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BLOOD & PRODUCTS

INDICATIONS RISK AND


COMPLICATIONS

Mallika Sinha

Moderator
DR. VINOD KUMAR
Introduction
• Blood transfusion is a double edged sword, thus
transfuse only when benefits outweigh the
risk.
• Restricted availability is the major limiting
factor hence, use of blood component improve
the overall economy of blood.
• Most of the associated complications are
preventable!!
Whole Blood
• Description - Increase haemoglobin by 1%
No functional platelets
No labile coagulation factors
• Indications
– Acute blood loss with hypovolemia
– Exchange transfusion
– Red cell transfusion when red cell
concentrate/suspensions are not available.
• Contraindication
– Chronic anemia
– Incipient cardiac failure
Whole Blood
• Risk : Capable of transmitting any agent present in cells
or plasma not detected by routine screening.
• Storage : Between +20C to +60C
35 days with CDPA.
• Administration
– Must be ABO and Rh compatible
– Transfusion should be started within 30 minutes .
– Transfusion should completed within 4 hours of starting.
– Medication should never be added to blood.
Whole Blood

• Effects of storage
↓ PH
↑ K+
↓ 2,3DPG
↓ Platelets, platelet function lost by 48 hours.
↓ Coagulations factors (V & VIII)
Adverse effects of transfusion
• Acute complications
– Within 24 hours of transfusion
1. Mild reaction
2. Moderately severe reaction
3. Life threatening reactions

• Delayed complications of transfusion


– Transfusion transmitted infections
– Other delayed complications
• Iron overload (repeated transfusion recipients)
• Graft-Vs-host disease
• Delayed haemolytic reaction
Adverse effects of transfusion
Mild Reaction
• Signs –Localized cutaneous reactions:
– Urticaria
– Rash

• Symptoms –
– Pruritus (itching):

• Possible cause –
– Hypersensitivity (mild):
Adverse effects of transfusion
Category 2 – Moderately severe
• Signs –: Flushing, Urticaria, Rigors, Fever,
Restlessness, Tachycardia
• Symptoms – Anxiety, Pruritus, Palpitation,
Mild Dyspnoea, Headache
• Possible cause –
 Hypersensitivity (moderate - severe)
 Febrile non haemolytic transfusion reactions:
1. Antibodies to WBC & Platelets.
2. Antibodies to proteins including IgA
 Possible contamination with pyrogens and/or bacteria
Management of Moderately Severe Reaction
Stop transfusion

Maintain vitals

Antihistamines

Corticosteroids + bronchodilators
(if anaphylactoid features)

If clinical improvement
↓ Yes No ↓
Restart Treat as category 3
Adverse effects of transfusion
Category 3 – Life threatening reaction
• Signs –: Rigors, Fever, Restlessness, Tachycardia (>20%),
Hypotension (>20%), Haemoglobinuria, Unexplained bleeding
(DIC)
• Symptoms – Anxiety, Chest Pain, Pain near infusion site,
Respiratory distress, Loin/Back pain, Dyspnoea, Headache.
• Possible cause –
 Acute intravascular haemolysis
 Bacterial contamination and septic shock
 Fluid overload,
 Anaphylaxis,
 Transfusion associated lung injury.
Management of Life threatening reaction

Stop transfusion

Maintain vitals / airway / oxygen

adrenaline

Diuretics

Corticosteroids + bronchodilators
(if anaphylactoid features)
Management of Life threatening reaction contd…

• Notify doctor & blood bank


• Fluid balance charting
• Close observation
• Watch for the signs of
– DIC
– Hypotension
– Endotoxemia
– Renal failure
When to transfuse if transfusion
reaction occurs?
• Mild reaction –
– Transfuse slowly with antihistamines
• Moderate reaction
– Transfuse new blood unit with close
observation
• Life threatening reactions
– Clinical improvement + coombs test
Adverse effects of transfusion
Transfusion transmitted infections
• HIV-1 And HIV-2
• HTLV-1 and II
• Viral hepatitis B and C
• Syphilis
• Malaria
• Chagas disease
• Cytomegalovirus(CMV)
• Other rare infections e.g. Human Parvovirus B19 and hepatitis A
Adverse effects of transfusion
Massive Blood transfusion
• Complications –
– Alkalosis
– Hyperkalaemia
– Citrate toxicity and hypocalcaemia
– Depletion of fibrinogen and coagulation factors
– Depletion of Platelets.
– Disseminated intravascular coagulation (DIC)
– Hypothermia
↓2,3,DPG
– Microaggregates
Blood Products
Whole blood
Red cell Platelet Plasma products
component component Component derivatives
Red cell Single donation Fresh frozen Albumin
concentrate unit plasma
Red cell Pooled unit Liquid plasma Coagulation
suspension factors
Buffy coat Single donor Cryoprecipitate immunoglobulin
depleted red cells apheresis product
(SDAP)
Leucocyte Cryo poor
depleted red cells plasma
Viral inactivated
plasma
Red Cell Concentrate/Suspension
• Description –
150-200 ml Red cell (Plasma removed)
Suspension with added diluent
1 unit increases haemoglobin by 1.5 – 2%
• Risk – Same as whole blood
• Storage - +20C – +60C
• Indications- Severe chronic anemia
- With crystalloids/colloids in Acute blood loss.
- Hypoplastic anemia
- Hemolytic anemia specially in aplastic crisis
Red Cell Concentrate/Suspension
Administration – To improve transfusion flow
normal saline (50-100ml) given with Y-pattern
giving set.
• Advantages
– Less blood group antibody so, ‘O’ negative blood or
(group non specific) can be given.
– Less anaphylactic reactions (less plasma proteins)
Red Cell Components
Composition Whole blood Red cell concentrate Red cell suspension
(PRBC)

Preparation Separate plasma at 2- Separate plasma and


60C under add additive soln. E.g.
gravity/centrifugation ADSOL
1 unit increase Hb by 1% 1.5-2% 1.5-2%

Packed red cells(ml) 120-250 120-250 120-250

Maximum storage 21 days: CPD 35 21 days:CPD 42 days-ADSOL


time at 2-60C days:CPDA 35 days: CPDA
Advantages Easy to prepare Low viscosity, more
shelf life

Disadvantages High viscosity Expensive


Leucocyte-depleted Red Cells
• Description –
– Red cell suspension/concentrate with <5 x 106 white cells per bag
by using leukocyte filters.
– No risk of CMV transmission.
• Risk – Same as whole blood
• Indications-
– Patients requiring repeated transfusion
– Patients > 2 previous febrile reactions to red cell
transfusion.
• Administration – Pre storage filtration should be done.
• Alternative – Buffy coat depleted red cells.
Buffy coat depleated red blood cells

• Buffy coat = white cells + platelets + Debris.


– Interface between red cells and plasma.
• Description –
– Red cell suspension with <5 x 108 white cells per pack,
• Advantage –
– Prevents Febrile Non-hemolytic Transfusion Reaction
(FNHTR).
– Platelets cant be harvested Buffy Coat
• Indications-
– Same as red blood cells.
Platelet Concentrate (Random Donor Platelets
• Description –
– Derived from single blood donation
– 65-80ml
– At least 55 x 109 Platelets
– <1.2 x 109 red cells (No visible RBC contamination)
– Single donor Unit, Pooled Unit
• Risk – Same as whole blood, Bacterial contamination in 1%
• Adult dose – 4-6 donor exposures,
• Dosage – 1 unit/10kg body weight
• Storage – 20-240C(with agitation) for upto 5 days.
– Longer storage – Bacterial proliferation and septicemia.
• Administration –
– Patients requiring multiple platelets transmission – set with lecuocyte filters.
– No crossmatching required .
– Platelets don’t carry Rh antigen.
– Group specific platelets desired.
Guidelines for platelet transfusions
• Adults –
a. Non bleeding patients with failure of platelet
production.
– Platelet count <15,000/µl
– Invasive procedure with platelet count <50,000/µl
– Bleeding patients.
– DIC with platelet count <50,000/µl
– Massive transfusion and platelet count (<50,000/µl)
– Active bleeding and platelet counts –20 –x 1011/L.
– Diffuse bleeding following cardiopulmonary bypass
and platelets and count not available or < 1,00,000/µl
– Platelet function defect
Fresh Frozen Plasma
• Description –
– Contains stable coagulation factors, albumin & immunoglobulin
– Factor VIII
– Fibrinogen 150-230mg
• Dosage : 15ml/kg body weight
• Risk – In untreated, same as whole blood
Methylene blue/ultraviolet light inactivation – very low risk
• Storage – <-250C for upto 1 year
• Indications - Multiple coagulation factor deficiency in :
Liver disease, Massive blood transfusion, Oral anticoagulants over
dose
DIC and TTP
• Administration –
– Should be ABO compatible, No cross matching required.
– Before use, thawing should be done in water at 30-370 C.
– Once thawed should be used within 6 hours
• Precaution – Acute allergic reaction with rapid infusion.
• Hypovolemia alone is not an indication for use.
Cryoprecipitate
• Description –
– Contains factor VIII 80-100 I.U.
Fibrinogen 150-300mg and Von Willebrand factor.
• Dosage : Depend on severity, normally 4-6 packs repeated 12 hourly
• Risk – Same as plasma.
• Storage – <-300C for upto 1 year
• Indication – As an alternative to factor VIII concentrate in
– Von Willebrand disease
– Hemophillia A
– Factor XIII deficiency
– Fibrinogen deficiency e.g. DIC
• Administration –
– Infuse as soon as possible after thawing
– Must be infused within 6 hrs after thawing
– No compatibility testing required, Use ABO compatible product.
Cryo Poor Plasma
• Description –
– Plasma after removing cryoprecipitate deficient in factor
VIII and fibrinogen but contains all other plasma
constituents.
• Risk – Same as whole blood.
• Indication –
– For volume replacement
– As replacement fluid in exchange transfusion
– As a source of plasma proteins
Human Albumin Solution
• Prepared by fractionation of large pools of donated human
plasma.
– Albumin 5% contains 50mg/ml of albumin
• Risk – No risk of viral infections.
• Indications –
– Replacement fluid in therapeutic plasma exchange : albumin 5%
– Treatment of diuretic resistant oedema in hypoproteinemia : Nephrotic
syndrome or ascites : albumin 20% with diuretic
– Burn and hypoalbuminaemia & volume replacement albumin 5%.
• Contraindications –
• Not use for IV nutrition.
• Precautions -
• Risk or pulmonary oedema with albumin 20%.
Apheresis blood Components

• Advantages–
– Adequate adult dose from single donor.
– Reduced donor exposure
– Reduced bacterial contamination, specially in platelets
– Low chances of refractoriness to blood components.
Irradiated Blood Components

• Radiation dose 15 - 25Gy


• Indications–
– Bone marrow transplant patients.
– Premature new born.
– Haematological malignancies
– Peripheral blood progenitor cell transplant patients.
– Intrauterine transfusion.
Autologous Blood Transfusion
• Preoperative donation of blood
– 2 or more units blood are drawn and stored prior to
anticipated need.
• Intra-operative blood collection.
– Blood is collected prior to or during surgery.
• Perioperative hemodilution (Acute normo volemic
hemodilution)
– 1 or 2 units drawn before surgery concomitant replcement with
crystalloid/colloid.
• Intraoperative blood
– Blood is collected (SALVAGE) from the surgical field, then
processed and then returned.
• Post operative blood collection
Guidelines for use of blood/blood products in
surgery & haemorrhage
• Blood/Blood products should only be infuse if other modes of
therapy have been proven ineffective and if benefits outweigh
the risk.
• Average healthy adult can withstand loss of 10% blood volume.
• Average healthy adult can afford 20% blood loss without any ill
effect, if circulatory blood volume is maintained.
• Proper assessment and management of patients required before
surgery.
• Autologous blood transfusion should be used wherever
appropriate.
• Adopt policy of Blood sparing techniques .
• Obtain typing and screening in all elective surgical cases
Summary
Packed red cells or Platelet concentrate FFP Cryoprecipitate
suspension
Contents Hb 20 g/100 ml Platelet Stable coagulation Factor VIII
No visible RBC factors + plasma vW
contamination proteins Factor XIII
Fibrinogen
Dosage 10 ml/kg 1 unit/10 kg 10-15 ml/kg 5-10 ml/kg
Storage Temp 2 to 60C 20-240C with -300C -300C
agitation
TIME FOR INFUSION Infuse as soon as
possible after
Start 30 mins As soon as possible thawing -do-

Completion 4 hrs 4 hrs 6 hrs -do-

Shelf life 35 days 5 days 1 yr 1 yr


42 days with Adsol
Improvement ↑ Hb by 1.5-2% ↑10% count ↑ Coagulation
↑5000-10000 factor by 2%
platelets
Synthetic Oxygen Carriers
• Perfluorocompounds
– Fluosol-DA
– Oxygent
• Stroma Free Haemoglobin
• Stroma Free Hb products
– Hemassist (Diaspirin-crosslinked Hb) (DCL Hb)
– Optro (recombinant Hb) rHb1.1
– Liposome – encapsulated Hb (LEH)
– Hemopure (Hb OC-201)
– PolyHeme (Poly-SFH)
– Polyethylene glycol (PEG) Hb
– Hemolink
Conclusion
• Appropriate use of blood/blood products should
be done.
• Transfusion carries risk of adverse reactions and
transfusion transmissible infections.
• Need of blood transfusion can be avoided by-
– Prevention/early diagnosis and treatment of anaemia
– Correction of anaemia and the replacement of
depleted iron stores before planned surgery.
– Use of simple alternatives to transfusion.
– Good anaesthetic and surgical management.
Thanks