Blood Transfusion

IIN NOVITA NURHIDAYATI MAHMUDA

FK UMS
RS PKU MUHAMMADIYAH SURAKARTA
Introduction

 Blood Transfusion is not without hazards

 you should weigh the risk against benefit
 use of right products to the right patient at
the right time
 Donor Patient

The risks associated with transfusion can be reduced by:

- Effective blood donor selection.
- Screening for TTI in the blood donor population.
high quality blood grouping, compatibility testing.
- Component separation and storage.
- Appropriate clinical use of blood and blood
products.
- Quality assurance
 Pre-Transfusion Testing
BLOOD TYPING: •
ABO –
(Other antigens are weak immunogens)
ANTIBODY SCREEN: •
Patient serum vs. cell panel –
CROSSMATCH •
Major: Patient Serum vs. Donor Cells –
 Platelets 2nd centrifugation Platelets
rich
concentrate
Whole
Whole plasma
blood
blood
1stcentrifugation
FFP for
clinical use
Red
Fresh plasma FFP for
Cell fractionation
concentrate

Optimal additive
Cryoprecipitate
solution

Red cells in
OAS
ABO Selection of Blood Components

Patient ABO Type RBCs, Platelets Plasma & Cryoprecipitate

O O O, A, B, AB

A A,O A,AB

B B,O B,AB

AB AB,A,B,O AB
Principles of Clinical Transfusion
Practices
 Avoid blood transfusion
 Transfusion is only one part of the
patient’s management.
 Prevention and early diagnosis and
treatment of Anemia & underlying
condition
 Use of alternative to transfusion.
eg. IV fluids
 Good anesthetic and surgical
management to minimized blood loss.
– Prescribing should be based on
national guidelines on the clinical use
of blood taking individual patient
needs into account.

– Hb level should not be the sole

deciding Factor Clinical evaluation is
important
– Consent form to be obtained from the patient
before transfusion.

– The clinician should record the reason for

transfusion clearly.

– A trained person should monitor the

transfused patient and if any adverse effects
occur respond immediately.
 Informed consent
• Patient should be informed that transfusion
of blood or blood component is a possible
element of the planned medical or surgical
intervention
• patient should be informed about the risks,
benefits and available alternative
• Consent form is a doctor responsibility
TO TRANSFUSE BLOOD

WHEN

NECESSARY
 Triggers of Component
Transfusion
• The lowest threshold for transfusion of
components are:
• Hb level of 6-7g/dl.
• FFP threshold PT & PTT 1.5 times the
upper limit of the normal range.
• Platelet threshold of:
10 000/µl- 20 000/µl for prophylactic
transfusion.
Consider: Clinical judgment
Invasive or surgical procedures:

• 20 000/µl for Biopsy

• 50 000/µl for surgery

100 000/µl for surgery to brain or eye.

American Society of clinical Oncology guidline,1996&2001.

Williamson LM. Transfusion Trigger in the UK. Vox sang
2002.
AABB Technical Manual 14th ed, 2002.
 Administration of blood
components
Pretransfusion :
Recipient identification: The name and identification
number on the patient’s identification band must
be identical with the name and number attached to
the unit.

Unit identification: The unit identification number on

the blood container, the transfusion form, and the
tag attached to the unit (if not the same as the
latter) must agree.
Guidelines for blood component therapy

Haemoglobin
(Hb) trigger for Indications NB: Hb should not be the sole deciding factor for
transfusion transfusion.

If there are signs or symptoms of impaired oxygen transport

Lower thresholds may be acceptable in patients without symptoms

< 7 g/dL
and/or where specific therapy is available e.g. sickle cell disease or iron
deficiency anemia

< 7 – 8 g/dL Preoperative and for surgery associated with major blood loss.

In a patient on chronic transfusion regimen or during marrow

suppressive therapy.
< 9 g/dL May be appropriate to control anaemia-related symptoms.

< 10 g/dL Not likely to be appropriate unless there are specific indications.
 Acute blood loss >30-40% of total blood volume.
Guidelines for Transfusion of RBCs in Patients Less than 4
Months of Age:
1. Hemoglobin <7 g/dL with low reticulocyte count and symptoms of anemia

2. Hemoglobin <10 g/dL with an infant

On <35% hood O2

On O2 by nasal cannula
On continuous positive airway pressure (CPAP)/intermittent mandatory
ventilation (IMV) with mechanical ventilation with mean airway pressure <6
cm H2O
Significant apnea or bradycardia
Significant tachycardia or tachypnea
Low weight gain

3. Hemoglobin <12 g/dL with an infant

On >35% hood O2

On CPAP/IMV with mean airway pressure 6 to 8 cm H2O

4. Hemoglobin <15 g/dL with an infant

On extracorporeal membrane oxygenation (ECMO)

Congenital cyanotic heart disease
Platelet Count
trigger for Indications
transfusion

< 10 x 109/L As prophylaxis in bone marrow failure.

Bone marrow failure in presence of additional risk factors: fever, antibiotics,

< 20 x 109/L evidence of systemic haemostatic failure.

Massive haemorrhage or transfusion.

In patients undergoing surgery or invasive procedures.
< 50 x 109/L Diffuse microvascular bleeding-DIC

Brain or eye surgery.

< 100 x 109/L

Appropriate when thrombocytopenia is considered a major contributory factor.

Any Bleeding Patient

In inherited or acquired qualitative platelete function disorders, depending on

clinical features & setting.
Any platelet count
FFP trigger for
transfusion Indications

Multiple coagulation deficiencies associated with acute DIC.

Inherited deficiencies of coagulation inhibitors in patients undergoing high-
risk procedures where a specific factor concentrate is unavailable.
Thrombotic thrombocytopenia purpura (plasma exchange is preferred)
Replacement of single factor deficiencies where a specific or combined
PT & PTT are more factor concentrates is unavailable.
than 1.5 times the Immediate reversal of warfarin effect in the presence or potentially life-
upper limit of normal threatening bleeding when used in addition to Vitamin K & / or Factor
range Concentrate (Prothrombin concentrate)
The presence of bleeding and abnormal coagulation parameters following
massive transfusion or cardiac bypass surgery or in patients with liver
disease

Cryoprecipitate
trigger for Indications
transfusion
Fibrinogen< 1gm/L Congenital or acquired fibrinogen deficiency including DIC.
Hemophilia A, von Willebrand disease (if the concentrate is not available).
Factor XIII deficiency.
 1. transfusion dependent patients
2. Bone marrow transplant candidates – either autologous / peripheral
blood stem cell transplants (PBSCT) or allogeneic bone marrow
Guidelines for transplants
routine blood
3. may be for Patients undergoing intensive chemotherapy regimens
leucodepletion
4. Previous repeated febrile reactions to red blood cells

Guidelines for 1.Intrauterine transfusion (IUT) and neonates received IUT.

blood Irradiation 2.One week prior to stem cell collection, and for 12 months post
(to prevent autografting or allografting.
3.Hodgkin’s disease
TAGVHD) 4.Treatment with purine analogues (fludarabine, 2-CdA,
deoxycofomycin)
5.Aplastic anaemia within 6 months of ATG treatment
6.Products obtained from close relatives or HLA matched donors.
7.Immunodeficiency patients: congenital or acquired
 Incompatible Blood Transfusion
Clinical Setting
A patient, lacking compatible blood, experiencing
life- threatening, rapid blood loss or hemolysis, in
whom the need for blood replacement is
immediate or urgent.
If there is evidence of a transfusion reaction
•Symptoms include fever, pain, apprehension, chills, sweating,
tachycardia, or fall in blood pressure.
•STOP the transfusion immediately, maintaining the IV with 0.9%
saline.
•Document vital signs at least every 15 minutes throughout the
reaction.
 Nonhemolytic Transfusion Reactions

Leukocyte Associated • Metabolic/ Physical •

FNHTR – Citrate Toxicity –
Transfusion GVHD – Hypothermia –
Neonatal Neutropenia – Circulatory Overload –
Immunoglobulin Associated • Massive Transfusions •
Urticaria/Fever – Haemostatic Abnormalities –
Ig E – Metabolic complications –
TRALI – Hgb-O2 Curve Shift –
Platelet Associated •
Post transfusion Purpura –
Neonatal Thrombocytopenia –
TRANSFUSION-RELATED INFECTION
 Risk of Transfusion-
Transmitted Infection
1 in 2,000,000 HIV
1 in 2,000,000 Hepatitis C
1 in 175,000 Hepatitis B
Rare Hepatitis A
1 in 3,000,000 HTLV I/II
1/3,000 (for platelets) Bacteria

Malaria, T Cruzi, Babesia, Yersinia,

Syphilis, Lyme, CJD, West Nile Virus…??
 Post Transfusion HCV
Number Percent

150-300,000 5-10 Incidence

75-150,000 50 Chronic
15-30,000 20 Cirrhosis
 Blood Transfusion - Acute Complications I
Complication Cause
Acute Intravascular ABO incompatibility
haemolysis (Commonest cause is administrative!)
Febrile Non-haemolytic Anti –Leucocyte Ig or
reactions Cytokines in platelet transfusions
Commonest in patients receiving
multiple transfusions or
previously pregnant
Urticaria Transfusion contains plasma proteins
or allergens causing an acute IgE
mediated allergic response
Occurs with plasma and platelet
rather than red cell transfusions.
Infective shock Bacterial contamination of transfused
blood
Anaphylaxis Anti-IgA antibodies ?others
Patients are often IgA deficient as
well!
Incidence / Likely timing with
regard transfusion
1:6x105
Occurs within a few mls of
starting transfusion
(Mortality 10%)
Becoming rarer because of
leucocyte depletion in many
transfusion practices.
Occurs towards the end of or up to
hours after transfusion
1 – 2% of all transfusions
Peri-transfusion
May occur recurrently
Rare; 1:5x 105
First 100mls of blood – ie early
Often fatal!
Extremely rare
Treatment
Shouldn’t happen!
STOP THE BLOOD!
Supportive treatment
Treat complications – ARF and
DIC
Unpleasant – but not life
threatening
Paracetamol and cooling.
Unpleasant – but not life
threatening
Anti-histamines –
(can be given prophylactically
in known patients)
That of Septicaemia and shock
– fluids, IV antibiotics
Life threatening
A.B.C / Crash team call
IV / IM adrenaline, steroids,
aHistamines, Oxygen
Nebulisers.
 Blood Transfusion – Delayed Complications
Complication
Delayed Red cell haemolysis
Transfusion associated Graft
versus Host disease
(TA-GvHD)
Post Transfusion Purpura
Post Transfusion Viral
Infection
Iron overload
Cause
Recipient IgG vs Red cell
antigens
Occurs in previously
transfused or pregnant
patients; Initial cross match
will not contain IgG but
subsequent cross matches
should!
Immune mediated donor T-
cell reaction (often occurs in
immunodeficient patients)
Fever, Rash, MOF,
Pancytopaenia
Anti-Platelet antibodies
(usually aHPA-1a)
Immune medicated TCP
Primarily during pregnancy
Virus (and other infective
agents e.g. prions) undetected
by UK screening system
Multiple transfusions
One unit of blood contains
250mg of iron
Incidence / Timing
5 – 10 days after transfusion
<1:500 red cell transfusions
Rare 1:750,000 units of
cellular blood components
transfused
4 – 30 days after transfusion
RHS Rare
5 -10 days after transfusion
Often severe TCP causing
bleeding
HIV <1: 3x 106
HBV and HCV < 1: 2 x 105
Only occurs after several
years of blood transfusions
e.g. Chronic haemolytic
disease
Treatment
No treatment per se but
Patient will receive less
benefit from
transfusion and once
present they will
cause problems for
future transfusions
Usually fatal!
Haematology specialist care
required
In susceptible recipients –
blood is subjected to Gamma
irradiation
Use HPA-1a negative red cell
and platelet transfusions or
LDBlood
High dose IV
Immunoglobulins for 5 days
0.4g / kg
Counselling and specialist
advice required
Desferrioxamine – increases
iron excretion
 ALTERNATIVES TO BLOOD
TRANSFUSION

CRYSTALLOID SOLUTIONS

COLLOID SLOUTIONS

DRUGS: DDAVP

BLOOD SUBSTITUTES: EPO

 AUTOLOGUS BLOOD TRANSFUSION

1- Preoperative Collection (PAD)

2-Acute normovolemic haemodilution (ANH).

3- Red Cell salvage

Table 1. Autologous Blood Donation
Advantages:
1. Prevents transfusion-transmitted
disease.
2. Prevents red cell
alloimmunization.
3. Supplements the blood supply.
4. Provides compatible blood for
patients with alloantibodies.
5. Prevents some adverse
transfusion reaction.
6. Provides reassurance to patients
concerned about blood risks.
7. Is acceptable to many Jehovah’s
witnesses.
Disadvantages:
1. Does not affect risk of bacterial
Contamination.
2. Does not affect risk of ABO
incompatibility
3. Is more costly than allogenic blood.
4. Results in wastage of blood not
transfused.
5. Increase prevalence of adverse
reactions to autologous donation.
6. Can subject patients to
perioperative anaemia and increased
likelihood of transfusion.