Transfusion Trends In Transfusion Trends In Surgical PatientsSurgical Patients

Dr. Hanan AL-Awadhi (FRCPc)

Hematology Unit

Farwaniya Hospital

Lecture OverviewLecture Overview

Compatibility testing.Selecting compatible RBCs.RBCs transfusion triggers.Platelet transfusion.Transfusion of plasma and

components.

Compatibility TestingCompatibility Testing

Group and screen. Cross-match.

Compatibility Testing..Grouping Compatibility Testing..Grouping

Determination of recipient blood groupABO and RhDUse recipient RBC

(forward testing)Use recipient plasma

(reverse)

Compatibility Compatibility

Red cell type Antibodies present

Recipient Compatibility

Approximate frequency

Group O (no ABO antigens)

Anti-A, anti-B All ABO groups 46%

Group A Anti-B Groups A & AB 42%

Group B Anti-A Groups B & AB 9%

Group AB Neither present Group AB 3%

Rhesus group D positive

Normally none Should be RhD identical, RhD

-ve acceptable

85%

Rhesus group D negative

Normally none Should be RhD identical

15%

Compatibility Testing…Screening Compatibility Testing…Screening

The recipient plasma is tested for unexpected red cell antibodies using screening cellsAntibodies due to

prior transfusion or previous pregnancy

Selecting Compatible Red CellsSelecting Compatible Red Cells

Identical ABO and RhD type preferred Red cells of non-identical ABO type

may be used.RhD +ve blood to RhD -ve recipient

should be avoided wherever possible

Selecting Compatible Red CellsSelecting Compatible Red Cells

RhD –ve females with child-bearing potential should NEVER receive any RhD +ve red cells unless….

Patients with an unexpected antibody should receive only red cells lacking the corresponding blood group antigen

Compatibility Testing…X-MatchCompatibility Testing…X-Match

X-match between the selected unit and the recipient plasma

The bag is labeled for the particular recipient and ready for transfusion.

Needs 45-60 mints needed for full x-match.

Emergency Blood ReleaseEmergency Blood Release

The clinician must weigh the risk of transfusing uncrossed matched or partially X-matched

blood against the risk of delaying transfusion.

Degree Of UrgencyDegree Of Urgency

Desperate blood releaseBlood needed immediately as life saving

measure.Blood will be issued without X-match.

• Group O –ve uncross-matched blood

Blood sample before administering the blood is needed for subsequent testing

Degree Of UrgencyDegree Of Urgency

Blood needed in 10-30 minutesThe blood will be group specific not fully X-

matchedProvided the patient blood sample is

delivered

Degree Of UrgencyDegree Of Urgency

Blood needed with in 45 minutesFully matched blood will be providedPlease note that delay can occur if:

• Antibodies are detected• Problems in X-match• Blood is not available in local BB

Transfusion Of RBCsTransfusion Of RBCs

Indications For Red Cell TransfusionIndications For Red Cell Transfusion

Acute blood lossAnemia in the critically illPerioperative transfusionChronic anemia

Transfusion in Acute Blood LossTransfusion in Acute Blood Loss

Maintain Hb over 70 g/L during active bleeding

Anticipate need when Hb drops to 80 g/L

Transfusion in Acute Blood LossTransfusion in Acute Blood Loss

Consider maintaining higher level (80-100 g/L) with: Impaired pulmonary

function Unstable coronary

disease Atherosclerosis Uncontrolled bleeding

Patients with levels above 100 g/L are unlikely to benefit

Transfusion in the Critically IllTransfusion in the Critically Ill

Patients needs immediate requirement Patients needs immediate requirement for any form of organ support for any form of organ support (intubation, ventilation, inotropes).(intubation, ventilation, inotropes).

Hemoglobin trigger recommended for Hemoglobin trigger recommended for transfusion is < 70g/L.transfusion is < 70g/L.

Transfusion in the Critically IllTransfusion in the Critically Ill

No general benefit (& possible harm) until hemoglobin falls to 70 g/L.

Consider higher levels (100 g/L) in patients with unstable angina or acute myocardial infarction.

Randomized Controlled TrialsRandomized Controlled Trials

Hebert et al.(1999) (1) assigned 418 critically ill euvolemic patients to a "restrictive" transfusion strategy (ie, transfusion for Hgb concentration <7 g/dL and Hgb maintained at 7 to 9 g/dL) and 420 patients to a "liberal" strategy (transfusion for Hgb <10 g/dL and Hgb maintained at 10 to 12 g/dL) Mortality significantly lower with the restrictive strategy (but

not among patients with clinically significant cardiac disease) Conclusion: restrictive strategy of red cell transfusion

is at least as effective as, and possibly superior to, a liberal transfusion

CRIT study 2004(3)

RBCs transfusion and outcome were prospectively collected on 4892 patients from 284 ICUs in 213 US hospitals showed that transfused patients had longer ICU stay, more severe organ failure and higher mortality rates at every admitting Hgb level compared with non-transfused patients.

Conclusion: the number of RBC units transfused is an independent predictor of worse clinical outcome.

Transfusion In The Perioperative PatientTransfusion In The Perioperative Patient

Pre-operativelyConsider alternatives in advance (at least 5

weeks) of surgery to allow planningIntra-operatively

Meticulous attention to surgical techniquePost-operatively

Adhere to good transfusion practice, minimize blood taking for laboratory tests

Transfusion and Chronic AnemiaTransfusion and Chronic Anemia

Consider alternatives and adjuncts to transfusion Ensure adequate stores of iron, B12 & folate Erythropoietin Treat underlying disease

Only transfuse when there is no effective alternative Maintain hemoglobin at a level avoid symptoms of

anemia Monitor long-term transfusion dependant patients for

iron overload

Platelet TransfusionPlatelet Transfusion

PlateletsPlatelets

Platelets for transfusion come in 2 forms: Random donor, from

single donation, contains > 55x109platelets; given in pools of 6, volume 300mL

Apheresis (single donor) platelets; pack contains 300x109 platelets,volume300ml

Platelets – Storage & TransfusionPlatelets – Storage & Transfusion

Shelf life 5 days Stored at 20-24 Co with constant mixing Longer storage increases risk of septic reaction Recommended infusion time 60 minutes One apheresis product is equivalent to 6 to 8 random

donor platelet concentrates increases the platelet count by 30,000/uL to 40,000/uL in a 70 kg patient.

Check post-transfusion platelet count within 1 hour of transfusion to determine response and detect refractoriness

Platelets and Blood GroupPlatelets and Blood Group

ABO/RhD identical preferred

ABO/RhD non-identical are acceptable

RhD –ve females of child-bearing potential receiving RhD +ve platelets require Rh-immunoglobulin prophylaxis

When To Give Platelets?When To Give Platelets?

ITPITP

A consensus reached by experts from the American Society of Hematology concluded that platelet transfusion was only justified in the presence of:  A platelet count less than 10x10 9 /L

AND serious bleeding.

NonNon--Immune Thrombocytopenia Immune Thrombocytopenia

Platelet transfusion support is required when the platelet count falls below 10x109/L.

Non-immune Thrombocytopenia AND Fever Non-immune Thrombocytopenia AND Fever Greater than 38.5°C and/or Coagulopathy Greater than 38.5°C and/or Coagulopathy

Platelet transfusion is recommended in the presence of Platelet count less than

20x10 9 /L AND

Fever = or > 38.5 AND/ORINR > 1.5

Procedures Not Associated with Procedures Not Associated with Significant Blood Loss Significant Blood Loss

Platelets count less than 20x109/L Transfuse single donor platelets

immediately prior to procedure. Platelets count 20-50x109/L

Platelets "on hold" Transfuse only if significant unexpected

bleeding occurs.

Procedures Associated with Major Blood Procedures Associated with Major Blood Loss or Major SurgeryLoss or Major Surgery Anticipated blood loss greater than 500 mL

aim at platelet count above 50x109/L. Platelet count less than 50x109/L, transfuse

platelets immediately prior to procedure.

Platelet Dysfunction and Marked Platelet Dysfunction and Marked Bleeding Bleeding Marked microvascular

(non-surgical) bleeding due to severe platelet dysfunction may require platelet transfusion. Example NSAIDs.

Transfusion may be required regardless of the platelet count.

Fresh Frozen PlasmaFresh Frozen Plasma

Fresh Frozen PlasmaFresh Frozen Plasma

Frozen Plasma is a source of clotting factors, with half lives in vivo of between 6 hours & 3 days.

30 minutes required for thawing

FFPFFP

Dose is 10-15 mL/Kg, or 4-6 units

Infusion time 30-120 minutes

Should be ABO compatible (Rh not important)

Check INR/APTT after infusion to confirm outcome

Reversal of Warfarin Anticoagulant Reversal of Warfarin Anticoagulant Effect Effect FFP for the emergency reversal of warfarin

anticoagulant effect: Patients with insufficient time (less than 6 hours)

for reversal by vitamin K

ANDPatient about to undergo an emergency operative

procedure

ORWith potentially life-threatening bleeding.

Think of AlternativesThink of Alternatives

 The warfarin effect should be reversed with vitamin K in a dose of 10 mg administered intravenously. 

This will produce partial reversal within 2 hours and normalization is usual in 24-48 hours.

Bleeding Patient With Impaired Bleeding Patient With Impaired Coagulation FunctionCoagulation Function Actively bleeding and INR/PTT greater than

1.5x normal Frozen plasma in a dose of 10-15mL/Kg (750-

1000mL) for an average sized adult should correct the INR/PTT to 1.5x normal or less

Failure to achieve the expected response should lead to review of the cause/diagnosis of impaired coagulation function

Microvascular Bleeding/Massive Microvascular Bleeding/Massive Transfusion Transfusion Massive rapid transfusion and/or

microvascular bleeding

Use of CryoprecipitateUse of Cryoprecipitate

Clinical Use of CryoprecipitateClinical Use of Cryoprecipitate

Must be ABO compatible, Rh not important.

Treatment of massive or microvascular bleeding with Fibrinogen < 1.0 g/L

CryoprecipitateCryoprecipitate

Hereditary Disorders of HemostasisFor bleeding in von Willebrand’s syndrome

patients ONLY if factor concentrate is unavailable and DDAVP is ineffective

For the emergency management of factor VIII deficiency ONLY if manufactured factor VIII is unavailable

Cryoprecipitate Cryoprecipitate

Dose1 unit per 10 kg of body weight (i.e. 8 to 12 units

per dose).• Small adult: 8 units

• Large adult: 12 units

Each dose will increase the fibrinogen by 0.5 g/L.Recommended infusion time is 10-30 minutes per

dose (maximum infusion time 4 hours).Half-life of fibrinogen is about 7 days.

Final Thought…Final Thought…

As beneficial as transfusion may seem to have zero transfusion risks is

impossible.

Thank you…Thank you…