Blood transfusion Done by raghad farajat

Principles of clinical transfusion practice 1.The patient with acute blood loss should receive effective resuscitation (intravenous replacement fluids, oxygen and other medication) immediately and the need for transfusion is estimated thereafter. 2. The patient’s hemoglobin (Hb) value, although important, should not be the sole deciding factor in the decision to transfuse blood. This decision should be supported by the need to relieve clinical signs and symptoms and to prevent significant morbidity or mortality. 3. Clinicians should be aware of the risk of transfusion transmissible infections in blood products prescribed for patients. 4.  Transfusion should be prescribed only when the benefits to the patient are likely to outweigh the risks. 5. Clinicians should clearly record the reason for ordering a transfusion (clinical diagnosis). 6. Trained staff should monitor a patient undergoing transfusion and respond immediately there are signs of an adverse effect

* Transfusion of blood and products should be undertaken only to treat a condition that would lead to significant morbidly or mortality and that cannot be prevented or managed effectively by other means

Indications of blood transfusion 1. Acute Blood Loss Best assessment of blood need is by an experienced clinician In general, will need to transfuse after 30% blood loss (1500ml) Once normovolaemic aim to keep Hb above 70 g/l

2. patients who are acutely unwell e.g perioperative, medical or critical care Use Hb of 70g/l as a guide for RBC transfusion Cardiovascular disease, consider transfusion at <80g/l Severe sepsis, traumatic brain injury or acute cerebral ischaemia use Hb < 90 g/l Be guided by symptoms rather than numbers

3. Chronic anaemia Maintain Hb to prevent symptoms of oxygen lack; e.g angina, syncope, breathless or tachycardia Hb >80g/l appropriate for many but some groups do better if Hb is higher: Patients known IHD Hb over 80 g/l Post chemotherapy Hb 80-90g/l Radiotherapy Hb more than 100 g/l CRF Hb more than 100g/l

4. Iron deficiency Anaemia Chronic IDA is not an indication for transfusion unless symptoms of end organ failure. * Note The rule that 1 unit of blood increases Hb by 10 g/l only holds for someone of 70 kg. In a ‘little elderly lady’ weighing 45kgs, the Hb may rise by 15 to 20 g/l after 1 unit It is very rare to need to transfuse to over 100 g/l.

Whole blood Whole blood is no longer commonly available or used in most of the United States. The most common use of whole blood in the United States is currently autologous donations for elective surgery. Whole blood, if available, may be indicated for large volume hemorrhaging, such as seen with major trauma, requiring massive transfusion and rapid correction of anemia, coagulopathy, acidosis, and hypothermia. Studies supporting this approach include military trauma where they are able to transfuse very fresh (<24 hours old) whole blood which is not currently routinely available in civilian institutions. Indications : Red cell replacement in acute blood loss with hypovolaemia ■ Exchange transfusion ■ Patients needing red cell transfusions where red cell concentrates are not available

Red cell concentrates [packed red blood cells (PRBC)] Description 150–200 ml red cells from which most of the plasma has been removed Haemoglobin approximately 20 g/100 ml (not less than 45 g per unit) Haematocrit 55%–75% 1. Replacement of red cells in anaemic patients 2. Use with crystalloid replacement fluids or colloid solution in acute blood loss

Platelet Indications:   Treatment of bleeding due to: 1. Thrombocytopenia. 2. Platelet function defects. 3.Prevention of bleeding due to thrombocytopenia as in bone marrow failure. Contraindications: 1. Idiopathic autoimmune thrombocytopenic purpura (ITP)(due to their rapid destruction by the underlying auto-immune process) . 2. Thrombotic thrombocytopenic purpura (TTP)(associated with arterial thrombi, acute myocardial infarction and in-hospital mortality and exacerbation ttp ). 3. Untreated DIC. 4.Thrombocytopenia associated with septicaemia, or in cases of hypersplenism

Fresh frozen plasma ■ Pack containing the plasma separated from one whole blood donation within 6 hours of collection and then rapidly frozen to –25°C or colder ■ Contains normal plasma levels of stable clotting factors, albumin and immunoglobulin ■ Factor VIII level at least 70% of normal fresh plasma leve ■ Replacement of multiple coagulation factor deficiencies: e.g. Liver disease Warfarin (anticoagulant) overdose Depletion of coagulation factors in patients receiving large volume transfusions Disseminated intravascular coagulation (DIC) Thrombotic thrombocytopenic purpura (TTP)

Cryoprecipitated anti‐haemophilic factor (Cryo‐AHF) Contains about half of the Factor VIII and fibrinogen in the donated whole blood. Indications:   As an alternative to Factor VIII concentrate in the treatment of inherited deficiencies of: 1. von Willebrand Factor (von Willebrand’s disease). 2. Factor VIII (haemophilia A). 3. As a source of fibrinogen in acquired coagulopathies; e.g. DIC 4. Can be used in isolated Factor XIII deficiency.

Monitoring the transfusion It is essential to take baseline observations and to ensure that the patient is monitored during the transfusion in order to detect any adverse event as early as possible. Before commencing the transfusion, it is essential to encourage the patient to notify a nurse or doctor immediately if he or she becomes aware of any discomfort such as shivering, flushing, pain or shortness of breath or begins to feel anxious. Ensure that the patient is in a setting where he or she can be directly observed. For each unit of blood transfused, monitor the patient: - Before starting the transfusion (baseline observation). - 15 minutes after starting the transfusion. - At least every hour during transfusion. - Carry out a final set of observations 15 minutes after each unit has been transfused.

Documentation of the transfusion Monitor the patient before, during and on completion of the transfusion. At each of these stages, record the following information on the patient’s chart: - Patient’s general appearance. - Temperature. - Pulse. - Blood pressure. - Respiratory rate. Make note of the following: - Time the transfusion started. - Time the transfusion was completed. - Volume and type of blood products transfused - Unique donation number of all products transfused. - Any adverse effect. Identify and respond immediately to any adverse effect, by stopping the transfusion

Severe reactions most commonly present during the first 15 minutes of a transfusion. All patients and in particular, unconscious patients should be monitored during this period and for the first 15 minutes of each subsequent unit.

Blood transfusion complications Though generally safe and simple , the procedure of blood transfusion is not free of complications. The majority of these are simple, yet some are immediately fatal and others produce serious illness as hepatitis and AIDS , attention to strict rules of donation and administration of blood greatly reduces the incidence of these complications.

Transfusion reaction Acute TR (<24 hours ) Delayed TR (>24 hours)

Early complications 1. Haemolytic transfusion reaction   An acute haemolytic transfusion reaction is the result of a mismatched blood transfusion, and causes acute intravascular haemolysis. 2. Bacterial contamination and septic shock Bacterial contamination affects up to 0.4% of red cells and 1‐2% of platelet concentrates Blood may become contaminated by: - Bacteria from the donor’s skin entering the blood unit during collection (usually staphylococci). - Bacteraemia present in the blood of the donor during collection (e.g. Yersinia). - Improper handling during blood processing. 3. Transfusion Associated Circulatory Overload Transfusion associated circulatory overload (TACO), i.e. fluid overload, can result in heart failure and pulmonary oedema. 4. Anaphylactic reaction  This is a rare complication of transfusion of blood components or plasma derivatives 5. Transfusion Related Acute Lung Injury    Transfusion related acute lung injury (TRALI) is usually caused by donor plasma that contains antibodies against the patient’s leucocytes

Delayed complications 1. Delayed haemolytic transfusion reaction Signs appear 5‐10 days after transfusion: 1.Fever. 2. Anaemia. 3.Jaundice. 4. Occasionally haemoglobinuria. Severe, life‐threatening delayed haemolytic transfusion reactions with shock, renal failure and DIC are rare. 2. Post‐transfusion purpura This is a rare but potentially fatal complication of transfusion of red cells or platelet concentrates, caused by antibodies directed against platelet‐specific antigens in the recipient. 3. transfusion transmitted infections The following infections may be transmitted by transfusion: HIV, Hepatitis B and C, syphilis (Treponema pallidum), malaria Cytomegalovirus (CMV) Other TTIs include human parvovirus B19, brucellosis, Epstein‐Barr virus

Since a delayed transfusion reaction may occur days, weeks or months after the transfusion, the association with the transfusion may easily be overlooked. It is essential to record all transfusions accurately in the patient’s case notes and to consider transfusion in the differential diagnosis.