Blood Transfusion, Massive Blood Transfusion and Blood
Component Therapy
Supervisor - LCS Dr.Phoo Pwint Khine
Roll No.- 73, 74, 75
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Blood Transfusion
~ Blood transfusion can be life-saving and many areas of surgery could not be
undertaken without reliable transfusion support.
~ However, as with any treatment, transfusion of blood and its components carries
potential risks, which must be balanced against the patient’s need.
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Blood Components & Blood
Component Therapy
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❖ Whole Blood
Main components - Plasma , RBCs, WBCs and Platelets
However , whole blood transfusion has signi cant advantages over packed cells
as it is coagulation factor rich and, if fresh, more metabolically active than stored
blood.
Indications
⁃ exchange transfusion in neonates
⁃ For volume loss (massive blood loss)
⁃ Limited blood banking facilities
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❖ Packed Red Cell
The remains of whole blood after the plasma and platelets have been
removed, the concentrated packs of RBCs
Each unit is approximately 330 mL and harmatocrit is 50-70%.
Packed cells are stored in a SA M solution (saline–adenine–glucose–
mannitol) to increase shelf life to 5 weeks at 2–6°C.
Indications
Goal is to increase oxygen carrying capacity.
⁃ acute massive blood loss
⁃ severe symptomatic anaemia (eg. Thalassaemia major, sickle cell disease,
aplastic anemia)
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❖ Fresh Frozen Plasma ( FFP )
Rich in coagulation factors and is removed from fresh blood and stored at −40 to
−50°C (Frozen). Hence, it needs to be thawed before use. It has a year shelf life.
Contains all of the clotting factors , brinogen , plasma proteins (albumin),
electrolytes and anticoagulants ( protein C , protein S, antithrombin ).
Firs line therapy in the treatment of coagulopathic haemorrhage
Indications
⁃ Coagulative haemorrhage (DIC)
⁃ Clotting factor de ciency (eg. Liver disease)
⁃ Dilutional coagulopathy
⁃ Replacement of single coagulation factor de ciency when the speci c
concentrate is not available. (eg. Hemophilia)
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❖Cryoprecipitate
a supernatant precipitate of FFP and is enriched in high molecular weight plasma
proteins such as brinogen(factor I), factor VIII, von Willebrand factor, factor XIII
and bronectin.
stored at −30°C with a year shelf life.
It is given in low brinogen states or factor VIII de ciency and DIC
Indications
⁃ Hemophilia A (factor 8 de ciency)
⁃ von Willebrand disease
⁃ Fibrinogen de ciency
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❖ Platelet
Platelet concentrates can be made either from centrifugation of whole blood
(random donor platelets [RDP]) or from an individual donor using apheresis) and
supplied as a pool platelet concentrate
stored on a special agitator at 20–24°C and have a shelf life of only 5 days .
Indications
⁃ Thrombocytopenia
⁃ Patients with platelet dysfunction who are bleeding or undergoing surgery.
⁃ Aplastic anemia
⁃ Drug induced platelet dysfunction
⁃ Hypersplenism
⁃ Cardiopulmonary bypass surgery
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❖ Factor VIII and factor IX concentrates
used in the treatment of Haemophilia A (VIII) & B (IX).
❖Prothrombin complex concentrates
highly pur ed concentrates prepared from pooled plasma.
contain factors II, IX and X. Factor VII may be included or produced separately.
Indications
⁃ Emergency reversal of anticoagulant (warfarin) therapy in uncontrolled
haemorrhage.
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❖ Human Albumin
5% solution used as a colloid resuscitation uid. But no more e ective and
more expensive than crystalloids.
20% solution is used in hypoproteinaemic oedema in Nephrotic syndrome and
refractory ascites in chronic liver disease. It's hypertonic and expands plasma
volume.
❖ Immunoglobulins
IV IgG is administered as regular replacement therapy to reduce infective
complications in patients with primary and secondary immune de ciency.
Anti rheus D immunoglobulin is used in pregnancy to prevent hemolytic disease of
the newborn.
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INDICATIONS FOR BLOOD TRANSFUSION
❖Acute blood loss, to replace circulating volume and mai tain oxygen delivery
❖ Perioperative anaemia, to ensure adequate oxygen deli ery during the perioperative
phase
❖Symptomatic chronic anaemia, without haemorrhage or impending surgery
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BLOOD GROUPS
❖ Human red cells have on their cell surface many di erent antigens. Two groups of
antigens are of major importance in surgical practice – the ABO and rhesus(Rh)
systems .
1). ABO System
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2). Rhesus System
●Rh(D) antigen is strongly antigenic
●Antibodies to the D antigen are not naturally present in the serum of the remaining 15% of
individuals
●Rh antibodies may be stimulated by the transfusion of R (+)red cells, or acquired during
delivery of a Rh(D positive baby.
●During pregnancy , Rh antibodies cross the placenta in Rh D(-) mother and cause severe
hemolytic anemia and even death ( hydrops fetalis ) in Rh D(+)fetus in utero
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PRETRANSFUSION TESTING
✦ Pretransfusion testing consists of three steps :
1). Blood grouping involves determining the
patient’s ABO and RhD type. The donors’ blood
groups will already be determined by the Blood
Service at the time of taking the donation.
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2). Antibody screening involves the
use of a panel of cells to screen a
sample of the patient’s serum for the
presence of clinically signi cant
antibodies. Around 2% of a patient
population is likely to have red cell
antibodies and where present the
speci city of these is identi ed using
further, more detailed, cell panels. The
sample is retained for up to 7 days.
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3). Cross-matching involves checking the compatibility of the donor units with the
patient’s serum to prevent transfusion reactions
✓ 95% positive for rhesus factor.
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COMPLICATIONS OF SINGLE BLOOD TRANSFUSION
1). Incompatibility hemolytic transfusion reaction
2). febrile transfusion reaction
3). Allergic reaction
4). Infections Bacterial infection (usually due to faulty storage)
Hepatitis , HIV
Malaria
5). Air embolism
6). Thrombophlebitis
7). Transfusio related acute lung injury (usually from FFP)
8). Transfusion associated Graft- Versus-Host Disease ( TA GVHD )
9). Circulatory overload
10). Post-transfusion purpura
11). Immunological intolerance
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1). Incompatibility hemolytic transfusion reaction;
- Severe immun -related transfusion reactions due to ABO incompa ibility result in
potentially fatal complemen -mediated intr -vascular hemolysis and multiple organ
failure.
- Transfusion reactions from other antigen systems are usually milder and sel -limiting
Acute hemolytic reactions
ABO incompatibility
Aetiology - error in patient identi cation and tube labeling
Pathophysiology - preformed IgM antibodies in the recipient's plasma against
antigens on donor's red cells that x completement. As a result, complement-
mediated cell lysis (intravascular haemolysis) and hemoglobinuria.
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Clinical features
⁃ fever with chills and rigor
⁃ ank pain
⁃ Anxiety, headache
⁃ Haemohlobinuria
⁃ Shortness of breath, chest pain
⁃ DIC - bleeding manifestation (bleeding from puncture site, wound)
⁃ shock - hypotension
⁃ acute renal failure
⁃ death
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Immediate Management
⁃ Stop transfusion and transfusion set : return intact to blood bank
⁃ Commence IV saline infusuon to maintain blood pressure
⁃ Ensure patency of airway
⁃ Monitor urine output by catheterization and maintain urine output at > 100ml/hr. Give
furosemide if urine output falls
⁃ Treat DIC with platelet and FFP/ cryoprecipitate
Investigation
⁃ Repeat ABO and Rh grouping on blood unit
⁃ Sample of patient's venous blood away from the transfusion site for antibody screening and cross
matching
⁃ Fresh urine sample
⁃ Full Blood Count and coagulation pro le
⁃ Urea, Creatinine, Electrolytes
Record & Report
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Delayed hemolytic reactions
Pathophysiology
⁃ Ig G Antibody that recognize red cell antigens that the recipient was sensitized to
previously (eg. Previous transfusion.
⁃ More common in minor blood groups like Kell and Kidd
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2). Non-haemolytic febrile transfusion reaction;
⁃ most common reaction
⁃ due to in ammatory mediators from donor's leukocyte.
⁃ Frequency of this reaction increases with storage age of product
⁃ prevented by using leuco-reduced blood.
Clinical Features - Fever with chills and rigors, dyspnea
Mx
⁃ Give paracetamol
⁃ Restart infusion at slower rate and
⁃ Frequent observation
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3). Allergic reaction
Urticarial allergic reaction
⁃ Presence of allergens in donor's blood that is recognized by IgE antibodies in recipient.
C/F - mild fever, urticarial rash
Mx
⁃ Give IV chlorphenamine slowly
⁃ Restart the transfusion at a slower rate
⁃ Frequent observation
Severe allergic reactions
⁃ These may occur when blood products containing certain antigens are given to
previously sensitized recipients. (Anaphylaxis)
C/F - bronchospasm, angioedema, abdominal pain , hypotension
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Mx
Discontinue transfusion
⁃ IV chlorphenamine 10 mg
⁃ Oxygen and uid support
⁃ Nebulized salbutamol
⁃ If severe hypotension and bronchospasm, IM adrenaline 0.5 mg
⁃ Take down units and giving sets and return intact to blood bank.
4). Infections
❖ Viruses : HIV, HBV, CV, CMV
❖ Parasites : malaria, Toxoplasmosis
❖ Bacteria: Syphilis, Prions: Cruetzfeldt-Jakob disease
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5). Air embolism
❖Results from entry of air into veins from transfusion tubing.
❖10 - 40 ml may cause death especially in patients with V S D.
❖Occur when air is injected into bottle under pressure or during changing of packs or
bottles
❖C/F: Sudden severe dyspnoea & cyanosis, fall in B.P, rapid thready pulse, Syncope due to
cerebral ischaemia
❖Treatment: Place in head down position on left side
6). THROMBOPHLEBITIS
❖Occur when transfusion at 1site for > 12 Hrs
❖more with Plastic cannulae than with steel needles
❖Occur more commonly after cutting down & cannulation & more in L.L veins
❖especially irritants such as dextrose & cytotoxic drug in addition to blood
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7). TRALI (Transfusion Related Acute Lung Injury)
Def - severe frequently fatal complication in which factors in transfused blood
products trigger the activation of neutrophils in the lung microvasculature.
Pathophysiology - Two hit hypothesis
First hit (primimg event) - an exposure that activates the endothelial cells in
pulmonary capillaries. (eg. Smoking, sepsis, shock) which leads to
sequestration of neutrophils.
Second hit - These primed neutrophils are activated by a factor present in
transfused blood products. These factors include antibody which recognize
antigen expressed on neutrophils.
It is associated with multiparous female donors who have been exposed to
multiple HLA antigens and developed multiple anti-leucocyte antibioties.
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Clinical features
⁃ Sudden onset of dyspena , cough, fever, hypoxia during or soon after transfusion.
Investigation
⁃ Bilateral pulmonary exudates on CXR (non cardiogenic pulmonary oedema)
Management
⁃ Mainly supportive (Oxygen therapy and mechanical ventilation)
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8). Transfusion associated Graft- Versus-Host Disease ( TA GVHD )
❖ It’s due to viable T lymphocytes in the donor blood which produce Ab attacks
the host cells.
❖ Rare but always fatal
❖It’s more common in immunocompromised patients.
❖Prevented by irradiation and deactivating of lymphocytes.
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9). Circulatory overload
C/F - Acute pulmonary edema, some time Heart failure, cyanosis, dyspnoea
Risk patients - Occur in chronic anaemia, elderly, very young, or cardiopulmonary d/s
Prevention - Use packed cells
Treatment - Diagoxin, Lasix, Morphine, Oxygen
10). Post-transfusion Purpura
❖ Sudden development of severe thrombocytopenia associated with bleeding 5-12
days following transfusion. Complications are related to bleeding. Platelet count
usually recovers with appropriate management, which includes IV immunoglobulin.
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Massive Blood Transfusion
❖ Transfusion of blood equal or more than the patient’s own blood volume
(>10U) within 24 hours
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COMPLICATIONS Of MASSIVE BLOOD TRANSFUSION
1). Metabolic
✓ Acidosis - d/t low pH of stored blood
✓ Hyperkalemia - d/t progressive leakage of K+ from lysis of stored blood during early
phase
✓ Hypokalemia - Citrate in the transfused blood is converted to bicarbonate which may
result in mild metabolic alkalosis and leads to hypokalaemia.
✓ Hypothermia - occur when large amount of cold blood stored at 4’C is transfused
rapidly , can cause cardiac arrest
✓ Hypocalcaemia - d/t Citrate intoxication >> citrate binds with calcium >> reduced free
calcium level >> metabolic tetany and cardiac irregularity
- ammonia intoxication in patients underlying with liver disease
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2). CVS
❖ Ventricular failure
❖ Cardiac arrhythmia- d/t hyperkalaemia, low temperature of transfused blood &
high acidity
3). Respiratory
TRALI ( Transfusion related acute lung injury )
❖ d/ t anti-leukocyte Ab in donor plasma
❖C/F - dyspnea, cough, fever, hypoxia, pulmonary in ltrates ( ARDS )
4). Haematological
❖ Dilutinal coagulopathy>> DIC
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Management of coagulopathy
⁃ Correction of coagulopathy is not necessary if there is no active bleeding and
haemorrhage is not anticipated (not due for surgery).
⁃ However, coagulopathy will occur during major haemorrhage and should be anticipated
and managed actively.
⁃ Prevention of dilutional coagulopathy is central to the damage control resuscitation of
patients who are actively bleeding.
⁃ This is the prime reason for delivering balanced transfusion regimes that deliver a
resuscitation which approximates that of whole blood.
⁃ In most practice this means delivering matched units of red blood cells, plasma and
platelets in a 1:1:1 ratio.
⁃ Crystalloids and colloids should be avoided if at all possible.
⁃ The balanced transfusion approach will not correct an established coagulopathy.
⁃ Most bleeding patients are hyper- brinolytic, and should be empirically given tranexamic
acid, an antihbrinolytic agent, as quickly as possible.
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COMPLICATIONS OF REPEATED BLOOD TRANSFUSION
Patients who receive repeated transfusions over long periods of time (e.g. patients with
thalassaemia) may develop iron overload and hemosiderosis.
Liver - COL
Pancreas - Bronze diabetes
Skin - slate grey coloration
Heart - cardiomyopathy
Repeated transfusions may cause isoimmunization which can lead to trouble in cross-
matching.
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Autologous blood transfusion
Autologous blood transfusion is a procedure in which blood is removed from a donor
(patient) and returned to his circulation at some later time.
Autologous blood transfusion can be performed in four di erent ways;
1) elective preoperative blood collection, storage and re-transfusion during surgery;
2) immediate preoperative phlebotomy with simultaneous arti cial hemodilution and
later reinfusion of phlebotomized blood;
3) pre or post operative salvage and re-transfusion of blood shed via wound drains as
an emergency method;
4) intraoperative blood salvage and retransfusion.
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Blood Substitutes
➢ an attractive alternative to the costly process of donating, checking, storing and
administering blood, especially given the immunogenic and potential infe tious
complications associated with transfusion
Blood substitutes are either biomimetic or abiotic.
➢ Biomimetic substitutes mimic the standard oxyge carrying capacity of the blood and
are haemoglobin based.
➢ Abiotic substitutes are synthetic oxygen carriers and are currently primarily pe
uorocarbon based
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References
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