transfusion and complication - srinakharinwirot university · 2019-01-15 · transfusion and...
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Transfusion and complication
Nisa Makruasi, MDDivision of Hematology, Department of Medicine,
HRH Princess Maha Chakri Sirindhon Medical Center,Srinakharinwirot University
Outlines
• Blood components• Transfusion reaction• Compatibility test• Special case: AIHA, massive
transfusion, bleeding case, DIC, thalassemia, hemophilia
Whole blood
• Cellular component– Red cells: PRC, LPB, LD-PRC– Platelets: random platelets, LPPC, SDP– Buffy coats
• Plasma component: FFP– FFP, Cryoprecipitate, Cryo-removed– Plasma Plasma fractionation: Factor VIII
concentrate, Prothrombin complex concentrate, Immunoglobulins, Albumin, etc...
Fresh whole blood
• No valid indications for transfusionif blood components are available
• Should be interpreted by Blood Bankwhich components is needed ?
Fresh whole blood
v450 ml or 350 ml vVolume 500 ml.( rbc, wbc, plt, plasma),
Hct ~40%, shelf life at 2–6oC• CPD 21 days, CPDA–1 35 days, AS 42 daysvIndication: loss of both rbc mass and plasma
volume (active bleeding, exchange transfusion, surgery)
• Contraindication: severe chronic anemia
PRCv Volume 250 – 300 ml, rbc, wbc, platelet,
reduced plasma, Hematocrit < 80%• Shelf life at 2 – 6oC, closed system (same as WB),
open system (24 hrs)v Indication
vLoss of rbc mass: bone marrow production, rbc survival, bleeding
v acute or chronic symptomatic anemiav Contraindication: CRF, nutritional anemia (IDA),
should not be used to (enhance general well – being, promote wound healing, prevent infection, prevent future anemia, expand blood volume)
Evaluation of WB, PRC
by repeat Hb / Hct after 4 hrs. of transfusion
• Hb increment ~ 1 gm / bag
• Hct increment ~ 3% / bag
Leukocyte depletion
•LD-PRC: WBC <1 x 106 per unit by count or <5 X 106 per unit (USA)
•LPB or LPRC: WBC < <5x108 per unit by count
Indication for red cells : Leukocyte reduced• Prevention of allo-immunization to leukocytes and
platelets ( 5x106 leukocytes)
– Platelet Refractoriness
– NHFTR
• Prevention of transmission of CMV ( 5x106
leukocytes)
• Treatment( Not prevention) of patients with multiple febrile transfusion reactions ( 5x108
leukocytes)
• Prevention of immunomodulatory effects of transfusion
LPB or LPRC
• Prepared by centrifugation• Wbc removal 70 – 80%, rbc recovery 80%• Volume 200 – 350 ml, reduced rbc, wbc,
platelet and plasma• Hematocrit < 80%, wbc <5x108 cells/bag• Shelf life same as WB, PRC
Triggers for transfusion of RBCs at our institution
• Hb < 7 g/dL >>>>non bleeding medical and surgical inpatints
• Hb <8 g/gL >>>>Inpatients with active acute coronary syndrome
• Hb < 10 g/dL >>>>Inpatients being treated for sepsis during the first 6 hours of resuscitation
LD-PRC
• Prepared by filtration• Wbc removal >99%, plt. Removal >95%, rbc
recovery >85% • Volume: LP–WB 450 ml, LP–PRC 200 – 350 ml.v Wbc <5x106 cells/bagv Shelf life: same as LPB
Platelet transfusion
• Random platelet: > 5.5x1010 cells/bag• LPPC ( Leukocyte pool platelet concentration) 1
unit from 4-5 donor, 150-250 mL/unit• SDP: >3x1011
• Indication: bleeding in thrombocytopenia, prophylaxis in thrombocytopenia undergoingsurgery and chemotherapy, platelet dysfunction with thrombocytopenia
• Contraindication: TTP, HIT
SDP
• Advantage– Reduce donor exposure
• Disadvantage– High cost
Platelet concentration (PC)
vPrepared by centrifugation volume vfew wbc, rbc, pH >6.2, > 5.5x1010 cells/bagvshelf life 5 days at 22+2oC platelet incubator
with gentle agitationvIndication: bleeding in thrombocytopenia,
prophylaxis in thrombocytopenia undergoingsurgery and chemotherapy, platelet dysfunction with thrombocytopenia
Single donor plateletpheresis (SDP)
• prepared by blood cell separator• volume 250 – 350 ml, platelet >3x1011
cells/bag, pH >6.2, shelf life same as random PC
• Indication: same as PC, patient with platelet antibodies, patient undergoing BMT
Relationship of Platelet Count to bleedingin Thrombocytopenia
due to Decreased Platelet Production
> 50,000 / ml Bleeding unlikely caused byplatelets
10,000 – 50,000 / ml Increased risks of bleedingduring trauma, surgery,ulceration in GI tract etc.
5,000 – 10,000 / ml Increased risks of spontaneousbleeding
< 5,000 / ml High risks of spontaneousbleedingSevere life–threatening bleeding
Indication for platelet treatment
• Platelet <50,000 + severe bleeding (hemoptysis, GI bleeding, hematuria, retinal hemorrhage, CNS or spinal hemorrhage)
• Bleeding per gum or severe epistaxis cause anemia
Platelet transfusionv ABO
§ group specific§ compatible
Ø PC “AB” to A / B patientsØ PC “O” to A / B patients
§ not considered (plasma volume 20 ml / bag)v Rh (D)
§ Rh negative patients should receiveRh negative PC
§ if Rh positive platelets are given to Rhnegative patients, RhIG should be given
§ a dose of 300 mg RhIG can protect rbcfrom 30 bags of PC, 3 bags of SDP
20
v no RhIG given when D-positive blood is givento D–negative patient(life – saving condition)
v crossmatching is not requiredEXCEPT :
HLA-Ab and / or Ab to HPA are developedHLA – Human Leukocyte AntigenHPA – Human Platelet Antigen
v DOSE 10 kg / bagv platelet increment 5,000 – 10,000 / ml / bag
21
v pooled PC should be transfused within 4 hrs.(kept at 20 – 24oC with gentle agitation inplatelet incubator)
v use fresh standard blood administration setspecial platelet infusion sets
v infuse over a period of about 30 mins.
v evaluation of platelet transfusion
§ clinical bleeding 30 – 60 mins.
§ PRE and POST platelet count... 1 hr, 24 hrs.
v No increment at 1 hr. ... platelet antibody?
Corrected count increment (CCI)
• CCx=<(Post-tx plt ct) – (pre-tx plt ct)> *BSAPlatelets transfused
• PC 6 X 1010 , SDP 3 X 1011
• If CCI > 7.5 to 10 X 109 /L from a sample drawn 10 minutes to 1 hr after transfusion or
• CCI > 4.5 X 109 /L from a sample drawn 18-24 hrs after transfusion
• >>>acceptable (not indicative of refractoriness)
Causes of platelet refractoriness
v platelet alloantibodies (HLA / HPA / ABO)v platelet autoantibodiesv active bleedingv fever / sepsis / DIC / splenomegalyv drug – dependent platelet antibodiesv immune complex : TTPv Allogeneic transplantation
FFPv volume 150 – 300 ml.due to preparation
method, all coagulation factors, Factor VIII :C > 0.7 IU/ml, no platelets
v shelf life at < -18oC, 1 year thawed FFP at 37oC, shelf life 24 hrs, NO REFROZEN
v Indication: abnormal PT, APTT, multiplecoagulation factors deficiencies ( liver disease, massive transfusion, DIC, etc.), Hemophilia?
• Dose 10-20 ml/kg, no cross matching, ABO identical / compatible (Rh – any), Ab screening in plasma
•
Fresh Frozen Plasma (FFP)
Coagulation FactorFibrinogenProthrombinFactor VFactor VIIFactor VIIIFactor IXFactor XFactor XIFactor XIIIvon Willebrand factors
Concentration Half–life (hrs.)
200 – 450 mg/dl~ 1 IU/ml“----------”“----------”“----------”“----------”“----------”“----------”“----------”“----------”
100 – 15050 – 8012 – 24
61224
30 – 6040 – 80
150 – 30024
Contraindication
vprophylactic use in cardiac surgery vvolume expansionv nutritional supportv formula treatmentv increased PT, PTT alone without bleedingv enhancement of wound healing
Triggers for transfusion of FFP
• INR > 1.5 Neurosurgical patients• INR > 2.0 Patients who will undergo
invasive procedure• Undefined Trauma patients who are
receiving trauma-associated transfusion algorithm
Cryoprecipitate• Factor VIII, Factor XIII, VWF, Fibrinogen,Fibronectin• volume 5 – 10 ml, Factor VIII : C > 80 IU/bag,
Fibrinogen 150 – 250 mg/bag, Factor XIII, vWFother protein
• shelf life at < -18oC 1 year, thawed and pooledcryo, kept at 20 –24oC for 4 hrs.
• Indication: source of Factor VIII ( Hemophilia A, vWD),source of Fibrinogen (obstetric cases, hypofibrinogenemia), source of vWF ( platelet dysfunction), fibrin glue ( cryo : fibrinogen, human thrombi)
CPP
vDosev Factor VIII-depends on severity,v Fibrinogen -10 bagsv vWF - 10 bags
v use immediately after thawing and poolingv kept at 20 – 24oC for 4 hoursv ABO group is not considered
Cryo-removed
• Plasma ทเหลอจากการแยกตะกอนโปรตน CPP ออกไปแลว• Indication: multiple coagulation factors
ทไมตองการ factor VIII, fibrinogen, V• ความเสยงตอโรคตดเชอ การเกบรกษา ขนาดและวธการให
เชนเดยวกบ FFP
Component
Whole Blood
Packed Red Cells
Leukocyte Reduced(filtration)
(centrifugation)
Platelet Concentrate
Cryoprecipitate
FFP
Volume(ml)
450 + 10%
45 – 65
Hematocrit(%)
< 80
Specifications
100% of unit tested
100% of unit tested
95% of unit tested– retained 85% of original rbc– wbc < 5 x 106 per bag
wbc < 5 x 108 per bag
90% of unit tested– platelet > 5.5 x 1010 per bag– pH > 6.2
100% of unit tested– Factor VIII > 80 IU / bag– Fibrinogen > 150 mg / bag
Factor VIII 0.7 – 1.0 IU / bag
Q.C. of Blood Component
Irradiated blood
• Prevent t-GVHD – Aim of irradiating blood components:
inactivate lymphocytes while causing little or no damage to other blood cells
– onset of TA–GVHD is typically 3 – 30 days after transfusion
– high mortarity rate: infection, hemorrhage– treatment is always ineffective
Compatibility test
Series of pre-transfusion tests• ABO grouping• Rh D typing• Antibody screening test• crossmatching
ABO grouping
• Do cell grouping and serum grouping• Verify ABO group: check previous record or test
cell grouping again
group cell grouping serum groupingAnti-A Anti-B A cells B cells O cells
A + - - + -B - + + - -AB + + - - -O - - + + -
Aag
BagAag Bag
Anti-BAnti-A
Anti-BAnti-A
Rh D typing
• Test for presence of D antigen
• D positive : Rh D positive • D negative : Rh D negative
Rh D antigen : potent immunogenicity•People who don’t have D antigen receive blood transfusion, or pregnancyà may produce anti-D which is importance for subsequence transfusion or pregnancy
99.7%0.3%
Antibody screening test
Group O red cellsserum
+ =Antibodydetection
Aim: Detect presence or absence of Ab to red cell Ag in serum (0.3 – 2 % of population have unexpected Ab), determine specificities and possible significance of Ab
IAT : indirect antiglobulin test
Sensitization
Visible clumption
Donor blood
• ABO• Rh (D) • Antibody screening test• Infectious screening test : HBsAg,
Anti-HCV, anti-HIV,HIV -1 p24 Ag, Syphilis screening test
Crossmatching
• To determine compatibility between Red cells of donor and pt’s serum
• Minor cross-matching donor’s serum + patient’s red cells
– Antibody screening :donor blood – Antibodies will dilute in pt’s body– Keep cross-matching simple to reduce error
Majorcross-matching
nottest
Complication• Immediate complication
– Acute hemolytic transfusion reaction– Transfusion associated circulatory overload
(TACO)– Acute non-hemolytic transfusion reaction:
urticarial reaction, anaphylaxis IgA deficiency,TRALI, FNHTR
• Delayed complication– Delayed hemolytic transfusion reaction– Post transfusion purpura– TaGVH– Iron overload– Transfusion-transmitted infections
Acute intravascular hemolysis• Incompatibility blood: plasma Ab recipient reaction with
RBC donor• ABO incompatible transfusion (common), others (Kidd, Kell
duffy: may be)• Cause: human error• S &S: Burning sensation at infusion site and along vein,
Facial flushing and feeling of discomfort, Chill and/or rigor with fever, Lumbar pain and/or chest tightness, Development of shock and/or diffuse bleeding DIC, hemoglobinurias
• Prevention: prevent human error, compatibility test, double checking, ชบงผปวยใหถกตองเมอนำโลหตไปใหผปวย มการทวนซำ และตดตามอาการอยางใกลชดใน 15 นาทแรก
• Transfusionist’s responsibilities– Stop reaction; Notify physician– Observe and document sign, symptom &
conditions– Check I.D. of patient and donor– ตรวจสอบเรองความถกตอง ของผปวยกบถงเลอด
– Collect samples for Blood Bank– Return product with all attached sets
• Tx– Record B.P., pulse, urine output– Insert CVP line if necessary– Catheteries if necessary– Force diuresis, load IV fluid– IV Furosemide or 20% manitol– Inotropic drugs: Dopamine
Bacterial contamination and septic shock
• Cause– Contaminate from skin (donor, ผเจาะเลอด),
Staphylococcus (common)– Bacteremia in donor– Contaminate in process e.g. ระหวางการละลาย CPP ใน water
bath, ถงรวซม• Incidence: 0.4% of red cell, 1-2 % of platelet conc.
(Pseudomonas growth 2-6 C, Stap growth 20-24 C)• S&S: sudden or graduate onset, high grade fever,
myalgia, chill, hypotension• Tx: ATB, supportive care• Prevention: sterile technique, diversion pouch bag
Fluid overload
• Heart failure• Occur in pt with underlying heart disease,
chronic anemia• Cause
– Large volume intravenous fluid– High rate of blood transfusion– Renal failure
FNHTR
• Unexplained rise in BT at least 1 C,with or without rigor
• Occur ~ 1%of RC transfusion, 30%of PLT transfusion
• not serious, fever response to antipyretic and rigor to meperidine
• Mechanism: release of inflammatory cytokine : IL-1 ,TNF which react with hypothalamus and stimulate PGE2production (reset the thermoregulatory center of brain)
Treatment
• Stop transfusion, maintain IV line• Evaluate as per hemolytic transfusion
reaction• Continue transfusion if no evidence of
Hemolysis • Pre-medication antipyretic drugs• Record evidence and consider leucocyte
removal blood products on next transfusion
Anaphylactic reaction
• Not uncommon, occur in red cell & plasma• Increase risk in high volume of plasma (e.g.
plasma exchange)– Cytokines in plasma >>>bronchial
constriction & vasoconstriction– In pt with IgA deficiency >>>severe
anaphylaxis• S&S
– Immediate onset, HF, RS failure, BP drop, no fever
Transfusion-related acute lung injury (TRAIL)
• Causes: plasma donor ม Ab ตอ WBC recipient• Target: lung tissue• S&S: acute RS failure in 1-4 hrs, CXR: diffuse
opacity• Tx: supportive tx (intensive RS care, general
support)
Delayed hemolytic transfusion reactions
• Cause: เกดจากการกระตนใหมแอนตบอดของหมโลหตระบบอน ๆ นอกเหนอจาก ABO system หลงไดรบเลอด ทำใหเกด hemolysis
• S&S: หลงไดรบเลอด 5-10 วน, fever, anemia with jaundice, hemoglobinuira (may be), DAT+, increase IB
• Tx: supportive tx• Prevention: ตองตรวจหาชนดของ Ab ในพลาสมาของผปวยและเลอก
ใหเลอดจากผบรจากทไมม Ag ตรงกน
Post-transfusion purpura
• Cause: Ab to platelet-specific Ag• Female, uncommon, life-threathening • Red cells and platelets • S&S: bleeding, severe thrombocytopenia (plt
<100,000, <20-50,000 อนตราย ), occur in 5-10 days• Tx: corticosteroid high dose, high dose IVIG 2 g/kg
or 0.4 g/kg * 5 days), plasma exchange, monitor platelet count, ถาจำเปนตองให plt ทไมม PSA ตรงกบ Ab ทพบในผปวย
และตองมหม ABO ตรงกน• Prevention: ใหเกลดเลอดทเขาไดกบผปวย
Graft versus host disease
• Cause: lymphocyte ในโลหตทไดรบ engraft อยในรางกายผปวยแลวแบงตวสรางภาวะอมมนตอตานผปวย
• มกพบในผปวยทมภาวะอมมนตำจากการปลกถายไขกระดก, รบเลอดทม HLA ใกลเคยงกน หรอจากญาต
• S&S: onset 10-12 days, fever, rash, diarrhea, hepatitis, pancytopenia
• Tx: supportive Tx• Prevention: irradiated blood (inh. lymphocytes )
Transfusion-transmitted infections
• HIV-1 and HIV-2• HTLV1 and HTLVII• HCV, HBV• Syphilis• Chagas disease• Malaria• CMV• Other rare: HPV-B19, brucellosis, EBV,
toxoplasma, infectious mononucleosis, Lymes dz, prions dz, Dengue, Chikungunya
Question 1
• ผปวยหญงไทยโสด อาย 30 ป มอาการเหนอยเพลย มคนทกมา
เหลองมา 3 สปดาห• ตรวจรางกาย pale, mild jaundice, spleen 3 cm• Hct 18%, MCV 110• PBS: autoagglutinations 3+, NCNC• DCT 3+, IDCT 1+• Need red cell transfusion ???
AIHA
• Indication– Life-threatening anemia: severe hemolysis– Co-morbidities (heart dz, old age)
• Most compatible blood• ใหเลอดทละนอย
Blood transfusionHb(g/dL) โอกาสทผปวยจะเกด
อาการจากภาวะซดการใหเลอด
≥10 ตำมาก หลกเลยงการใหเลอด
8-10 ตำ หลกเลยงการใหเลอด(พจารณาใหเลอดกรณทมโรคอนทอาจแยลงจาก
ภาวะซด)
6-8 ปานกลาง พกผอนและลดกจกรรมหนก ในกรณทมอาการรนแรงจากภาวะซดมากหรอม
โรคอนทอาจแยลงจากภาวะซดอาจพจารณาใหเลอด
≤6 สง สวนมากมกมอาการรนแรงจากภาวะซดและมกจะไดรบเลอด
Question 2
• ผปวยชายไทย อาย 18 ป ไดรบการวนจฉยวาเปน B-thalassemia ตงแตอาย 3 ขวบ ไดรบเลอดบอยทก 1-2 เดอน Hct baseline 20-22% 1 สปดาหกอนมารพ. รสกเพลย
ลง เหนอยงาย ปสสาวะสเขมขน ไมมไข
• ตรวจรางกาย thalassemic face, markedly pale, mod jaundice, liver 10 cm, spleen 20 cm
• CBC: Hct 14%• Management in this patient??
Thalassemia: transfusion program• Hypertransfusion program
– high transfusion (pre-transfusion Hb 9-10 g/dl, keep mean Hb 12 g/dl)
– low transfusion (pre-transfusion Hb 7 g/dl, keep mean Hb 8 g/dl)
• normal physical activity• improve growth• reduction of chronic hypoxemia, hypervolemia, GI
absorption of iron • retardation of development of splenomegaly and
hypersplenism• Symptomatic transfusion• Thalassemia post splenectomy with pul. HT: keep
Hct 25%
Allo-immunization• 3% of patients in Thailand• Antibody ตอ Rh, Duffy, Kell, Kidd blood
group• X Leucodepleted blood products
Autoimmune hemolytic anemia
• สงสยเมอผปวยซดลงอยางรวดเรว
• พบในผปวย thalassemia มากกวาคนปกต
• Treatment– Steroid– IVIG– Splenectomy
Post transfusion hypertension
• Not common• High mortality rate (> 30%) ถาม cerebral
hemorrhage• Occur when receive 3-7 blood units• Onset: since 1-15 days after
transfusion
Complication of transfusion
• Infection• Iron overload, hemochromatosis
– 1 unit of PRC = 200 mg of iron– Blood products (5-10 gm/ year),Fe in food
(1-2 gm/ year)– Gold standard diagnosis: liver biopsy– Non-invasive investigation: serum ferritin
(>1,000)
Question 3
• ผปวยหญงไทยค อาย 52 วนจฉยวาเปน AML, M1 ได
induction chemotherapy 7+3 regimensหลงไดยาเคมบำบดวนท 10 มปญหา FN มจดเลอดออกตามตว
• CBC: Hct 19%, platelet 5,000, WBC 200• Management in this patients ???
Prophylactic plt transfusion
• Platelet < 5,000 ( incidence severe bleeding 10-30%)• Platelet 5,000-10,000 ในกรณทเกลดเลอดลดลงอยางรวดเรว หรอเปนมะเรง
เมดเลอดขาว (incidence severe bleeding 4.4%)• Platelet 10,000-20,000 ควรใหกรณ
– Abnormal coagulation or plt dysfunction– Bleeding : wet purpura or dimeter > 1 cm or large
ecchymosis– Procedure (กดเพอหามเลอดใหหยดไดลำบาก): CVP, abdominal
paracentesis, thoracocentesis, bronchial Bx, liver Bx, LP, ETT, dentral extraction ตองเพมเกลดเลอดอยางนอย
40,000-50,000, fiberoptic bronchoscope & GI scope without Bx (มความชำนาญสง สามารถทำไดแมเกลดเลอด
<20,000)
Prophylactic plt transfusion
– Procedure ทคาดวาจะมเลอดออกไมมากหรอการคลอดทางชองคลอด สามารถทำ
ไดถาเกลดเลอดมากกวา 50,000– Procedure บรเวณทเลอดมาเลยงมาก e.g. percutaneous liver
Bx, percutaneous kidney Bx, keep plt 60,000-100,000
– Abdominal Sx: plt 60,000-100,000– Brain, spinal, eye, heart Sx: plt >100,000– Spinal epidural block: plt ≥80,000
• Plt >20,000 ไมตองใหเกลดเลอด ยกเวนกรณ
– Local bleeding: gastric ulcer, นวในทางเดนปสสาวะ– Procedure or Sx พจารณาใหเกลดเลอดในกรณผาตดอวยวะทคาดวาจะเกด
การเสยเลอดมากหรอควบคมการหามเลอดไดยาก
Question 4• ผปวยหญงไทยค อาย 26ป ปวดทอง 1 วน และมอาการหนามดคลายจะเปน
ลม 2 ชม. กอนมารพ. ไมมเลอดออกทใด ผปวยไมมประจำเดอนมา 2 เดอน• ตรวจรางกาย
• BP 90/60, PR 120 bpm• GA: drowsiness, markedly pale, no jaundice, no
petechiae or ecchymosis, no cyanosis• Abdomen: soft, mild generalized tenderness,
no guarding• PR: no melena• CBC: Hb 7 g/dL, Hct 21%, WBC 13,000/mm3,
Platelet 260,000/mm3; polychromasia 2+• Diagnosis and management ???
Internal Bleeding
• Abdominal Trauma– Tearing or rupture of liver, spleen
• Local Intraabdominal pathology– Ruptured ectopic pregnancy– Ruptured hepatoma– GI bleeding
• Underlying bleeding disorders– Retroperitoneal hemorrhage
Volume lossML % of Total
blood volumeClinical signs
500 10 None, occasionally vasovagal syncope in blood donors
1000 20 Slight postural drop in BP, tachycardia with exercise
1500 30 Postural hypotension, flat supine neck vein
2000 40 Supine hypotension, cold clammy skin, tachycardia
2500 50 Signs of shock, tachycardia, oliguria, drowsiness or coma
Transfusion management guideline for major hemorrhage
• Control the bleeding: may need surgical intervention• Fluid resuscitation: crystalloid or colloids• Avoid exacerbating coagulation problems: keep warm• Use laboratory data to guide management
– CBC, PT, APTT, fibrinogen, blood bank sample, biochemical profile, blood gases
– Repeat CBC, PT, APTT, fibrinogen every 4 hrs, or after 1/3 blood volume replacement, or after infusion of FFP
PRC:FFP:platelet = 1:1:1, 3:1:1, 5:1:1
Handbook of transfusion medicine: Editor D B L McClelland, UK 2007
Have blood components available when needed
• Request red cells– PRC (universal donor=gr. O Rh-negative blood)– Rh-positive may be used for male or post-menopausal
female in emergency– Dose of 4 ml/kg (one pack to 70 kg adult) typically
raises venous Hb concentration by about 10 g/l– Use blood warmer– Depend on host status (age, heart disease, peripheral
vascular disease, previous Hb level), volume loss
Handbook of transfusion medicine: Editor D B L McClelland, UK 2007
• Platelets needed? (anticipate plt < 50,000 after 1-1.5Xblood volume replacement)– Dose: 10 ml/kg body weight for a neonate or small
child– One adult therapeutic dose’ (one pack)= 2.5–3X1011
(SDP 1 unit, platelet con 4-6 units)– Target plt >100,000 CNS/multiple trauma,
plt>75,000 others condition
Handbook of transfusion medicine: Editor D B L McClelland, UK 2007
• FFP needed? (anticipate coagulation factor deficiency after blood loss of 1–1.5Xblood volume)– Aim for PT and APTT < 1.5 X mean control,
fibrinogen > 1.0 g/l – Dose: 10–20 ml/kg body weight = 1 litre or 4 units for
an adult– Note PT and APTT > 1.5Xmean control correlates with
increased surgical bleeding, may need to use FFP before laboratory results are available
Handbook oftransfusionmedicine:EditorDBLMcClelland, UK2007
• Cryoprecipitate needed?(replace fibrinogen,FVIII)– Aim for fibrinogen > 1.0 g/l– Dose: 2-5 donation pools for mid-sized adult
(equivalent to 10 single donor units) containing 3–6 g fibrinogen in a volume of 200 to 500 ml.
– Fibrinogen < 0.5 strongly associated with microvascular bleeding, Low fibrinogen prolongs all clotting times (PT and APTT)
Handbook of transfusion medicine: Editor D B L McClelland, UK 2007
An example of a major haemorrhage protocolIf there is a local protocol for your hospital, that should be used
Handbook oftransfusionmedicine:EditorDBLMcClelland, UK2007
Handbook oftransfusionmedicine:EditorDBLMcClelland, UK2007
Use of blood components in the patient who is bleeding
Recombinant F VIIa (Novoseven) in hemorrhage: RCT have not yet established clear indications in haemorrhage
Handbook oftransfusionmedicine:EditorDBLMcClelland, UK2007
Blood components and hemorrhage
Handbook oftransfusionmedicine:EditorDBLMcClelland, UK2007
Question 5
• ผชายอาย 19 ป สบลอทบมอเตอรไซด ม fracture pelvis ได packed red cell 20 units ตอมามเลอดไหลไมหยดจากบรเวณทเจาะเลอด
• Platelet 50,000• APTT 60.5 sec (25-35)• PT 25.0 sec (11-14)• Fibrinogen 1.02 g/L (2-4 g/L)
Prolonged APTT, PT and thrombocytopenia
• DIC• Liver disease*• Massive transfusion**• Coagulopathy of trauma***
*Liver disease อาจพบรวมกบ DIC ได **blood transfusion > 10 unit in 24 hrs รวมกบ crystalloid ทาใหม
dilutional coagulopathy***มกม acidosis + hypothermia ทาใหการแขงตวของเลอดไมด
Massive transfusion
• Blood transfusion ≥ total blood volume within 24 hrs ( 70 ml/kg in adult, 80-90 ml/kg in infant & child)
• Problems– Dilution: dilutional coagulopathy, microvascular
bleeding– Consumption: DIC, microvascular bleeding– Decreased production
• FFP, platelets, and red cells in trauma patients, rupture aortic aneurysm (often to develop DIC)– Red cell : FFP : platelet = 1:1:1
Others complication of large volume transfusion
Handbook oftransfusionmedicine:EditorDBLMcClelland, UK2007
Question 6
• ผปวยชายอาย 19 ป ไดรบการวนจฉยเปน hemophilia A มาพบแพทยเนองจากขมอเตอรไซดลม มปวดบวมทขอสะโพกดานซาย
• ตรวจรางกาย swelling with tenderness around left hip joint, warm limited ROM
• Management ????
Factor VIII replacement• Cryoprecipitate: F VIII, F XIII, vWF,
fibrinogen, fibronectin• FFP• Factor VIII concentration• สตรคำนวณ 1 U/Kg raise F VIII 2 %• Half life 12 hr (repeated dose q 8-12 hr)
• ***F IX def: 1 U/Kg raise F IX 1 % (use FFP, F IX concentration), half life 24 hr
Recommended plasma factor
level and duration of
administration
จงใหการรกษาในผปวยรายนB
• BW 50 kg
Question 7
• ผปวยหญงอาย 45 ป มาดวยเลอดออกตามไรฟน มเลอดออกตามตว
• ตรวจรางกายพบ petechiae and ecchymosis • PBS: AML (M3)• Platelet 48,000 • APTT 37.3 sec (25-35)• PT 19.1 sec (11-14)• TT 17.0 sec (11-14)
Prolonged APTT, PT and thrombocytopenia
• DIC• Liver disease*• Massive transfusion**• Coagulopathy of trauma***
*Liver disease อาจพบรวมกบ DIC ได**blood transfusion > 10 unit in 24 hrs รวมกบ crystalloid ทำใหม dilutional coagulopathy***มกม acidosis + hypothermia ทำใหการแขงตวของเลอดไมด
DIC• Diagnosis• 1. Clinical
– ตองมสาเหตของ DIC เสมอ– Bleeding and/or thrombosis
• 2. Lab– Prolonged coagulation ( prolonged PT, low fibrinogen)– Thrombocytopenia– FDP or D-dimer rising
• ***fibrinogen: acute phase protein ซงจะสงในภาวะ
sepsis ดงนนถาพบ fibrinogen ปกตในผปวยตดเชอ อาจบงวาเรมม DIC• ***chronic DIC อาจม plt, clotting time ปกต
Treatment• Correct cause• keep plt > 20,000• Fibrinogen: keep 1-1.5 g/L, (Cryoprecipitate 10
bag q 12-24 hrs)• Bleeding or need surgery
– FFP 10-20 ml/kg; keep PT, PTT > 1.5 – Platelet transfusion keep 50,000-100,000
• Thrombosis + no bleeding: Low dose heparin• In APL: keep platelet 30,000-50,000,
fibrinogen > 100-150 g/dL
Question 8
• ผปวยชายไทยค ไดรบการวนจฉยเปน UGIB หลงจากไดรบเลอดไป
30 นาท มอาการไข หนาวสน ปวดเอว ปสสาวะสโคก
• Diagnosis and management