Blood Transfusion: It is best to AVOID it Dr. Syed Muhammad Irfan MBBS, FCPS (PK), FACP (USA) Professor and Head Department of Hematology & Transfusion Medicine Liaquat National Hospital, Karachi 1

Why we transfuse To restore or maintain Blood Volume Improve Oxygen carrying capacity Achieve Hemostasis Leukocytes in neutropenic patients

Can We do without blood Highly ethical and Professional Issues pertinent to PK ? Shortage To avoid Adverse blood reactions Cost saving Personal / Religious concerns

Avoiding blood & using Alternative Indication and judicious use . . . Alternative Products: - Hematinic drugs - Growth Factors - Hemostatic Agents - Crystalloids, Colloids - Autologus Transfusion Therapeutic Practices Management Policies Miscellaneous . . . . . .

If Transfusion is unavoidable Blood is life saving but is life threatening also. Only when necessary Specific & safe product, Lowest effective dose & frequency Diagnose and treat the cause

What to Transfuse Cellular Products: Red Cells Platelets Granulocytes: Plasma products FFP Cryoprecipitate (CP) Other Products

Red Cell Concentrate (RCC or PRC) Universal Hb threshold ? ? Clinical decisions are best Ch anemias are well compensated; Identify and treat the cause Trigger in Acute Loss ? No functional plts and granulocytes Volume is about 200 cc 1 unit increases Hb: 1 gm / dl (HCT 3 % ) Use G 18-20 canula

“Group O” PRC are universal donors How much, how frequent, How to give Transfuse as soon as you receive: 2-4 hr Perioperative period: > 8 gm/dl. We have no MSBOS (C/T ratio) Can use leukocyte filters / washed NS irradiated RC in special situations Autologus transfusion in some cases

Practical transfusion 2006 When to transfuse PRC ? stable patients bleeding patients < 4g/dl: transfuse 4-7g/dl: Tx usually necessary 7-10g/dl: usually not necessary > 10 g/dl: Tx rarely required Blood loss < 15% : Fluids only; no blood Blood Loss 15-30% consider Tx 30-40% : Tx usually necessary > 40%: tx indicated Practical transfusion 2006

Washed Red Cells

Leukocyte Reduction Filters (maintains closed system) http://www.pall.com/39378_39479.asp Final unit must have less than 5 x 106 WBCs

Platelets Treat Patient – Not counts Clinical status is main determinant - Serious bleeds < 5000 - Uncomplicated: 10,000-20,000 is safe - Complicated: 30,000 - 50,000 - Epidural & Massive transf > 50,000 ? - Most surgeries: 80,000-100,000 - Neuro and retinal surg > 100,000 No Rh antigen. +ive can be given to –ive Survival is < 24 hrs

Platelets Generally not indicated if no bleeding . . ITP, Septicemia, DIC Drug induced Thrombocytopenia Hypersplenism TTP HIT and HITT Routine cross match is not require, but if contains more than 2ml of red cells. D typing is not require, less than 0.5 ml of red cells transfused carry small risk of immunization.

Random Donor Must give in right dose: 1 unit / 10 kg Mixed groups can be given Volume / unit: 50-70 ml Increment: 5000 – 10,000/bag Not widely available in PK Less RBC and Leukocytes contamination 5.5x1010 per unit (55x109) ABO compatible preferably n=(P0-P1)x BSA/10 CI=(P1-P0)x BSA/n

Single Donor Increase 30,000 – 60,000 (equals 6-8 RDP) Advantages: Less donors No volume overload Lesser disease transmission Less Plt Alloimmunization Volume: 250 ml Cost is the main concern 3x1011 per unit (300x109)

Fresh Frozen Plasma Has all coagulation factors and AT-III Usual dose: 1 bag / 10 kg ABO compatible & without regard to Rh Volume / unit is about 200 cc Not indicated as Plasma expander in routine cases Nutritional / Power source Immunoglobin source

Fresh frozen plasma: indication Deficiency: VIII, Fibrinogen, vWbD etc Prolonged PT/APTT in surgical patients Prolonged PT/APTT in bleeding patients Masive transfusion Reversal of warfarrin toxicity Replacement of protein C/S/ATIII Plasma exchange in TTP, BCSH guidelines 2004

Cryoprecipitate Cryosupernatant By-product of FFP Volume not a problem: just 15-20 cc Group specific or mixed (without Rh type) Specifically used for factor VIII, I, XIII, VII deficiency and vWD. Topical hemostatic agent: Fibrin glue Cryosupernatant Volume about 180 cc Mainly contain Factor II, VII, IX, and X BCSH guidelines 2004

Whole Blood 450 +/- 50 ml Rarely used and minimally available No sufficient labile coagulation factor Restore blood volume & red cell mass Indications : - Exchange transfusion Acute massive loss: Contraindications Volume replacement correction of anemia in normovolumics

Irradiated products WHY ? To Prevent TA-GVHD (Graft vs. Host Disease) TA-GVHD carries 90 % mortality WHOM ? Family donors Immunocompromised recipients HLA matched SCT donors I/U transfusion

More Special blood products CMV negative HbS negative Antigen negative Deglycerolysed red cells Autologus blood 22

Summarising . . . . Best to avoid transfusion If indicated; go for specific component - It is Ethical - Less transfusion Reactions - Reduced cost - More availability Always consider alternatives

References: AABB (USA) Ludman Blood Transfusion ABC of Blood Transfusion (UK) 24