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Home , Blood substitute

Transfusion

Dr. Arkaprovo Roy Associate Professor Department of Surgery Medical College Kolkata Discussions on

• Definition and indications of • Blood banking • Blood grouping and cross matching • Blood products • Blood substitutes • Auto transfusion • Complications of blood transfusion • Massive blood transfusion Definition

• It is the transfusion of the or its components such as blood corpuscles or plasma from one person to another Indications for blood transfusions

1. Blood loss greater than 20% of blood volume 2. Haemoglobin level < 8g/dl without any risk factors 3. Haemoglobin level <10g% with major diseases /major surgery How to prepare blood for transfusion

• Screening for blood borne infections • Blood grouping and compatibility testing

RBC Contains >300 antigens, 20 blood group antigens are well known Blood Banking

• In 1937 Bernard Fantus, director of therapeutics at the Cook County Hospital in Chicago, established one of the first hospital blood banks in the United States. • It preserved, refrigerated and stored donor blood - Fantus originated the term "". • Blood banking is the process that takes place in the lab to make sure that donated blood, or blood products, are safe for blood transfusions and other medical procedures. • Blood banking includes typing the blood for transfusion and testing for infectious diseases. Blood group systems

Major system- • ABO system • Rhesus system Minor system • H-antigen • MNS antigen system • Lutheran system • Kell system • Duffy system Blood Grouping

• Here are 4 main blood groups (types of blood) – A, B, AB and O. • The ABO and Rh blood grouping system is based on agglutination reaction. • When red blood cells carrying one or both the antigens are exposed to the corresponding antibodies they interact with each other to form visible agglutination or clumping. Forward and reverse blood grouping

• In this method, both forward (cell), as well as reverse (serum) grouping is carried out. • The forward grouping suggests the presence or absence of A and B antigens in RBCs • Reverse grouping indicates the presence or absences of anti-A and anti-B in serum.

Rh blood group system

• It is a blood group system • It contains proteins on the surface of red blood cells • It is the second most important blood group system, after the ABO blood group system. • The consists of 49 defined blood group antigens, among which the five antigens D, C, c, E, and e are the most important. • Rh(D) status of an individual is normally described with a positive or negative suffix after the ABO type (e.g., someone who is A Positive has the A antigen and the Rh(D) antigen, whereas someone who is A Negative lacks the Rh(D) antigen). • The terms Rh factor, Rh positive, and Rh negative refer to the Rh(D) antigen only. • Antibodies to Rh antigens can be involved in hemolytic transfusion reactions and antibodies to the Rh(D) and Rh antigens confer significant risk of hemolytic disease of the fetus and newborn. Cross matching in Blood banks • Cross Matching is a procedure performed prior to a blood transfusion to determine whether donor blood is compatible (or incompatible) with recipient blood • Compatibility is determined through matching of different blood group systems • Most important of which are the ABO and Rh system, and/or by directly testing for the presence of antibodies against a sample of donor tissues or blood

Purpose of Cross-matching

• The crossmatch is routinely used as the final step of pretransfusion compatibility testing. • The purposes of compatibility testing are to detect: Irregular antibodies; Errors in ABO grouping, Clerical errors in patient identification and result recording. • The cross-match will detect the following: Most recipient antibodies directed against antigens on the donor red blood cells. Major errors in ABO grouping, labeling, and identification of donors and recipients. Compatibility testing

• Major crossmatch- between donor’s blood and recipient’s plasma • Minor crossmatch- between donor’s plasma and recipient’s blood Emergency transfusion

• Give o negative blood when blood group is available then switch over to transfusion of specific blood group Storage of blood

• In the refrigerator at 2 degree celcius • Blood stored in preservative anticoagulants— – Acid citrate dextrose(ACD)- upto 21 days – CDPA-1 (citrate, dextrose, phosphate, adenine)- upto 35 days- most commonly used in india – ADSOL(adenine, glucose, , sodium chloride) – 42 days – NUTRICE (adenine, glucose, citrate, NaCl) – 42 days – OPTISOL – 42 days Blood Products Whole blood- specific indications

• Hypovolemic shock and hemorrhagic shock • Burns (PRBC)

• Preferred over Whole blood transfusion because- – Cardiac overload can be avoided – Infectious and allergic reactions related to plasma can be avoided – Increase in Hb per pack of PRBC is 1 g/dL – Whole Blood can be utilized to extract other products like FFP, , factor concentrate

• 1 unit = 200-250 ml Common uses • Additional factors: • Acute blood loss anemia Fibrinogen 10-75 mg • Massive blood Clotting factors – none transfusion • Surgical blood loss • Volume- 180 - 300 mL • Plasma is separated from the blood corpuscles by centrifugation and then frozen within 6 hours of collection. • Contains all coagulation factors and plasma proteins. • ABO compatibility not necessary but highly desirable

• Indications: • Coagulopathies associated with liver disease or which is to be corrected immediately(eg-With active bleeding) • Reversal of Warfarin Therapy • Antithrombin III deficiency • Plasma protein deficiency(poor man’s albumin) concentrates

• Volume-50mL • Only blood products which are stored at room temperature for 4-5 days • At 2°C survives for only 24-48 hrs • Transfused Platelets survive in the circulation for 2-7 days • Indications- – Platelet count<10,000 in absence of active bleeding – <50,000 with active bleeding or patient undergoing major surgery • 1 unit platelet increases the count by 5000-10,000 • ABO compatibility is not necessary but desirable SDP VS RDP

• Single donor platelet or SDP is when it is derived from a single donor’s blood • Random Donor Platelet or RDP is when it is derived from pooled plasma of multiple donors • One unit SDP = 6 units of pooled RDP • Chances of disease transmission is high with RDP

• Volume = 10 ml • Supernatant precipitate of FFP • Contains 80-145 units of Factor VIII and 1200-1500 unit of Fibrinogen • Also contains Von Willebrand Factor and Factor XIII. • Pooled from many donors • Indications: vWD DIC Haemophilia A

Disadvantage- • Maximum chance of disease transmission • Must be infused within 6 hours Leukocyte-Reduced Red Blood Cells

• An association between immunosuppression and allogeneic transfusion has found • This effect, termed transfusion-related immunomodulation, is thought to be principally related to exposure to leukocytes • Can be decreased or prevented with leukocyte-reduced components Leukocyte-Reduced Red Blood Cells

Uses • To decrease the incidence of subsequent refractoriness to . Caused by HLA alloimmunization in patients requiring long-term platelet support

• To provide blood components with reduced risk for transmission of cytomegalovirus (CMV) • To prevent subsequent febrile nonhemolytic transfusion reactions in patients who have had one documented episode • To decrease the incidence of HLA alloimmunization in non-hepatic solid-organ transplant candidates Granulocyte Concentrate

• Used in profound granulocytopenia (<500/mm3) with evidence of infection (e.g., positive blood culture, persistent temperature higher than 38.5°C) unresponsive to therapy • Daily transfusions are given until the infection is under control or the granulocyte count is greater than 1000/mm3 • Such products have a shelf life of 24 hours and are not routinely available Blood Substitutes

• A (also called artificial blood or blood surrogate) is a substance used to mimic and fulfill some functions of biological blood • It aims to provide an alternative to blood transfusion, which is transferring blood or blood based products from one person into another • There are no well-accepted -carrying blood substitutes, which is the typical objective of a transfusion • There are widely available non-blood volume expanders for cases where only volume restoration is required. • These are helping avoid the risks of disease transmission and immune suppression, address the chronic blood donor shortage, and address the concerns of Jehovah's Witnesses and others who have religious objections to receiving transfused blood. Characteristics of an ideal blood substitute

The most important adverse effects of blood transfusion relate to the antigenicity of donor blood and its ability to transmit infections. An ideal blood substitute - • Should lack antigenicity and eliminate, or at least substantially reduce, the ability to transmit infections • Readily available • Long half-life • Capable of being stored at room temperature • The biologic properties of an ideal blood substitute should include a reasonable amount of oxygen delivery, when compared to normal human red blood cells

Classification

• First-Generation Products Perfluorocarbon • Stroma-Free • Next-Generation Blood Substitutes (PEG) hemoglobin Raffinose-x-linked HB

Plasma substitutes

Colloid solutions: • Albumin 5% and 25% • Plasma protein fraction: 5% albumin and non albumin plasma proteins Crystalloid solutions: • NS, RL

Indications:

Volume expansion/protein replacement without risk of transmission of viruses Types of blood transfusions

• Allogenic blood transfusion • Autologous blood transfusion • Exchange blood transfusion Autotransfusion

• A process of collecting a patients own shed blood , cleaning it, and giving back the washed red blood cells. • Autologous Blood – Blood donated and received by the same person. Benefits of Autotransfusion:  Lower risk of clerical error  Significant reduction in blood-borne infection  Fresh red blood cells  Better oxygen transfer  More cost-effective medicine Mechanism of Autotransfusion

• As bleeding starts to occur, blood is collected through a suction line and collected in a sterile reservoir. • The collected blood is then washed with a specialized instrument to remove contaminants & debris. • This washed blood can now be safely returned to the patient, thus decreasing the risk and need for banked blood.

By collecting all of the patients’ blood that was lost, the patient is able to avoid complications associated with blood bank transfusions and can get on the right track to a healthy recovery Indications of Autotransfusion

• Cardiothoracic Surgery • Vascular Surgery • Orthopedic Surgery • General Surgery • Gynecological Surgery • Urological Procedures • Trauma • Organ transplantation procedures • Selected neurosurgical procedures. Complications of Blood transfusion

• Transfusion reactions:

– Allergic – Infectious Viral Bacterial Parasitic – Nonhemolytic – Hemolytic • Acute • Delayed

Infectious agent or outcome Viruses • HIV-1 and -2 • HTLV-I and -II • HAV • HBV • HCV • B19 parvovirus Bacteria • RBCs • Platelets (screened by Gram stain, pH, or glucose concentration) • Platelets (screened by early aerobic culture) Parasites • Babesiosis • Malaria • Trypanosoma cruzi Noninfectious complications

– Fluid overload and pulmonary edema – Metabolic- • Hyperkalemia • Hypocalcemia • Hyperammonemia – Acid base abnormalities – Coagulation abnormalities – Hypothermia – Immune complications – Disseminated intravascular coagulation – Tissue hypoxia Complications from a single transfusion

Infection • Bacterial infection • Allergic reaction (usually due to faulty • Febrile transfusion reaction storage) • Viral Hepatitis HIV • Incompatibility haemolytic • Parasite transfusion reaction Malaria • Delayed hemolytic reaction • Transfusion-related acute lung injury (usually from FFP) • GVHD • • Alloimmunisation • Thrombophlebitis • Post transfusion purpura • Volume overload after blood transfusion Allergic reactions

– Most common type of transfusion reactions and – Occurs when the patient reacts to donated plasma proteins in the blood. – Symptoms include itching or hives – Can often be treated with antihistamines – Prophylactic administration of diphenhydramine and prednisone (in patients with a previous history of allergic reaction)

Rarely, severe reactions may involve bronchospasm or laryngospasm. Prompt discontinuation of the infusion. Steroids and subcutaneous epinephrine may also be required. Febrile nonhemolytic reactions

– Involve the development of a high fever during or within 24 hours of a transfusion. – This reaction is mediated by the body's response to WBCs in donated blood. – General malaise, chills, nausea, or headaches may accompany the fever – Because fever can be the first manifestation of a more serious transfusion reaction, the situation must be promptly evaluated. – Patients with a previous history of a febrile reaction should receive leukoreduced blood products. Acute immune hemolytic reactions • Most serious transfusion reactions • Patient antibodies react to transfused RBC antigens causing intravascular . • This typically occurs with ABO or Rh incompatibility. • Symptoms include nausea, chills, anxiety, flushing, and chest or back pain. • Anesthetized or comatose patients may show signs of excessive incisional bleeding or oozing from mucous membranes. • The reaction may progress to shock or renal failure with hemoglobinuria. • If a transfusion reaction is suspected, the infusion should be stopped immediately. • Identities of the donor unit and recipient should be rechecked because clerical error is the most common cause. • A repeat cross-match should be performed in addition to a CBC, coagulation studies, and serum bilirubin. • Treatment includes maintenance of intravascular volume, hemodynamic support as needed, and preservation of renal function. • Urine output should be maintained at greater than 100 mL/hour using volume resuscitation and possibly diuretics if resuscitation is attained. • Alkalinization of the urine to a pH of greater than 7.5 by helps to prevent precipitation of hemoglobin in the renal tubules. Delayed hemolytic reactions

– Result from an anamnestic antibody response to antigens other than the ABO antigens to which the recipient has been previously exposed. – Transfused blood cells may take days or weeks to hemolyze after transfusion. – Typically there are few signs or symptoms other than a falling RBC count or elevated bilirubin. Specific – Treatment is rarely necessary – Severe cases should be treated like acute hemolytic reactions, with volume support and maintenance of urine output. Transfusion-related acute lung injury (TRALI)

– May be one of the most common causes of morbidity and mortality associated with transfusion. – TRALI typically occurs within 1 to 2 hours of transfusion but can occur any time up to 6 hours later. – Patients complain of shortness of breath and may have a fever. – Support can vary from supplemental oxygen to intubation and ventilation. – Although most cases resolve on their own, severe cases can be fatal. GVHD

– Can occur after transfusion of immunocompetent T cells into immunocompromised recipients or human leukocyte antigen-identical family members. – GVHD presents with a rash, elevated liver function tests and pancytopenia. It has an associated mortality of greater than 80%.

– Irradiation of donor blood from first-degree relatives of immunocompetent patients and all blood for immunocompromised patients prevents this complication. Volume overload after blood transfusion

• Can occur in patients with poor cardiac and renal function • Also can occur as a component of the transfusion – associated circulatory overload (TACO) phenomenon • Careful monitoring of fluid status and judicious use of diuretic therapy can reduce the risk of complication Alloimmunizaton

• Occurs in 50% to 70% of patients receiving repeated platelet transfusions • Presents as a failure of the platelet count to increase significantly after a transfusion • This occurs in immuno-competent individuals who mount an immune response to platelet specific antigens which include class I HLA • Therefore, in patients needing long term platelet therapy, HLA matched SDP transfusion slow the process.

Post perfusion purpura

• Rare complications of platelet transfusions • Seen in previously transfused patients and multipara • This condition presents with severe thrombocytopenia, purpura and bleeding • Occurs 7-10 days after platelet transfusion • Usually self limiting disease • or infusion of IV immunoglobulins may be helpful Massive blood transfusion

• Massive transfusion is defined as replacement of the patient's blood volume with packed RBCs in 24 hours or transfusion of more than 10 units of blood over a period of a few hours • Massive transfusion can create significant changes in the patient's metabolic status

Infusion of large volumes of cold citrate-containing blood that has undergone changes during storage. • When blood is stored at 1°C to 6°C, changes occur over time – ▪ Leakage of intracellular potassium, ▪ Decrease in pH, ▪ Reduced levels of intracellular ATP and 2,3-DPG in RBCs with increased affinity of hemoglobin for oxygen, ▪ Degeneration of functional granulocytes and platelets, ▪ Deterioration of factors V and VIII. • If a large volume of stored blood is infused rapidly, significant effects may be seen in the recipient. • Many of the expected changes can be reversed after transfusion or may produce metabolic patterns different from those predicted. Complications from massive transfusion

• Coagulopathy – might arise as a result of platelet or coagulation factor depletion. • Hypocalcaemia – can be treated with 10% calcium gluconate • Acidosis and Hyperkalaemia – can develop after massive transfusion in patients with hepatic dysfunction • Hypokalaemia • Hypothermia – can be prevented with the use of blood warmers Hypothermia can lead to dysrhythmias and coagulopathy. Barnes-Jewish Hospital massive transfusion protocol (MTP) algorithm 1. Class IV shock and estimated requirement of > 10 units of blood YES Stop MTP Initiate MTP activation Incomplete 1. Patient expiration 2. Hemodynamic Transfuse Box 1 stability 1. 10units of PRBC 3. Attending 2. 6 units of FFP discretion 3. 1 unit of SDP

Transfusion complete

Transfuse Box 2 1. 6 units of PRBC Incomplete Stop MTP 2. 6 units of FFP 3. 1 unit of SDP

Transfusion complete

Transfuse Box 1 1. 6 units of PRBC Incomplete Stop MTP 2. 6 units of FFP 3. 1 unit of SDP