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Topic modules
1. 2. 3. 4. Blood blank practices Indication to blood transfusion Complication Alternative strategies for management of blood loss during surgery
T&S:
Type O red cells are mixed with pt serum Antibody screen
T&C
Type O red cells are mixed with pt serum Antibody screen
Donor red cells are then mixed with the pts serum to determine possible incompatibility
Allowable blood loss = EBV*( Hct Hct)/ Hct Hct. 30% not magic number Jehovah s witness
Practice guideline
$$ case series : reports of Jehovah witness; some may tolerate very low Hb< 6-8 g/dl in the perioperative period without an incresae in mortality
Practice guideline
$$ In healthy, normovolemic individual, tissue oxygenation is maintained and anemia tolerated at Hct as low as 18-25%(Hb 6-8gm%)
$$ RBC transfusion is rarely indicated when Hb> 10 g/dl and is almost always indicated when Hb< 6 g/dl
3. PLATELETS **thrombocytopenia or dysfunction platelets in the presence bleeding * prophylactic : plt.counts below 10,000-20,000 * prophylactic preoperative : plt.counts below 50,000 *Microvascular bleeding in surgical patient with platelets < 50,000 *Neuro/ ocular surgery > 75,000
3. PLATELETS
*Massive transfusion with microvascular bleeding with platelets < 100,000 2 BVs = 50,000 *Qualitative dysfunction with microvascular bleeding (may be > 100,000)
Blood is still the best possible thing to have in our veins - Woody Allen
Blood transfusion is a lot like marriage. It should not be entered upon lightly, unadvisedly or wantonly, or more often than is absolutely necessary - Beal
TRANSFUSION REACTIONS
is any unfavorable transfusion-related event occurring in a patient during or after transfusion of blood components
TRANSFUSION REACTIONS
@RBCs !
Nonhemolytic 1-5 % transfusions
Causes -Physical or chemical destruction of blood: freezing, heating, hemolytic drug -solution added to blood
-Bacterial contamination : fever, chills, urticaria Slow transfusion, diphenhydramine , antipyretic for fever
Anesthesia: hypotension, urticaria, abnormal bleeding Stop infusion, blood and urine to blood bank, coagulation screen (urine/plasma Hb, haptoglobin) Fluid therapy and osmotic diuresis Alkalinization of urine (increase solubility of Hb degradation products) Correct bleeding, Rx. DIC
CBC, UA, Bilirubin, BUN, Cr, Coagulation screening Repeat compatibility test - Pre Tx sample & Donor unit - Post Tx sample & Donor unit
Delayed: (extravascular immune)1/ 5-10,000 Hemolysis 1-2 weeks after transfusion (reappearance of Ab against donor Ag from previous exposure) Fever, anemia, jaundice Alloimmunization Recipient produces Abs against RBC membrane Ag Related to future delayed hemolytic reactions and difficulty crossmatching
@WBCs!
Europe: All products leukodepleted USA: Initial FDA recommendation now reversed pending objective data (NOT length of stay for expense)
Febrile reactions
Recipient Ab reacts with donor Ag, stimulates pyrogens (1-2 % transfusions) 20 - 30% of platelet transfusions Slow transfusion, antipyretic, meperidine for shivering
Pathophysiology
Leukocyte Ab in donor react with pt. leukocytes Activate complements Adherence of granulocytes to pulmonary endothelium with release of proteolytic enz.& toxic O2 metabolites Endothelial damage
Symptoms and signs Fever Hypotension Tachypnea Dyspnea Diffuse pulmonary infiltration on X-rays Clinical of noncardiogenic pumonary edema
Graft-versus-Host Reaction
Signs & Symptoms
Onset ~ 3 to 30 days after transfusion Clinical significant pancytopenia Other effects include fever, liver enzyme, copious watery diarrhea, erythematous skin erythroderma and desquamation
@Platelets!
Alloimmunization
50 % of repeated platelet transfusions Ab-dependent elimination of platelets with lack of response Use single donor apheresis Signs & Symptoms mild slight fever and Hb severe platelet refractoriness with bleeding
Post-transfusion purpura Recipient Ab leads to sudden destruction of platelets 1-2 weeks after transfusion (sudden onset) Rare complication
Cancer recurrence (mostly retrospective) Colon: 90 % studies suggest increased recurrence Breast: 70 % studies Head and neck: 75 % studies Allogeneic blood products increase cancer recurrence after potentially curative surgical resection - Landers Evidence circumstantial NOT causal
INFECTIOUS COMPLICATIONS
I. Viral (Hepatitis 88% of per unit viral risk)
Hepatitis B Risk 1/ 200,000 due to HBsAg, antiHBc screening (7-17 % of PTH) Per unit risk 1/63-66,000 0.002% residual HBV remains in negative donors (window 2-16 weeks) Anti-HBc testing retained as surrogate marker for HIV
NANB and Hepatitis C Risk now 1/ 103,000 (NEJM 96) with 2nd/ 1/ 125,000 with 3rd generation HCV Ab/ HVC RNA tests Window 4 weeks 70 % patients become chronic carriers, 10-20 % develop cirrhosis
HIV
Current risk 1/ 450- 660,000 (95) With current screening (Abs to HIV I, II and p24 Ag), window 6-8 weeks (third generation ELISA tests in Europe) sero -ve window to < 16 days
HTLV I, II
Only in cellular components (not FFP, cryo) Risk 1/ 641,000 (window period unknown) Screening for antibody I may not pick up II
CJD (and variant CJD)
CMV
Cellular components only Problem in immunocompromised, although 80 % adults have serum Ab WBC filtration decreases risk of transmission CMV -ve blood: CMV -ve pregnant patients, LBW neonates, CMV -ve transplant recipient, CMV-ve/ HIV +ve
II. Bacterial
Contamination unlikely in products stored for > 72 hours at 1-6 0 C gram ve, gram +ve bacteria most frequent Yersinia enterocolitica Produced endotoxin Platelets stored at room temperature for 5 days, with infection rate of 0.25%
III. Protozoal
Trypanosoma cruzi (Chagas disease) Malaria Toxoplasmosis Leishmaniasis
METABOLIC COMPLICATIONS
Citrate toxicity
Citrate (3G/ unit WB) binds Ca2+ / Mg+ Metabolized liver, mobilization bone stores Hypocalcemia ONLY if > 1 unit/ 5 min or hepatic dysfunction Hypotension more likely due to cardiac output/ perfusion than calcium (except neonates) Worse with hypothermia/ hepatic dysfunction
Hyperkalemia
After 3 weeks, K+ is 25- 30 mmol/l Only 8- 15 mmol per unit PRBC/ WB Concern with > 1 unit/5 min @ infants
Acidosis
Acid load after after 3 weeks 30-40 mmol/l (pH 6.6 - 6.9) Metabolic acidosis more likely due to decreased perfusion, hepatic impairment, hypothermia NaHCO3 or THAM if base deficit > 7-10 mEq/l
2, 3 DPG
Depleted within 96 hours of storage O2 Hb DC to left Restored within 8- 24 hours of transfusion
E. REFERENCES
Practice Guidelines for Blood Component Therapy (ASA Task Force). Anesthesiology 1996; 84: 732-47. Safety of the Blood Supply. JAMA 1995; 274:1368--73. Infectious Disease Testing for Blood Transfusions (NIH Consensus Conference). JAMA 1995; 274: 1374-9.