Blood Components Therapy &Transfusion Reactions Dr. Muhammad Asim Rana MBBS, MRCP(UK), FCCP, SF-CCM , EDIC Critical Care Medicine

One evening duty in ICU• Bed no 1 is a 68 yrs old chronic case

for tracheostomy and the Hb% is 8.5• ENT and Ansthesia has demanded Hb

% of 10.0• What will you do?

You will transfuse 2 Unit PRBCsPRBCs Ideal for patients requiring red

cells but not volume replacement. Increase O2 carrying capacity

• Transfusion trigger (HCT<30% ; HB<10g/dl)• 1 Unit increases 3% HCT or 1g/dl• Shelf life =42 d (1-6 ℃)

Case 2 Medical ICU• Bed no 14 Medical ICU, a 35 yrs old

female case of Sickle Cell Anemia has been admitted with chest pain and cough, has anemia Hb% is 6.0, your consultant advised therapeutic exchange.• What will be your plan?

Case 3 Surgical ICU• Bed no 34 surgical ICU, a 25 yrs old male

victim of RTA admitted with severe abdominal injury with ruptured spleen and tear in liver is admitted post OR.• His Hb% pre OR was 3.0 he received 10

PRBCs in OR as he was massively bleeding during surgery• Came hypotensive, hypothermic, oozing from

wounds and active bloody out put from drains• What will be your plan?

Case 3 Surgical ICU• His resuscitation started with PPF,

Hes-steril and PRBCs but his bleeding is not stopped• GS has no plan to re-explore him• His labs showed that he is in severe

DIC• Why?• What is the solution now?

Case 4 Surgical ICU• Bed no 50 surgical ICU, a 55 yrs old

male ESRD on haemodialysis admitted post fixation of his fracture femur. • You found he has a constant ooz from

the incision so that his Hb% dropped to 6.0• What will be your plan?• What is the cause of constant oozing in

this pt?

Case 5 Medical ICU• Bed no 23 a 65 yrs old female, case

of hydrocephalus due to TBM is going for EVD insertion and you see that she has very low platlets around 30,000 (thrombocytopenia)• What will be your plan?• What is the risk in this pt?

Composition of Blood • Consists of formed elements (cells)

suspended & carried in plasma (fluid part)• Total blood volume is about 5L• Plasma is straw-colored liquid

consisting of H20 & dissolved solutes• Includes ions, metabolites, hormones,

antibodies

FFP ( initial therapeutic dose : 10-15 ml/kg ) and used inIsolated factor deficienciesReverse warfarin therapyCorrection of coagulopathy associated with liver diseaseMassive blood transfusion with microvascular bleeding(>1 BV/ 24 hrs or > 50 % BV within 3 hrs or > 150 ml/min)Antithrombin III deficiency

TTP ( Thrombotic thrombocytopenic purpura )

PRBCs Ideal for patients requiring red cells but not volume replacement. Increase O2 carrying capacity

Transfusion trigger (HCT<30% ; HB<10g/dl)1 Unit increases 3% HCT or 1g/dlShelf life =42 d (1-6 ℃)PlateletsThrombocytopenia (< 5,000)Platelet dysfunctionEach unit increase 5,000 PLTs after 1hr

History of blood transfusionChristian Zagado (1665)

Dr. James Blundell, a British obstetrician (1825)

First human blood transfusion

Discovery of ABO typeAustrian Karl Landsteiner 

(1900)

Oswald Hope Robertson US Army Capt 1916

First Blood Bank World War 1

Formed Elements

Erythrocytes (RBCs)• RBCs are flattened biconcave

discs• Shape provides increased surface area for diffusion• Lack nuclei & mitochondria• Each RBC contains 280 million hemoglobins

13-9

Leukocytes• Have nucleus, mitochondria, & amoeboid ability • Granular leukocytes help detoxify foreign substances &

release heparin• Include eosinophils, basophils, & neutrophils

13-10

• Agranular leukocytes are phagocytic & produce antibodies ,Include

lymphocytes & monocytes

Platelets (Thrombocytes)• Are smallest of formed elements,

lack nucleus• Are fragments of megakaryocytes • Constitute most of mass of blood

clots• Release serotonin to vasoconstrict

& reduce blood flow to clot area

• Secrete growth factors to maintain integrity of blood vessel wall

• Survive 5-9 days

13-12

Plasma Proteins • Constitute 7-9% of the plasma• Three types : albumins, globulins, &

fibrinogenAlbumin accounts for 60-80%

• Creates colloid osmotic pressure that draws H20 from interstitial fluid into capillaries to maintain blood volume & pressure

Globulins carry lipids. Gamma globulins are antibodiesFibrinogen serves as clotting factor

Serum is fluid left when blood clots13-8

Type of Transfusions Whole Blood ； Blood Component ； RBC PLT FFP Leukocyte

concentrate Plasma Substitutes ；

Use of whole blood is considered to be waste of resourcesIndications • Acute massive blood loss;• Anaemia and hypoalbuminemia• Overwhelming Infection• Dysfunction of Coagulation;

Approach Route: PVL, CVL Filtration before Transfusion Velocity of Transfusion ： 5-10ml/min Double Check: Name, Type and Cross-

match Storage Time Pre-heat No any other Medication Observation during / after Transfusion

Blood Transfusion

Case 1• The pt of bed 1 is receiving 2 units of PRBCs for

possible tracheostomy. After his 1st unit of blood he developed a temp of 38.3 °C (101.0°F). He has no other symptoms.

On exam he appears anxious but his vital signs are stable with BP 120/70mmHg, HR 80bpm RR18 Sat O2 98% on Room Air

he has no skin rash and his urine color is amber

What is your diagnosis? How would you manage this patient ?

Febrile non hemolytic reaction• Most common, usually benign without sequelae• Concerning because initial presentation is similar to

more adverse reactions. i.e. fever, chills +/- mild dyspnea.

• 15% will have a recurrence in the future with subsequent transfusion

Management

• Discontinue transfusion, rule out hemolysis i.e. check labels, repeat type and cross match, coombs test

• Antipyretics +/- meperidine for chills and rigors• Although antihistamine premedication is widely used

there are no evidence to support that their use actually prevents reaction.

Case scenario 2• A 35-year-old woman with sickle cell disease, she

is receiving 2 units of PRBC. Her 1st unit of blood was transfused without events but 5minutes into her 2nd unit, She complains of new flank pain and fever.

On exam she appears very anxious, diaphoretic and in acute distress, she is febrile to 38.8C with BP 100/60mmHg, HR101/m RR 22/m, Pulse Ox 98% 0n RA

She has no skin rash but is oozing out of IV sites and her urine color is now reddish brown.

Labs: elevated Bun/creat, increased PTT, PT and decreased HCT.

What is the diagnosis and how would you manage this patient?

Acute hemolytic reaction• Medical emergency• Occurs due to rapid transfused RBC destruction

by preformed recipients Abs• Mostly due to ABO incompatibility• Most common causes are clerical or procedural

errors• Complications includes DIC, shock, ARF

secondary to ATNClinical presentation • Classic presenting triad of Fever, flank pain

and reddish brown urine from hemoglobinuria are rarely seen

• DIC may be presenting mode• Positive Direct Coombs

Transfusion Reactions• People with Type A

blood make antibodies to Type B RBCs, but not to Type A

• Type B blood has antibodies to Type A RBCs but not to Type B

• Type AB blood doesn’t have antibodies to A or B

• Type O has antibodies to both Type A & B

• If different blood types are mixed, antibodies will cause mixture to agglutinate

Transfusion Reactions (continued)

• If blood types don't match, recipient’s antibodies agglutinate donor’s RBCs

• Type O is “universal donor” because lacks A & B antigens• Recipient’s antibodies won’t agglutinate donor’s Type O RBCs

• Type AB is “universal recipient” because doesn’t make anti-A or anti-B antibodies•Won’t agglutinate donor’s RBCs

•Insert fig. 13.6

Management1. Stop transfusion, alert blood bank to start

search for clerical error since another patient may be at risk , repeat type and cross matching

2. Supportive care; ABC +/-pressors3. Cardiac monitoring because of risk of

hyperkalemia4. Infuse N/S to maintain BP and promote diuresis,

avoid LR and dextrose because calcium in LR will promote clotting in IV line and dextrose will increase hemolysis. Maintain urine output >100-200ml/hour

5. With DIC early heparinization 10u/kg/hr may be beneficial

Anaphylactic reactionslife threatening emergency

•Occurs within a few seconds to minutes following transfusion•Characterized by rapid onset of anaphylaxis •Can occur with all blood products •Incidence ; 1 in 20-50 thousand•Presence of class specific IgG and anti IgA abs in patients who are IgA deficient•Treatment: Epinephrine , ABC +/- pressor support

Case Scenario 3After 3days of treatment, he had improved however, he developed a cough and a temperature of 38.3°C , with increasing FiO2 requirementO/E, BP is 120/80 mm Hg. There is no rash . he is tachycardic . Oxygen saturation is 80% on FiO2 of 85%, and a blood gas study shows an arterial PO2 of 45 mm Hg. A chest radiograph reveals diffuse opacifications of both lungs. Which of the following is the most likely cause for this patient's reaction?

1. Pulmonary embolism 2. Antileukocyte antibodies 3. Allergy to donor plasma proteins 4. Circulatory overload

Transfusion related acute lung injury (TRALI) • New acute lung injury occurring during or within 6 hour of

blood product transfusion• 1 case for every 1000-2400 units transfused with 6-9%

mortality rate• Abs against HLA

Clinical presentation • Acute onset of respiratory distress (hypoxemia) during or

shortly after blood transfusion.• Fever, tachycardia, tachypnea, +/-hypotension • In intubated pts; elevated peak airway pressures, pink

frothy airway secretion • CXR bilateral patchy alveolar infiltrates, normal cardiac

picture

Management • Mostly supportive with abrupt resolution in symptoms within

a few days• A majority of patients may require mechanical ventilation

Types of ReactionsImmune mediated transfusion reactions• Febrile non hemolytic transfusion reactions• Acute and delayed hemolytic reactions • Anaphylactic transfusion reaction• Urticarial transfusion reaction• Post-transfusion purpura• GVHD • TRALI (Transfusion Related Acute Lung

Injury)

Non immune mediated reactions• Physical reactions: thermal i.e. heat or cold

induced• Infectious; Hepatitis B/C, malaria, HIV, CMV,

West Nile virus• Chemical; citrate toxicity, hypo/hyperkalemia,

iron overload• Acute hypotensive reaction: mediated by

bradykinins and occurs in patients with faulty bradykinin metabolism on ACE I

• Osmotic injury

Conclusion • Transfusion reactions are mostly due to

documentation errors and can range from benign reactions to life threatening emergencies

• Early detection, discontinuation of transfusion and instituting supportive care are key to management.

• Reporting of all reactions helps to improve standard practices and reduce future occurrences.

Thank you Dr. Asim Rana