1. Transfusion practice in anesthesia
Jutarat Luanpholcharoenchai

2. Objectives Blood and blood components
Physiologic response to blood loss
Indication for blood /blood component transfusion
Intra-operative transfusion practices
Transfusion reactions : diagnosis & management

3. Blood and blood components
Water
Blood electrolyte
Plasma protein: fibrinogen, albumin, globulin, immunes
Substances : hormones, CO2, waste products

4. Blood volume Blood volume Preterm newborn 90-100 ml/kg Term newborn
Infant <3 mo
3mo-12 mo
80-90 ml/kg
80 ml/kg
Child > 1 year
70 ml/kg
Adult : Male
Female
75 ml/kg
65 ml/kg

5. Blood group
Rhesus(Rh) blood group

6. Oxygen transportation
Oxygen delivery (DO2) =
arterial oxygen content(CaO2) x Cardiac output(CO)
=(1.34 x Hb x O2sat)+ (0.003 x PaO2)
PaO2 = partial pressure of O2 in arterial

7. Physiologic response to blood loss
Acute mechanism
Increase cardiac output : heart rate & contractility
Redistribution to vital organ
Vasoconstriction of venous reservior
Arterioles constriction
Anesthetic agents induces vasodilation :
severe hypotension and tachycardia

8. Physiologic response to blood loss
Increase oxygen extraction ratio
Changes in O2-Hb affinity
O2 demand/O2 supply

9. Blood &blood components transfusion

10. Indication transfusion
Increase oxygen carrying capacity :
tissue hypoxia
Increase intravascular volume
Coagulopathy

11. Practice guideline “In healthy, normovolumic individuals,
tissue oxygenation is maintained & tolerated anemia at Hct as low as 18-25% (Hb 6-8 mg/dL)”
“ RBC transfusion :
almost always indicated when Hb < 6 mg/dL”
American Society of Anesthesiologist : 1996

12. RBC transfusion trigger
Hb 7-10 mg/dL
Increased O2 demand
Limited ability to increase cardiac output
Occlusive vascular disease(cerebral, coronary)
Left shift of O2-Hb dissociation curve
Impaired oxygenation
Ongoing or imminent blood loss

13. Type and screen vs Type and crossmatch
Type and screen (T&S)
pt blood  screen for ABO, Rh, Antibody
Type and crossmatch (T&C) (50 min)
Donor RBC + pt serum for Ab screening

14. Emergency transfusion
First choice(5 min)
Type-specific partially crossmatch blood
Type-specific un-crossmatch blood
Second choice
Group O RBCs, Rh-negative (esp. woman of child-bearing age)
Group O RBCs, Rh-positive
FFP : group AB
Universal donor > 2 u then continue gr O

15. BLOOD PRODUCTS : Packed red blood cell
PRBC
volume 300 ml, Hct 75-80%
PRC+WBC+plasma+CPDA
CPDA : citrate + Ca  anticoagulation
10 ml/kg : raise Hct 10 %

16. BLOOD PRODUCTS : Fresh-Frozen plasma
FFP : ABO compatible only
10-15 ml/kg : raise clotting factor level %
Indication
Correction of coagulation
PT/PTT > 1.5 times
Microvascular bleeding during massive transfusion
Single coagulation factor deficiency
Urgent reversal of warfarin
Heparin resistance (antithrombin III deficiency)

17. BLOOD PRODUCTS : Platelets
Platelet concentration : 7.5x1010 platelets in 50 ml
Single Donor Platelets : Apheresis platelets=6-8 plt conc.
ABO compatability is ideal. No Rh Antigen
0.1 unit/kg of platelet conc. platelet 5,000-10,000 /mm3
Transfusion threshold : 50, ,000 /mm3
Type of surgery: Closed space surgery, cardiopulmonary bypass
Coagulation abnormality
Platelet dysfunction: renal failure, Aspirin
Microvascular bleeding

18. BLOOD PRODUCTS : Cryoprecipitate
Factor VIII, von Willebrand factor (vWF), fibrinogen, factor XIII
ABO compatible : not essential
0.1 unit/kg  raise fibrinogen 50 mg/dL
Indications
Microvascular bleeding
fibrinogen < mg/dL
Massive blood transfusion
Hemophilia A, vWD, congenital fibrinogen deficiency, FXIII deficiency

19. Intra-operative transfusion practices
Maximal allowable blood loss “MABL”
MABL = EBV x ( Hct actual – Hct acceptable )
Hct average
EBV = Estimated blood volume
= Blood volume x Bodyweight (Kg)
Ex A 30 year old, healthy man BW 70 kg, actual Hct 35 %
MABL = 70 x 75 ( ) = 1,750 ml 30

20. Intra-operative transfusion practices
1. check for blood component integrity 2. check for indication for transfusion : risk/benefit 3. confirm positive patient identification 4. check unit tag against unit label, prescription, pt ID 5. perform observetion

21. Transfusion reactions
Hemolytic transfusion reactions
Acute : ABO incompatibility
hypotension, fever, shivering, nausea, bleeding diathesis , hemoglobinuria
Delayed (2-21 d): immune mediator, Rh, Kidd
progressive anemia, jaundice, hemoglobinuria
Treatment : stop transfusion
hydration: isotonic solution
alkalinized urine
recheck with blood bank

22. Transfusion reactions
Non-hemolytic transfusion reaction : 1-5%
Febrile reaction : Ab=Ag at WBC
repeat transfusion
Prevention: Leukocyte-poor red blood cell
Allergic reaction: Foreign protein, Histamine release
urticaria, puritus, angioedema, bronchospasm, hypotension, anaphylactic reaction
Treatment : slow tranfusion
symptomatic supportive eg. antihistamine

23. Transfusion reactions
Transfusion-related acute lung injury (TRALI)
non-cardiogenic pulmonary edema, 2-6 hr
Supportive treatment
Transfusion-associated Graft-versus-Host disease (TA-GVHD)
Lymphocyte VS organ
Prevention : grammar ray (irradiated RBC)

24. Transfusion reactions: non immune
Transfusion-transmissible infections
Virus: HBV, HCV, HIV, CMV, EBV
Parasites: Chagars’, Malaria
Bacteria: contamination eg Platelet(room temperature)
Circulatory overload

25. Massive blood loss Massive blood transfusion Definition
Loss of 1 blood volume within 24 hr.
50% blood volume loss within 3 hr.
Rate of loss : 150 ml/min
Massive blood transfusion

26. Massive blood transfusion
Hypothermia
Slowing hemostasis
Sequestration of platelets
Dysrrhythmias
Volume overload
Dilutional coagulopathy

27. Massive blood transfusion
Decrease in 2,3-DPG
 left shift of O2-Hb dissociation curve
 increase affinity of Hb for oxygen
Citrate intoxication: reduced in ionized Ca2+
Hyperkalemia
Metabolic acidosis

28. Question??