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Transfusion Trends In Transfusion Trends In Surgical PatientsSurgical Patients
Dr. Hanan AL-Awadhi (FRCPc)
Hematology Unit
Farwaniya Hospital
Lecture OverviewLecture Overview
Compatibility testing.Selecting compatible RBCs.RBCs transfusion triggers.Platelet transfusion.Transfusion of plasma and
components.
Compatibility TestingCompatibility Testing
Group and screen. Cross-match.
Compatibility Testing..Grouping Compatibility Testing..Grouping
Determination of recipient blood groupABO and RhDUse recipient RBC
(forward testing)Use recipient plasma
(reverse)
Compatibility Compatibility
Red cell type Antibodies present
Recipient Compatibility
Approximate frequency
Group O (no ABO antigens)
Anti-A, anti-B All ABO groups 46%
Group A Anti-B Groups A & AB 42%
Group B Anti-A Groups B & AB 9%
Group AB Neither present Group AB 3%
Rhesus group D positive
Normally none Should be RhD identical, RhD
-ve acceptable
85%
Rhesus group D negative
Normally none Should be RhD identical
15%
Compatibility Testing…Screening Compatibility Testing…Screening
The recipient plasma is tested for unexpected red cell antibodies using screening cellsAntibodies due to
prior transfusion or previous pregnancy
Selecting Compatible Red CellsSelecting Compatible Red Cells
Identical ABO and RhD type preferred Red cells of non-identical ABO type
may be used.RhD +ve blood to RhD -ve recipient
should be avoided wherever possible
Selecting Compatible Red CellsSelecting Compatible Red Cells
RhD –ve females with child-bearing potential should NEVER receive any RhD +ve red cells unless….
Patients with an unexpected antibody should receive only red cells lacking the corresponding blood group antigen
Compatibility Testing…X-MatchCompatibility Testing…X-Match
X-match between the selected unit and the recipient plasma
The bag is labeled for the particular recipient and ready for transfusion.
Needs 45-60 mints needed for full x-match.
Emergency Blood ReleaseEmergency Blood Release
The clinician must weigh the risk of transfusing uncrossed matched or partially X-matched
blood against the risk of delaying transfusion.
Degree Of UrgencyDegree Of Urgency
Desperate blood releaseBlood needed immediately as life saving
measure.Blood will be issued without X-match.
• Group O –ve uncross-matched blood
Blood sample before administering the blood is needed for subsequent testing
Degree Of UrgencyDegree Of Urgency
Blood needed in 10-30 minutesThe blood will be group specific not fully X-
matchedProvided the patient blood sample is
delivered
Degree Of UrgencyDegree Of Urgency
Blood needed with in 45 minutesFully matched blood will be providedPlease note that delay can occur if:
• Antibodies are detected• Problems in X-match• Blood is not available in local BB
Transfusion Of RBCsTransfusion Of RBCs
Indications For Red Cell TransfusionIndications For Red Cell Transfusion
Acute blood lossAnemia in the critically illPerioperative transfusionChronic anemia
Transfusion in Acute Blood LossTransfusion in Acute Blood Loss
Maintain Hb over 70 g/L during active bleeding
Anticipate need when Hb drops to 80 g/L
Transfusion in Acute Blood LossTransfusion in Acute Blood Loss
Consider maintaining higher level (80-100 g/L) with: Impaired pulmonary
function Unstable coronary
disease Atherosclerosis Uncontrolled bleeding
Patients with levels above 100 g/L are unlikely to benefit
Transfusion in the Critically IllTransfusion in the Critically Ill
Patients needs immediate requirement Patients needs immediate requirement for any form of organ support for any form of organ support (intubation, ventilation, inotropes).(intubation, ventilation, inotropes).
Hemoglobin trigger recommended for Hemoglobin trigger recommended for transfusion is < 70g/L.transfusion is < 70g/L.
Transfusion in the Critically IllTransfusion in the Critically Ill
No general benefit (& possible harm) until hemoglobin falls to 70 g/L.
Consider higher levels (100 g/L) in patients with unstable angina or acute myocardial infarction.
Randomized Controlled TrialsRandomized Controlled Trials
Hebert et al.(1999) (1) assigned 418 critically ill euvolemic patients to a "restrictive" transfusion strategy (ie, transfusion for Hgb concentration <7 g/dL and Hgb maintained at 7 to 9 g/dL) and 420 patients to a "liberal" strategy (transfusion for Hgb <10 g/dL and Hgb maintained at 10 to 12 g/dL) Mortality significantly lower with the restrictive strategy (but
not among patients with clinically significant cardiac disease) Conclusion: restrictive strategy of red cell transfusion
is at least as effective as, and possibly superior to, a liberal transfusion
CRIT study 2004(3)
RBCs transfusion and outcome were prospectively collected on 4892 patients from 284 ICUs in 213 US hospitals showed that transfused patients had longer ICU stay, more severe organ failure and higher mortality rates at every admitting Hgb level compared with non-transfused patients.
Conclusion: the number of RBC units transfused is an independent predictor of worse clinical outcome.
Transfusion In The Perioperative PatientTransfusion In The Perioperative Patient
Pre-operativelyConsider alternatives in advance (at least 5
weeks) of surgery to allow planningIntra-operatively
Meticulous attention to surgical techniquePost-operatively
Adhere to good transfusion practice, minimize blood taking for laboratory tests
Transfusion and Chronic AnemiaTransfusion and Chronic Anemia
Consider alternatives and adjuncts to transfusion Ensure adequate stores of iron, B12 & folate Erythropoietin Treat underlying disease
Only transfuse when there is no effective alternative Maintain hemoglobin at a level avoid symptoms of
anemia Monitor long-term transfusion dependant patients for
iron overload
Platelet TransfusionPlatelet Transfusion
PlateletsPlatelets
Platelets for transfusion come in 2 forms: Random donor, from
single donation, contains > 55x109platelets; given in pools of 6, volume 300mL
Apheresis (single donor) platelets; pack contains 300x109 platelets,volume300ml
Platelets – Storage & TransfusionPlatelets – Storage & Transfusion
Shelf life 5 days Stored at 20-24 Co with constant mixing Longer storage increases risk of septic reaction Recommended infusion time 60 minutes One apheresis product is equivalent to 6 to 8 random
donor platelet concentrates increases the platelet count by 30,000/uL to 40,000/uL in a 70 kg patient.
Check post-transfusion platelet count within 1 hour of transfusion to determine response and detect refractoriness
Platelets and Blood GroupPlatelets and Blood Group
ABO/RhD identical preferred
ABO/RhD non-identical are acceptable
RhD –ve females of child-bearing potential receiving RhD +ve platelets require Rh-immunoglobulin prophylaxis
When To Give Platelets?When To Give Platelets?
ITPITP
A consensus reached by experts from the American Society of Hematology concluded that platelet transfusion was only justified in the presence of: A platelet count less than 10x10 9 /L
AND serious bleeding.
NonNon--Immune Thrombocytopenia Immune Thrombocytopenia
Platelet transfusion support is required when the platelet count falls below 10x109/L.
Non-immune Thrombocytopenia AND Fever Non-immune Thrombocytopenia AND Fever Greater than 38.5°C and/or Coagulopathy Greater than 38.5°C and/or Coagulopathy
Platelet transfusion is recommended in the presence of Platelet count less than
20x10 9 /L AND
Fever = or > 38.5 AND/ORINR > 1.5
Procedures Not Associated with Procedures Not Associated with Significant Blood Loss Significant Blood Loss
Platelets count less than 20x109/L Transfuse single donor platelets
immediately prior to procedure. Platelets count 20-50x109/L
Platelets "on hold" Transfuse only if significant unexpected
bleeding occurs.
Procedures Associated with Major Blood Procedures Associated with Major Blood Loss or Major SurgeryLoss or Major Surgery Anticipated blood loss greater than 500 mL
aim at platelet count above 50x109/L. Platelet count less than 50x109/L, transfuse
platelets immediately prior to procedure.
Platelet Dysfunction and Marked Platelet Dysfunction and Marked Bleeding Bleeding Marked microvascular
(non-surgical) bleeding due to severe platelet dysfunction may require platelet transfusion. Example NSAIDs.
Transfusion may be required regardless of the platelet count.
Fresh Frozen PlasmaFresh Frozen Plasma
Fresh Frozen PlasmaFresh Frozen Plasma
Frozen Plasma is a source of clotting factors, with half lives in vivo of between 6 hours & 3 days.
30 minutes required for thawing
FFPFFP
Dose is 10-15 mL/Kg, or 4-6 units
Infusion time 30-120 minutes
Should be ABO compatible (Rh not important)
Check INR/APTT after infusion to confirm outcome
Reversal of Warfarin Anticoagulant Reversal of Warfarin Anticoagulant Effect Effect FFP for the emergency reversal of warfarin
anticoagulant effect: Patients with insufficient time (less than 6 hours)
for reversal by vitamin K
ANDPatient about to undergo an emergency operative
procedure
ORWith potentially life-threatening bleeding.
Think of AlternativesThink of Alternatives
The warfarin effect should be reversed with vitamin K in a dose of 10 mg administered intravenously.
This will produce partial reversal within 2 hours and normalization is usual in 24-48 hours.
Bleeding Patient With Impaired Bleeding Patient With Impaired Coagulation FunctionCoagulation Function Actively bleeding and INR/PTT greater than
1.5x normal Frozen plasma in a dose of 10-15mL/Kg (750-
1000mL) for an average sized adult should correct the INR/PTT to 1.5x normal or less
Failure to achieve the expected response should lead to review of the cause/diagnosis of impaired coagulation function
Microvascular Bleeding/Massive Microvascular Bleeding/Massive Transfusion Transfusion Massive rapid transfusion and/or
microvascular bleeding
Use of CryoprecipitateUse of Cryoprecipitate
Clinical Use of CryoprecipitateClinical Use of Cryoprecipitate
Must be ABO compatible, Rh not important.
Treatment of massive or microvascular bleeding with Fibrinogen < 1.0 g/L
CryoprecipitateCryoprecipitate
Hereditary Disorders of HemostasisFor bleeding in von Willebrand’s syndrome
patients ONLY if factor concentrate is unavailable and DDAVP is ineffective
For the emergency management of factor VIII deficiency ONLY if manufactured factor VIII is unavailable
Cryoprecipitate Cryoprecipitate
Dose1 unit per 10 kg of body weight (i.e. 8 to 12 units
per dose).• Small adult: 8 units
• Large adult: 12 units
Each dose will increase the fibrinogen by 0.5 g/L.Recommended infusion time is 10-30 minutes per
dose (maximum infusion time 4 hours).Half-life of fibrinogen is about 7 days.
Final Thought…Final Thought…
As beneficial as transfusion may seem to have zero transfusion risks is
impossible.
Thank you…Thank you…