Use of blood productsUse of blood products

Dr Revathi RajDr Revathi Raj

Principles of clinical transfusion Principles of clinical transfusion practicepractice

Transfusion - part of patient’s Transfusion - part of patient’s managementmanagement

National guidelines / individual needs National guidelines / individual needs Minimise blood lossMinimise blood loss Hb value should not be a sole Hb value should not be a sole

consideration for transfusionconsideration for transfusion Clinician takes sole responsibilityClinician takes sole responsibility Record reason for transfusionRecord reason for transfusion Trained person to administerTrained person to administer

Transfusion should be Transfusion should be prescribed prescribed

only when benefits clearly only when benefits clearly outweigh outweigh

the risksthe risks

Packed red cellsPacked red cells

Each unit raises haemoglobin up by 1 Each unit raises haemoglobin up by 1 gmgm

Shelf life 35 daysShelf life 35 days

PlateletPlatelet concentrates concentrates

Shelf life of 4-5 daysShelf life of 4-5 days

ABO compatible if possibleABO compatible if possible

1 unit/10 kg body weight1 unit/10 kg body weight

Apheresis platelets are 6-10 times Apheresis platelets are 6-10 times superiorsuperior

Fresh frozen plasmaFresh frozen plasma

Stored at –25Stored at –25°°C for up to 1 yearC for up to 1 year

No compatibility testing requiredNo compatibility testing required

Replacement of multiple clotting Replacement of multiple clotting factor deficienciesfactor deficiencies

Hypovolaemia alone is not an Hypovolaemia alone is not an indication for useindication for use

Recent advancesRecent advances

Solvent detergent FFP – OctoplasSolvent detergent FFP – Octoplas

Methylene blue FFPMethylene blue FFP

CryoprecipitateCryoprecipitate

Rich in fibrinogen and factor VIIIRich in fibrinogen and factor VIII

Lower volumeLower volume

Increased donor exposureIncreased donor exposure

LeucodepletionLeucodepletion

Removes white cells using a Removes white cells using a filterfilter

Reduces risk of viral Reduces risk of viral transmission and transmission and alloimmunisationalloimmunisation

Red cell and platelet filtersRed cell and platelet filters

IrradiationIrradiation

Kills leucocytesKills leucocytes

Reduces risk of transfusion Reduces risk of transfusion associated graft versus host associated graft versus host diseasedisease

Who is at risk of TAGvHD?Who is at risk of TAGvHD?

Bone marrow transplantation Bone marrow transplantation Congenital immunodeficiency Congenital immunodeficiency Hodgkin’s diseaseHodgkin’s disease FoetusFoetus Related donor transfusionsRelated donor transfusions Fludarabine therapyFludarabine therapy

Factor concentratesFactor concentrates Human albumin solutions 4.5% Human albumin solutions 4.5%

and 20%and 20%

Factors VIII, IX, X, VII, protein C Factors VIII, IX, X, VII, protein C and Sand S

Fractionation and filtrationFractionation and filtration

Virally inactivatedVirally inactivated

Fresh whole bloodFresh whole blood – fact and fancy – fact and fancy

No viable plateletsNo viable platelets

Reduced levels of clotting factors Reduced levels of clotting factors like like

IX, VIII and VIX, VIII and V

Plasma transmits most of the Plasma transmits most of the infections in whole blood / immune infections in whole blood / immune complicationscomplications

Fresh whole bloodFresh whole blood- current indications- current indications

Exchange transfusion in newbornExchange transfusion in newborn

Advanced renal or liver disordersAdvanced renal or liver disorders

RCTRCT

• A multicentre, randomised, controlled A multicentre, randomised, controlled clinical trial of transfusion requirements clinical trial of transfusion requirements in critical care.in critical care.

Transfusion Requirements in Critical Care Transfusion Requirements in Critical Care Investigators,Canadian Critical Care Trials Investigators,Canadian Critical Care Trials Group.Group.

Critical Care Program, University of Ottawa, ON, Critical Care Program, University of Ottawa, ON, CanadaCanada..

838 critically ill patients838 critically ill patients

Hb 7 or 9 gmHb 7 or 9 gm

30 day mortality lower in 30 day mortality lower in transfusion restricted patientstransfusion restricted patients

• A restrictive strategy of red-A restrictive strategy of red-cell transfusion cell transfusion is at least as is at least as effective as and possibly effective as and possibly superiorsuperior toto a liberal a liberal transfusion strategy in transfusion strategy in critically ill patients, with the critically ill patients, with the possible exception of patients possible exception of patients with acute myocardial with acute myocardial infarction and unstable angina.infarction and unstable angina.

Acute transfusion reactionsAcute transfusion reactions

Acute haemolytic transfusion Acute haemolytic transfusion reactionreaction

Infusion of a bacterially Infusion of a bacterially contaminated unitcontaminated unit

Transfusion- associated lung injuryTransfusion- associated lung injury

Severe allergic reactionSevere allergic reaction

Acute haemolytic transfusion Acute haemolytic transfusion reactionreaction

Feeling of apprehensionFeeling of apprehension AgitationAgitation FlushingFlushing Pain at venepuncture sitesPain at venepuncture sites Pain abdomen / flank or chestPain abdomen / flank or chest

Acute haemolytic transfusion Acute haemolytic transfusion reaction…reaction…

FeverFever HypotensionHypotension Generalised oozing from Generalised oozing from

puncture sitespuncture sites HaemoglobinaemiaHaemoglobinaemia HaemoglobinuriaHaemoglobinuria

ManagementManagement

Stop transfusionStop transfusion Check vitalsCheck vitals Preserve unit of bloodPreserve unit of blood Take blood cultures / repeat group / Take blood cultures / repeat group /

crossmatch / cbc / coagscreen / crossmatch / cbc / coagscreen / biochem / ldh / urinalysisbiochem / ldh / urinalysis

IV saline infusionIV saline infusion Keep urine output > 100 ml/hourKeep urine output > 100 ml/hour DIC managed with appropriate DIC managed with appropriate

componentscomponents

Bacterial contaminationBacterial contamination Fever>1.5 C from baselineFever>1.5 C from baseline

Sustained hypotensionSustained hypotension

FluidsFluids

Broad spectrum antibioticsBroad spectrum antibiotics

FFP / platelets guided by coag screenFFP / platelets guided by coag screen

Severe allergic reactionSevere allergic reaction

OxygenOxygen ChlorpheniramineChlorpheniramine HydrocortisoneHydrocortisone AdrenalineAdrenaline Salbutamol nebsSalbutamol nebs Suspect IGA deficiencySuspect IGA deficiency

TRALITRALI

Clinical PictureClinical Picture

Noncardiogenic pulmonary edemaNoncardiogenic pulmonary edema Dyspnea, cyanosis, hypotension, Dyspnea, cyanosis, hypotension,

fever, chillsfever, chills Develops within 1-2 hours of Develops within 1-2 hours of

transfusion. Usually present by 4-6 transfusion. Usually present by 4-6 hourshours

Difficult to distinguish from Acute Difficult to distinguish from Acute Respiratory Distress SyndromeRespiratory Distress Syndrome

TRALI…TRALI…

AetiologyAetiology

Antibodies against granulocyte, HLA Antibodies against granulocyte, HLA class I or class II antigensclass I or class II antigens

Biologically active lipids in stored Biologically active lipids in stored cellular blood componentscellular blood components

Pulmonary oedema arises from capillary Pulmonary oedema arises from capillary injury rather than volume overloadinjury rather than volume overload

TRALI…TRALI…

InvestigationsInvestigations

Hypoxaemia with respiratory alkalosisHypoxaemia with respiratory alkalosis

Bilateral pulmonary infiltrates Bilateral pulmonary infiltrates persisting for 7 days at leastpersisting for 7 days at least

No fluid overload / cardiacNo fluid overload / cardiac compromisecompromise

TRALI…TRALI…

TreatmentTreatment

Supportive ventilatory assistanceSupportive ventilatory assistance

Maintenance of haemodynamic status Maintenance of haemodynamic status (e.g., saline infusion) (e.g., saline infusion)

Diuretics are contraindicatedDiuretics are contraindicated

Other complicationsOther complications

Delayed haemolytic transfusion Delayed haemolytic transfusion reactionreaction

Post transfusion purpuraPost transfusion purpura

Transfusion associated graft Transfusion associated graft versus host diseaseversus host disease

HOW CAN WE HELP?HOW CAN WE HELP?HOW CAN WE HELP?HOW CAN WE HELP?

EducationEducation Avoid unnecessary transfusionsAvoid unnecessary transfusions Dedicated multiple satellite packsDedicated multiple satellite packs Avoid using first time donors for Avoid using first time donors for

transfusing infantstransfusing infants Salvage techniquesSalvage techniques Autologous predepositAutologous predeposit Recombinant erythropoietinRecombinant erythropoietin Blood substitutesBlood substitutes

Case 1Case 1

26 year old primip, bleeding 26 year old primip, bleeding profusely post partumprofusely post partum

Tachycardic, BP 80/40, consciousTachycardic, BP 80/40, conscious Labs Hb 5.4, WBC 16,000, Platelets Labs Hb 5.4, WBC 16,000, Platelets

150,000150,000

Case 2Case 2

20 year old student20 year old student Drowsy, febrile, extensive petechiae Drowsy, febrile, extensive petechiae

after a brief illnessafter a brief illness Hb 8.2, WBC 6000, platelets < 5000, Hb 8.2, WBC 6000, platelets < 5000,

PT,PTT,Fibrinogen normal, creatinine PT,PTT,Fibrinogen normal, creatinine 1.81.8

Peripheral smearPeripheral smear

Case 3Case 3

32 year old male32 year old male Admitted with suspected dengue Admitted with suspected dengue

feverfever Hb 17, WCC 3100, Platelets 12,000, Hb 17, WCC 3100, Platelets 12,000,

extensive petechiae, PT 13/13, PTT extensive petechiae, PT 13/13, PTT 49/3749/37

What do we do?What do we do?

Thank youThank you