THE INSIDE STORY OF BLOOD TRANSFUSION DR.MOHAMED BILAL DELVI ASSISTANT PROFESSOR DEPT OF ANAESTHESIA COLLEGE OF MEDICINE KSU. Done by : 428 surgery team 1428 surgery team

What is blood? A highly specialised circulating tissue which has several types of cells suspended in a liquid medium called plasma. Origins from Greek ‘haima’ Blood is a life sustaining fluid 2428 surgery team

Blood is an amazing fluid! Keeps us warm Provides nutrients for cells, tissues and organs Removes waste products from various sites 3428 surgery team

Blood Composition Plasma: 55%. (50% water + 5% plasma substance) Formed elements: 45%. - RBC: live in circulation for 120 days. (near 45%) - WBC: their life in circulation extends from months to years. - Platelets: their life in circulation is 6-10 days. WBC + platelets less than 1% 4428 surgery team

Blood components Blood Products: Whole Blood Packed red cells RBC. Platelets concentrate. White cell concentrate. Plasma Products: Fresh Frozen Plasma FFP. Frozen plasma Cryoprecipitate. Albumin containing solution. Human Immunoglobulins. Prothrombin complex concentrate. Factor VIII concentrates. 5

Whole Blood Red Cell Concentrate Centrifugation Platelet – rich Plasma Platelet Concentration Platele – poor Plasma Freezing - 30° C Centrifugation 6428 surgery team

Fresh Frozen Plasma (FFP) Factor VIII Concentrate Precipitate (fibrinogen) Prothrombin Complex Concentrate Plasma Protein Fraction (PPF) Albumin Immunoglobulins Supernatant Precipitate (cryoprecipitate) Cryoprecipitation 4° C 7428 surgery team

Packed Red Blood Cells One unit contains 300 ml. Out of this, 70% are RBC. Indicated in: - Acute blood loss, - Chronic anemias. Shelf life 42 days at 4 C 8428 surgery team

Platelet Concentrate One unit contains 50 x 109 platelets. Usually 5-6 units are given as one pool. Indicated in: - Bleeding due to platelet deficiency. - Bleeding due to platelet dysfunction. Shelf life 5 day at 22 C 9428 surgery team

WBC Concentrate Difficult to get sufficient quantities. Half life is only 8 hours. Rarely indicated because most patients respond to antibiotics and do not need white blood cells. Nonhemolytic transfusion reactions are common surgery team

Plasma Products 1. Fresh frozen plasma (FFP): Stored at – 30° C. Shelf life 1 year. Rich in all components of plasma. Indicated in: - Disseminated intravascular coagulation (DIC). - Liver failure. - Warfarin overdose. - Massive RBC transfusions surgery team

2- Cryoprecipitate Prepared from FFP after thawing it to 4° C. When refrozen, the shelf life is 3 to 6 months. Rich in factors VIII, XII, XIII and VWF (Von Willebrand factor). 3- Factor VIII concentrate: Prepared by fractionation of cryoprecipitate. Large numbers of cryoprecipitate are required. Indicated in hemophilia. Type A surgery team

4- prothrombin complex concentrate: Contains factors II, VII, IX, and X. Indicated in hemophilia B. 5- Human immunoglobulins: Nonspecific immunoglobulins are used in: - Congenital immunodeficiencies. - Acquired immunodeficiencies. - Idiopathic thrombocytopenia purpura (ITP). Specific immunoglobulins are used in: - Hepatitis B. - Herpes zoster. - Rubella. - Rabies. - Tetanus. - Measles surgery team

6- Albumin containing solutions: Used as plasma expander in severe hemorrhage while waiting for blood. Also used to maintain plasma albumin levels in: - Liver failure. - Malnutrition. - Protein losing states surgery team

Blood Types: O Rh-positive 38% O Rh-negative 7% universal donor A Rh-positive 34% A Rh-negative 6% B Rh-positive 9% B Rh-negative 2% AB Rh-positive 3% universal recipient AB Rh-negative 1% surgery team

INDICATIONS FOR BLOOD TRANSFUSION Massive blood loss – acute blood loss. Different types of anaemia – chronic anemias. Haemophilia & other clotting factor deficiency – chronic deficiency of any blood component. Cancer patients For surgeries surgery team

HISTORICAL ASPECTS * 15 th century- unsuccessful attempts dog to dog transfusion (بعض الشباب قالوا جا عليها سؤال ) 1667-animal to human human to human major breakthrough- discovery of A,B,O groups surgery team

HISTORICAL ASPECTS cross matching anticoagulant discovered first blood bank 1939/40- Rh factor discovery plastic blood containers surgery team

DOG TO DOG TRANSFUSION surgery team

SHEEP TO HUMAN TRANSFUSION surgery team

HUMAN TO HUMAN TRANSFUSION surgery team

Theoretical Yield of components 1 unit of blood theoretically gives 1 unit FFP 1 unit PRBC’s 1 single donor unit cryoprecipitate, single donor unit platelets Plasma for Ig and albumin surgery team

BLOOD GROUP SYSTEMS ABO System Most studied & important Rh system from clinical point of view. Lewis Kell Duffy surgery team

BLOOD GROUP SYSTEMS MNSs Lutheran P Ii kid surgery team

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DIFFERENT BLOOD GROUPS surgery team

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BLOOD GROUPANTIGENANTIBODY A A Anti-B B B Anti-A AB A,B None O H Anti-A, Anti-B Bombay Group None Anti-A, Anti-B,& Anti-H surgery team

RHESUS MONKEYS surgery team

BLOOD DONATION CRITERIA Good general condition. Age: 18 to 60 years. Weight- >45kg for 350ml, >55kg for 450ml. BP: syst mmHg diast mmHg. Pulse: 60 to 100beats/min surgery team

BLOOD DONATION CRITERIA Temp. >37.5deg.C Hb. >12.5gm% Jaundice Malaria High risk behaviour Pregnancy surgery team

BLOOD DONATION CRITERIA Surgeries Last blood donation Tattooing Chronic diseases Last blood transfusion surgery team

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INSTRUCTIONS TO DONOR AFTER DONATION More fluids than usual. Do not remain hungry. Do not smoke for 1hour. Remove bandage after 6 hours. If bleeding from puncture site, apply pressure. If feeling faint/dizzy, lie down surgery team

MISCONCEPTIONS/ REASONS FOR NOT DONATING BLOOD Fear of contracting some disease I do not have enough blood/ I will become weak. I am too old I am too busy surgery team

REASONS TO DONATE BLOOD New blood formation. Regular health check up. Blood investigations done. Satisfaction of noble work surgery team

TESTS DONE IN BLOOD BANK Blood grouping & Rh typing Cross matching Tests for irregular antibodies HBsAg test & Anti-HBc HCV test HIV test (HIV1 & HIV2) Test for syphilis Test for malaria surgery team

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Cell Grouping Serum GroupingInterpretation Anti A Anti B Anti AB A cellsB cellsO cells A B AB O Bombay Blood Group surgery team

BLOOD GROUP ANTIGENANTIBODYCan give blood to Can receive blood from A A Anti-B A,AB A,O B B Anti-A B,AB B,O AB A,B None ABA,B,AB,O O H Anti-A, Anti-BA,B,AB O Bombay Group None Anti-A, Anti-B,& Anti-H Bombay group (Oh) Bombay group (Oh) surgery team

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Screening tests on donors’ blood: - Hepatitis B surface antigen (HBsAg). - Hepatitis B core antibody (anti-HBc). - Hepatitis C virus antibody (anti-HCV). - HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2). - HTLV-I and HTLV-II antibody (anti-HTLV-I and anti- HTLV-II). -Serologic test for syphilis. Prerequisites: -Take samples for full blood count (FBC), serum iron or ferritin B, and folate levels. - Cross match. - Choose the appropriate blood group in emergency. - Appropriate IV access surgery team

MISMATCHED TRANSFUSION Group A + Group B = Clumping of RBCs surgery team

AUTOLOGOUS DONATION Self help is the best help. Planned gynaecological, orthopedic, plastic general surgeries Individuals with rare blood groups/ irregular antibodies/ infectious disease positive surgery team

AUTOLOGOUS DONATION Advantages Safest blood. Easy availability No risk of TTDs Best option in patients with irregular antibodies, rare blood groups, infectious disease positive. Blood scarcity can be reduced to some extent surgery team

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Blood Transfusion: A.Autologous: -Blood donor and transfusion recipient are the same in order to avoid blood borne diseases or infections. -Four types: 1. Preoperative donations: - Donating the patient’s own blood before surgery. - The blood bank draws the patient’s blood and stores it until he/she needs it during or after surgery. - Only for elective surgery. 2. Preoperative hemodilution: - Immediately before surgery, some of the patient’s blood is taken and replace with IV fluids, i.e. normal saline. - Only for elective surgeries surgery team

3. Perioperative (intraoperative) collection: - Recycling the patient’s blood during surgery. - Blood lost during surgery is filtered, and put back into the patient’s body during surgery. - Can be done in emergency and elective surgeries. 4. Postoperative collection: - Recycling the patient’s blood after surgery. - Blood lost after surgery is collected, filtered and returned to the patient’s body. - Can be done in emergency and elective surgeries surgery team

B. Allogenic: Blood transfused to someone other than the donor. Practical tips: Give one unit over 4 hours. Use blood warmer if patient is hypothermic. Give 40 mg IV frusemide in between each unit. If possible, give transfusions early in the day. Check hemoglobin hours after transfusion surgery team

Complications of Transfusion: Transfusion reaction. Transmission of infections. Hyperkalemia. Hypocalcemia. Thrombocytopenia. Depletion of clotting factors. Transfusion reaction: Fever. Urticarial rash. Agitation. Chest or abdominal pain. Hypotension. Wheezing. Severe back pain surgery team

Management of transfusion reaction: Stop transfusion. Return the remaining blood to lab. Give 100 mg of hydrocortisone and 10 mg chlorpheniramine IV. Recheck the cross matches. Monitor vital signs. Monitor urine output. Inform your senior colleague surgery team

In emergencies, the Rh – person can receive few units of Rh + blood if he/she has no anti-D antibodies. They are generally elderly male patients. Compatibility chart for elective transfusion (for your knowledge) A+B+AB+O+A-B-AB-O- A B AB O A B AB- O Donor’s blood group Recipient’s blood group surgery team

BLOOD COMPONENTS Blood separated into different parts. 1) Packed red cells 2) Platelets 3) Fresh frozen plasma 4) Cryoprecipitate 5) Granulocytes 6) Factor IX conc. 7) Factor VIII conc surgery team

COMPONENTS Advantages Overload avoided. Better patient management. Greater shelf life than whole blood. Blood shortage can be overcome surgery team

COMPONENT SEPARATION surgery team

COMPONENT SEPARATION surgery team

FINAL PRODUCTS surgery team

Blood componentContentsVolumeShelf life Whole bloodHct.35%,RBCs, WBCs.450ml blood,63ml CPDA1 520ml35 days at 4deg.C. Red cellsHct.60%,RBCs,25mlplasma, 100 ml Adsol. 340ml42 days at 4deg.C PlateletsPlatelets,few WBCs,RBCs, 50ml plasma 50ml5 days at 22deg.C FFP Cryoppt. Pl.proteins,clot. Factors Fibrinogen,factor VIII,IX. 225ml 15ml 1year at -18deg.C surgery team

APHERESIS CELL SEPARATOR surgery team

APHERESIS Plasmapheresis: plasma is removed. Plateletapheresis: platelets are removed. Leukapheresis: leucocytes are removed surgery team

The rational use of blood and blood products surgery team

BLOOD LOSS- Signs, Symptoms and Indication for Transfusion Volume Lost Clinical signs Preparation of choice mL % of Total Blood Volume None; No transfusion or crystalloid solution tachycardia crystalloid solution or colloids or RBC if necesssary drop in BP crystalloid solution plus colloids plus RBC or blood if available shock crystalloid solution plus colloids plus RBC or blood if available surgery team

RED CELLS TRANFUSION-Indication(1) 1. Whole blood acute hypovolemia (hemorrhagic shock) massive transfusion exchange transfusion in infants for hemolytic anemia of the newborn surgery team

Packed red cells mls. of red cells with plasma removed Haemoglobin 20g/ 100 ml, PCV Expected rise in Hb with 1 unit of red cells is approximately 1g/dL surgery team

Indications for Packed Cells Massive blood loss Anaemia of chronic disease Haemoglobinopathies Perioperative period to maintain Hb> 7g/dL No need for transfusion with Hb > surgery team

Platelets x10 9 /L Platelet units can be either Single donor units Apheresis units 1 single donor unit contains 55 x apheresis unit contains 240x surgery team

Platelets Stored at room temperature Constantly agitated Only last for 5 days 1 dose of platelets should raise patient’s counts by 30 x10 9 after 1 hour Infused in 15 mins surgery team

Indications for platelet transfusion BLEEDING due to thrombocytopaenia Due to platelet dysfunction Prevention of spontaneous bleeding with counts < surgery team

Recommended counts to avoid bleeding Platelet count /ul Clinical Condition > Major abdominal, chest or neurosurgery > Trauma, major surgery > Minor surgical procedures > Prevention/treatment of bleeding in pts with sepsis, leukemia, malignancy > Uncomplicated malignancy, leukemia > ITP patients at low risk surgery team

FFP Fresh Frozen Plasma Plasma collected from single donor units or by apheresis Frozen within 8 hours of collection -18 o to -30 o C Can last for a year surgery team

FFP 1 unit is 250 ml Contains all plasma proteins Indications: Correction of bleeding due to excess warfarin, Vitamin K deficiency, liver disease DIC, dilutional coagulopathy Inherited factor XI deficiency TTP surgery team

FFP Dose: 15 mls/kg about 3-5 units FFP and INR <2 Give at 1ml/kg per hour in likely fluid overload patients Given within 24 hours of thawing Requesting FFP surgery team

Frozen Plasma Plasma frozen within 24 hours of collection Maintains level of plasma proteins except factor VIII Same indications as FFP surgery team

Cryoprecipitate FFP thawed at 4 o C and centrifuged Cryoprecipitate is the by-product Contains Fibrinogen, Factor VIII, Factor XIII, von Willebrand’s Factor surgery team

Cryoprecipitate No longer indicated for Hemophilia* Source of Fibrinogen in acquired coagulopathies as in DIC; platelet dysfunction in uremia Indicated for bleeding in vWD, Factor XIII deficiency surgery team

Cryoprecipitate Infused as quickly as possible Give within 6 hours of thawing mls; usually 10 units pooled 10 bags contain approx. 2gm of fibrinogen and should raise fibrinogen level to 70mg/dL surgery team

Almost there!!!!!!! surgery team

Appropriateness of transfusion May be life-saving May have acute or delayed complications Puts patient at risk unnecessarily ‘ The transfusion of safe blood products to treat any condition leading to significant morbidity or mortality, that cannot be managed by any other means’ surgery team

Inappropriateness of transfusion Giving blood products for conditions that can otherwise be treated e.g. anaemia Using blood products when other fluids work just as well Blood is often unnecessarily given to raise a patient’s haemoglobin level before surgery or to allow earlier discharge from hospital. These are rarely valid reasons for transfusion surgery team

Inappropriateness of Transfusion Patients’ transfusion requirements can often be minimized by good anaesthetic and surgical management. Blood not needed exposes patient unnecessarily Blood is an expensive, scarce resource. Unnecessary transfusions may cause a shortage of blood products for patients in real need surgery team

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Problems faced Too few donors Lack of equipment Insufficient products Insufficient reagent Infectious disease testing surgery team

Recommendations Increase public awareness about need for blood and hence the number of voluntary donors Continue to encourage relatives to donate for patients* Increase the number of mobile clinics Extend the opening hours for blood collecting surgery team

Recommendations Management of stocks of blood and blood products Maintenance and replacement of equipment On-going training of Haematology Lab Staff Better management of reagents for- infectious disease testing, antigens etc. Improved record keeping Move to electronic record keeping surgery team

Recommendations View to reduce the need for allogeneic transfusions Autologous transfusions Blood saving devices in OR (operating room) Acute normovolemic haemodilution Oxygen carrying compounds surgery team

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Bibliography Uptodate.com British Transfusion guidelines 2007 Clinical use of blood, WHO MJA: Tuckfield et al.,Reduction of inappropriate use of blood products by prospective monitoring of blood forms Transfusion practice: Palo et al., Population based audit of fresh frozen plasma transfusion practices Vox Sanguinis: Titlestead et al., Monitoring transfusion practices at two university hospitals Transfusion: Schramm et al., Influencing blood usage in Germany Transfusion: Healy et al., Effect of Fresh Frozen Plasma on Prothrombin Time in patients with mild coagulation abnormalities Transfusion: Sullivan et al., Blood collection and transfusion in the USA in 2001 Transfusion: Triulzi, The art of plasma transfusion therapy surgery team

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