products should, however, be monitored closely
during the transfusion period. If symptoms associated
with a potential transfusion reaction are recorded (see
table on page 198), the transfusion should be stopped
and the cause of the reaction investigated.
The most common types of specific transfusion reactions and complications are listed in the box below.
Transfusion ractions
cmMpl cations
*
*
*
*
*
*
*
*
Haemolysis
Acute hypersensitivity reactions
Pyrexia
Bacterial contamination of blood bag
Hypocalcaemia (citrate toxicity)
Vomiting
Circulatory overload
Transmission of infectious diseases
195
*.
Jaundice: a sign
of a potential transfusion
reaction
even small volumes of mismatched blood are administered as a first transfusion, due to the presence of naturally occurring alloantibodies. Type B cats which receive
type A blood are at greatest risk of a haemolytic reaction
owing to the high levels of naturally occurring antibody
that they possess (see box below).
In both dogs and cats the acute haemolytic reaction
is characterised clinically by depression, recumbency,
cardiac arrhythmia, apnoea, seizures or signs of shock.
Patients may urinate, defecate, salivate or vocalise (cats)
and subsequently become tachycardic and tachypnoeic
for a prolonged period. Haemoglobinaemia and haemoglobinuria can occur within hours of transfusion but are
only clinically apparent when large volumes of blood are
transfused. The rapid destruction of transfused red cells
will also result in a dramatic fall in the recipient's PCV.
HAEMOLYSIS
198
Pre-transfusion haemolysis
Haemolysis can also occur during storage of whole
blood, particularly if the blood is subjected to overheating or freezing or has become contaminated with
microbes (Harrell and Kristensen 1995). The concurrent
administration of blood and hypotonic solutions via the
same catheter can also result in red cell lysis through
osmotic 'cell bursting'.
PYREXIA
Transfusion-related pyrexia is the most common transfusion reaction and is characterised by an increase in body
temperature of 1C or more within four hours of the feeding around the time of transfusion. If no other symptransfusion (Turnwald and Pichler 1985). Pyrexia may toms of transfusion reaction or haemolysis are evident,
be related to bacterial contamination of transfused blood the transfusion can be continued after 15 minutes at a
or an acute reaction caused by antibodies to platelets, slower rate.
white blood cells or plasma proteins which are not
detected by blood typing or cross-matching. The blood CIRCULATORY OVERLOAD
bag should be evaluated for evidence of bacterial conta- Circulatory overload is a common transfusion complicamination (see below) and the patient should be examined tion in small animals and is most often associated with
for evidence of haemolysis. Fortunately, non-infectious, rapid administration of whole blood to patients with
non-haemolytic pyrexia - the most common cause of cardiac disease, renal failure or normovolaemic anaemia
pyrexia - is usually transient and does not require (Turnwald and Pichler 1985). Circulatory overload with
treatment.
pulmonary oedema is characterised clinically by tachycardia, tachypnoea, dyspnoea and coughing. The use of
BACTERIAL CONTAMINATION OF BLOOD BAG
appropriate flow rates and packed red cell transfusions
Incorrect collection or storage of whole blood can result rather than whole blood reduces this problem. If circulain bacterial contamination of the blood prior to adminis- tory overload is encountered, the transfusion should be
tration. Bacteria will survive refrigeration and start to stopped immediately and frusemide and oxygen given as
multiply if the blood is warmed. Pyrexia will develop necessary to control the symptoms.
within 15 minutes of the start of blood administration
and may be accompanied by other signs such as shock, TRANSMISSION OF INFECTIOUS DISEASES
abdominal pain, vomiting and diarrhoea. If bacterial con- The risk of transmission of infectious disease via transtamination is suspected, the bag should be checked for fusion cannot be completely eradicated. However, in
evidence of haemolysis (by spinning down the bag or a order to minimise it all donors should be healthy and
sample of blood from the bag) and a sample of donated fully vaccinated. Feline donors should be indoor cats that
blood submitted for culture and sensitivity. Antibiotics have been tested for FeLV, FIV and Hfelis. In endemic
should be administered and supportive therapy provided areas, canine donors should be tested for heartworm,
as necessary.
rickettsial diseases and blood parasites such as Babesia
canis.
HYPOCALCAEMIA
Clinical signs of hypocalcaemia (tremors, vomiting and
cardiac arrhythmia) are occasionally associated with the
rapid administration of large amounts of citrate anticoagulant (which chelates calcium) (Tumwald and Pichler
1985). In practice, this is a rare problem unless inappropriate amounts of anticoagulant have been used, the
patient has severe liver disease (causing failure of citrate
metabolism) or very large volume transfusions are given
rapidly.
VOMITING
Vomiting is common during and after transfusions and
may be associated with rapid administration of blood or
In Practice * APRIL 1998
SUMMARY
Blood transfusions can be life-saving in a number of
clinical situations and, provided a few simple guidelines
are followed, there is little risk of associated complications. The main problem in veterinary practice is finding
an appropriate donor when blood is needed. If donors are
identified prior to the need for blood, blood collection
and administration can be performed within an hour of
identifying a need for transfusion.
It is likely that blood transfusions will be used with
increasing frequency within veterinary practice.
199
References
vasopressin analogue
desmopressin for polyuria and
bleeding disorders. Journal of
the American Veterinary Medical
Association 205, 168-173
PICHLER, M. E. & TURNWALD,
G. H. (1985) Blood transfusion
in dogs and cats, Part I.
Physiology, collection, storage
and indications for whole blood
therapy. Compendium on
Continuing Education for the
Practicing Veterinarian 7, 64-71
TURNWALD, G. H. & PICHLER,
M. E. (1985) Blood transfusion
in dogs and cats, Part II.
Administration, adverse effects
and component therapy.
Compendium on Continuing
Education for the Practicing
Veterinarian 7, 115-122
doi: 10.1136/inpract.20.4.191
These include:
References
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Notes