1. Transfusion Trends In Surgical Patients
Dr. Hanan AL-Awadhi (FRCPc)
Hematology Unit
Farwaniya Hospital

2. Lecture Overview Compatibility testing. Selecting compatible RBCs.
RBCs transfusion triggers.
Platelet transfusion.
Transfusion of plasma and components.

3. Compatibility Testing
Group and screen.
Cross-match.

5. Compatibility Testing..Grouping
Determination of recipient blood group
ABO and RhD
Use recipient RBC (forward testing)
Use recipient plasma (reverse)

6. 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 3%
Rhesus group D positive
Normally none
Should be RhD identical, RhD
-ve acceptable
85%
Rhesus group D negative
Should be RhD identical
15%

7. Compatibility Testing…Screening
The recipient plasma is tested for unexpected red cell antibodies using screening cells
Antibodies due to prior transfusion or previous pregnancy

8. Selecting 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

9. Selecting 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

10. Compatibility 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 mints needed for full x-match.

11. Emergency Blood Release
The clinician must weigh the risk of transfusing uncrossed matched or partially X-matched blood against the risk of delaying transfusion.

12. Degree Of Urgency Desperate blood release
Blood 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

13. Degree Of Urgency Blood needed in 10-30 minutes
The blood will be group specific not fully X-matched
Provided the patient blood sample is delivered

14. Degree Of Urgency Blood needed with in 45 minutes
Fully matched blood will be provided
Please note that delay can occur if:
Antibodies are detected
Problems in X-match
Blood is not available in local BB

15. Transfusion Of RBCs

16. Indications For Red Cell Transfusion
Acute blood loss
Anemia in the critically ill
Perioperative transfusion
Chronic anemia

17. Transfusion in Acute Blood Loss
Maintain Hb over 70 g/L during active bleeding
Anticipate need when Hb drops to 80 g/L

18. Transfusion in Acute Blood Loss
Consider maintaining higher level ( g/L) with:
Impaired pulmonary function
Unstable coronary disease
Atherosclerosis
Uncontrolled bleeding
Patients with levels above 100 g/L are unlikely to benefit

19. Transfusion in the Critically Ill
Patients needs immediate requirement for any form of organ support (intubation, ventilation, inotropes).
Hemoglobin trigger recommended for transfusion is < 70g/L.

20. Transfusion 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.

21. Randomized 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

22. 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.

23. Transfusion In The Perioperative Patient
Pre-operatively
Consider alternatives in advance (at least 5 weeks) of surgery to allow planning
Intra-operatively
Meticulous attention to surgical technique
Post-operatively
Adhere to good transfusion practice, minimize blood taking for laboratory tests

25. Transfusion 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

26. Platelet Transfusion

27. Platelets 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

28. Platelets – Storage & Transfusion
Shelf life 5 days
Stored at 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

29. Platelets 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

30. When To Give Platelets?

31. ITP
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.

32. Non-Immune Thrombocytopenia
Platelet transfusion support is required when the platelet count falls below 10x109/L.

33. Non-immune Thrombocytopenia AND Fever Greater than 38
Non-immune Thrombocytopenia AND Fever 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/OR INR > 1.5

34. Procedures Not Associated with 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.

35. Procedures Associated with Major Blood Loss 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.

36. Platelet Dysfunction and Marked 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.

37. Fresh Frozen Plasma

38. Fresh 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

39. FFP 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

40. Reversal of Warfarin Anticoagulant Effect
FFP for the emergency reversal of warfarin anticoagulant effect:
Patients with insufficient time (less than 6 hours) for reversal by vitamin K AND
Patient about to undergo an emergency operative procedure OR
With potentially life-threatening bleeding.

41. Think 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 hours.

42. Bleeding Patient With Impaired Coagulation Function
Actively bleeding and INR/PTT greater than 1.5x normal
Frozen plasma in a dose of 10-15mL/Kg ( mL) 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

43. Microvascular Bleeding/Massive Transfusion
Massive rapid transfusion and/or microvascular bleeding

44. Use of Cryoprecipitate

45. Clinical Use of Cryoprecipitate
Must be ABO compatible, Rh not important.
Treatment of massive or microvascular bleeding with Fibrinogen < 1.0 g/L

46. Cryoprecipitate Hereditary Disorders of Hemostasis
For 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

47. Cryoprecipitate
Dose
1 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 minutes per dose (maximum infusion time 4 hours).
Half-life of fibrinogen is about 7 days.

48. Final Thought…
As beneficial as transfusion may seem to have zero transfusion risks is impossible.

49. Thank you…