Blood Transfusion

TRANSFUSION MEDICINE BY DR. C .C . OKAN Y Consultant Physician/Haematologist LUTH

PR INC IPL ES OF BLOOD TRANS FUS ION - B.T. should only be given when the potential benefits clearly outweigh the risks. - Patients for elective surgery should have their anaemias corrected by appropriate means before surgery. - Moderate anaemia is not a contraindication for surgery especially when the surgery is likely to correct the cause of the anaemia - Habit of “topping up” to be condemned. - Hb concentration alone is not enough indicator for need of B.T.

BLOOD COMPONENTS • O2 Carrying Components - Red Cell concentrate - Leucocyte – poor blood - Frozen – thawed red cells • Platelet Products - Platelet rich plasma (PRP) - Platelet concentrate

PLASMA DERIVATIVES • Plasma Products - Fresh frozen plasma - Cryoprecipitate - Stored plasma (X, IX, XII, VII) • Coagulation factor concentrates - factor VIII - factor IX • Oncotic Agents - Albumin

• Immune Serum Globulin - Immune serum globulin(IgG) - Hepatitis B immune globulin - Varicella – zoster immune globulin - Rh immune Globulin - Tetanus Immune globulin - Rabies - Rubella - Hepatitis A.

INDICATIONS FOR TRANSFUSION OF RED CELLS • Anaemia produced by recurrent haemorrhage • Pre-op transfusion • Anaemia discovered late in pregnancy • Chronic anaemia in conditions like leukaemia, aplastic anaemia malignancies, CRF etc.

COMPATIBILITY TESTING • Defined as invitro demonstration of serological compatibility between the prospective recipient’s (patient’s) serum and donor’s red cells. • Types of cross matching - saline at room temperature - saline at 37oC - Albumin at 37oC - Indirect Coomb’s test - with enzyme Papain

SELE CTI ON OF BLO OD FO R TR AN SFUSI ON AC CORD ING TO PAT IENT S AB O G ROUP

Patient Group

Blood for transfusion Blood group when 1st Blood groups1st choice

choice is not available

0

0

-

A

A

0

A with anti – A1

A2

0

B

B

0

AB

AB

A or B (exceptionally 0)

• • • • • •

Complications of blood transfusion Febrile reactions Allergic reactions Circulatory overload immediate Haemolytic reaction delayed Infected blood Transfusion of diseases - Viruses, HBV, HCV, HIV, CMV - Malaria - syphilis - Chagas disease (Trypanosoma cruzi) - Other rare transfusion-transmissible infections e.g. human parvovirus B19, brucellosis, EpsteinBarr virus, toxoplasmosis, infectious mononucloeosis.

Complications of blood transfusion (contd) • • • •

Thrombophlebitis Air embolism Haemosiderosis Complication of massive BT - Cardiac Arrythmias (excessive citrate, low pH, cold blood, hyperkalaemia - bleeding (excess citrate, thrombocytopenia)

CATEGORIES OF ACUTE TRANSFUSION REACTIONS

• Category 1: Mild Reactions Signs symptoms possible cause Localised cutaneous Pruritus Hypersensitvity Reactions (itching) (mild) - Urticaria - Rash

CATEGORIES OF ACUTE TRANSFUSION REACTIONS (CONTD) • Category 2: Moderately Severe Reactions Signs symptoms Possible cause * Flushing * Anxiety * Hypersensitivity * Urtricaria * Pruritus (moderate-severe) * Rigors * Palpitations * Febrile nonhaemolytic * Fever * Mild dyspnoea transfusion reactions: * Restlessness * Headache - Antibodies to WBC, platetlets, * Tachycardia Antibodies to proteins, including IgA - Pyrogens and/or bacteria

CATEGORIES OF ACUTE TRANSFUSION REACTIONS (CONTD) CATEGORY 3: Life Threatening Reactions Signs symptoms Possible cause * Rigor * Anxiety * Acute intravascular * Fever * Chest pain haemolysis * Restlessness * Dyspnoea * Bacterial * Hypotension * Loin/back pain contamination and * Tachycardia * Headache septic shock * Haemoglobinuria * Fluid overload * Unexplained bleeding * Anaphylaxis (DIC)

De layed haemo lytic tra nsfu sion • • • • • • 7.

reactio ns

Sign appears 5-10 days after transfusion Fever Anaemia Jaundice Occasionally haemoglobinuria. Post-transfusion purpura A rare but potentially fatal complication or transfusion of red cells or platelet concentrates, caused by antibodies directed against platelet-specific antigens in the recipient 8. Most commonly seen in female patients. Signs and symptoms • Signs of bleeding • Acute, severe thrombocytopenia 5-10 days after transfusion defined as a platelet count of less than 100 x 20 x 109/L.

MANAGEMENT OF TRANSFUSION REACTIONS Category 1: Mild Reactions 2. Slow the transfusion 3. Administer antihistamine IM (e.g. chlorpheniramine 0.1 mg/kg or equivalent) Category 2: Moderately Severe Reaction • Stop the transfusion, replace the infusion set and keep IV line open with normal saline. • Send blood unit with infusion set, freshly collected urine and new blood sample (1 clotted and 1 anticoagulated) from vein opposite infusion site with appropriate request form to blood bank for laboratory investigations.

MANAGEMENT OF TRANSFUSION REACTIONS (CONTD) 1. Administer antihistamine IM (e.g. chlorpheniramine 0.1mg/kg or equivalent) and oral or rectal antipyretic (e.g. paracetamol 10 mg/kg: 500mg – 1 g in adults). Avoid aspirin in thrombocytopenic patients. 2. Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. broncospasam, stridor).

MANAGEMENT OF TRANSFUSION REACTIONS (CONTD) Category 3: Life-Threatening Reactions 2. Stop the transfusion. Replace the infusion set and keep IV line open with normal saline 3. Infuse normal saline (initially 20-30ml/kg) to maintain systolic BP. If hypotensive, give over 5 minutes and elevate patient’s legs. 4. Maintain airway and give high flow oxygen by mask. 5. Give adrenaline (as 1:1000 solution) 0.01mg/kg body weight by low intramuscular injection.

MANAGEMENT OF TRANSFUSION REACTIONS (CONTD) •

Give IV corticosteriods and bronchodilators if there is anaphylactoid features (e.g. broncospasm, stridor).

•

Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent. Send blood unit with infusion set, fresh urine sample and new blood samples (1 clotted and 1 anticoagulated) from vein opposite infusion site.

•

COMPLICATIONS OF MASSIVE BLOOD TRANSFUSION • Massive transfusion is the replacement of blood loss equivalent to or greater than the patient’s total blood volume in less than 24 hours. • 70 ml /kg in adults. • 80-90 ml/kg in children or infants. Complications • Cardiac abnormalities For the prevention of cardiac complications calcium gluconate (2ml of 10% solution to be given per a unit of blood). • Acidosis To prevent this fresh blood should be given as much as possible.

COMPLICATIONS OF MASSIVE BLOOD TRANSFUSION (CONTD) • Haemostatic failure • Shock lung syndrome (ARDS) The pathogenesis of ARDS is unclear, but direct damage to alveolar lining cells, local DIC, microvascular fluid leakage and emoblisation by microaggregates from stored blood all contribute. • Jaundice

OTHER TYPES OF BLOOD TRANSFUSION 1. Exchange blood transfusion Indications Haemolytic Disease of the New Born Sickle Cell Anaemia - Pre-operative - Severe sequestration crisis - Severe crisis around labour puerperium - CNS infarction - Acute Priapism - Acute chest syndrome Treatment of fulminant Hepatitis or coma Drug poisoning D.I.C in infants

OTHER TYPES OF BLOOD TRANSFUSION (CONTD)

Autologous Blood Transfusion Advantages Types • Salvage autologous B.T • Peri-operative haemodilution • Pre-deposit autologous B.T

PLASMA SUBSTITUTES •

These are colloid and crystalloid solns used for maintaining the circulation volume following acute haemorrhage, shock, burns and septicaemias. Plasma substitutes have no 02 carrying capacity and also lack haemostatic properties. Crystalloids – no oncotic activity Colloids – temporary oncotic activity (short half life)

•

Plasma substitutes are used in emergency to “buy time” necessary for provision of compatible blood and appropriate blood product.

Advantages and Disadvantages Soln Crystalloids

Advantage Readily available Easy storage Easy administration Non-immunogenic Non-toxic Do not inhibit synthesis of albumin

Disadvantage Lack of oncotic pressure in plasma

Colloids

Readily available Easy storage Easy to administer

short halflife in circulation mildly immunogenic may interfer with haemostasis may interfer with grouping and cross-matching may delay replenishment of albumin.

Do no transient disease Provides oncotic pressure Cheap

-

COLLOIDS

Dextrans Polysaccharide fragment (mol wt 40-15,000) stored at room temp shelf life 3-5yrs Side effects - hypotension due to release of vasoactive substances - Circulatory overload - Rarely anaphylactoid reaction - Renal failure (plugging or capillaries by polysaccharide pigments) - Bleeding - Hydroxyethyl starch (derived from a waxy starch mol wt 450,000) Side effects are rare circulatory overload Renal failure Mild bleeding tendency - Gelatin (Haemacel) Side effects – release of vasoactive substances especially if administered rapidly.

CRYSTA LLOID S Normal saline (Na+ Cl-) Ringer’s soln (Na+, K+ Ca++, Cl-) Hartman’s Soln (Na+, K+, Ca++, HCO -)

Artificial blood (synthetic O2 carrying Agents)

Synthetic O2 carrying agents are still experimental Two classes exist Perfluorochemicals Chemically modified haemoglobin

The perfluorochemicals are fluorinated hydrocarbons. They readily dissolve oxygen, but are poorly soluble in plasma. One of these compounds “ fluorosol – DA” has been studied in animals and is currently being studied in humans. Side effects: hypotension and DIC, leucopenia, thrombocytopenia, toxic to macrophages. Free haemaglobin has a very short life. It can be chemically modified to increase its intravascular survival and make it more effective in carrying oxygen.

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