1. Blood transfusionBlood transfusion
therapytherapy
RENE PSA MENDOZA, MD, MHSARENE PSA MENDOZA, MD, MHSA
Associate Professor, Department of SurgeryAssociate Professor, Department of Surgery
FEU-NRMF Institute of MedicineFEU-NRMF Institute of Medicine

2. Functions and Properties
of Blood
 A vehicular organ that perfuses all
other organs
 Blood and interstitial fluid deliver
nutrients to cells and remove wastes
 Hemostatic governors are carried to
and from appropriate sites

3. Functions of Blood
 Transport:
– suspended cells include rbc that carry O2
– Platelets that contributes to the
hemostatic process
– chemicals dissolved in plasma (nutrients,
waste, hormones, etc)
– metabolic heat for disposal

4. Functions of Blood
 Regulation:
– plasma contains pH buffers
– plasma water absorbs heat
– plasma solutes maintain osmolality

5. Functions of Blood
 Protection:
– plasma precursor proteins form blood clot
when stimulated
– suspended wbc attack bacteria and
viruses ( body’s defense )
– plasma contains antibodies and opsonins
for immunity

6. Fluid compartmentsFluid compartments
ICF
ECF
Interstitial
PlasmaCapillary
Membrane Cell Membrane
~ 15% of
body weight
~ 40% of
body weight
~ 5%
of
body
weight

7. Blood volume
plasma + cells and cell fragments
~ 5% ~ 2-3% of body weight+

8. Banked Whole bloodBanked Whole blood
 No components have been removed.No components have been removed.
 consists of red blood cells, white bloodconsists of red blood cells, white blood
cells and platelets in plasmacells and platelets in plasma
 can be stored for 5 weekscan be stored for 5 weeks

9. Banked Whole bloodBanked Whole blood
 Transfusions of whole blood areTransfusions of whole blood are rarelyrarely
required.required.
 stored in the refrigeratorstored in the refrigerator, the platelets, the platelets
are useless and factors V and VIII areare useless and factors V and VIII are
greatly reduced.greatly reduced.

10. Banked Whole bloodBanked Whole blood
 transfusion of whole blood may betransfusion of whole blood may be
necessarynecessary
– certain types of major surgerycertain types of major surgery
 ACUTE BLOOD LOSS > 15%ACUTE BLOOD LOSS > 15%
– major trauma such as a car accident ormajor trauma such as a car accident or
gunshot wound requiring emergencygunshot wound requiring emergency
surgerysurgery

11. Changes in rbcChanges in rbc
 ReductionReduction
– pH from 7.00 to 6.68pH from 7.00 to 6.68
– 2,3 DPG2,3 DPG
– Intracellular ADPIntracellular ADP
oxygen transportoxygen transport
 Poor sourcePoor source
– PlateletsPlatelets
– clotting factors V and VIIIclotting factors V and VIII

12. Changes in rbcChanges in rbc
 Increase levelsIncrease levels
– Lactic acid from 20 to 150mg/dlLactic acid from 20 to 150mg/dl
– Potassium concentration to 32 mEq/dlPotassium concentration to 32 mEq/dl
– Ammonium concentration from 50Ammonium concentration from 50
to 680 mg/dlto 680 mg/dl
 Hemolysis is insignificantHemolysis is insignificant

13. Fresh whole bloodFresh whole blood
 Blood that is administered within 24Blood that is administered within 24
hours of its donationhours of its donation
 Rarely indicatedRarely indicated
 Poor source of platelets and factor VIIIPoor source of platelets and factor VIII

14. Blood ComponentBlood Component
TherapyTherapy
 The process of transfusing only thatThe process of transfusing only that
portion of the blood needed by theportion of the blood needed by the
patientpatient
 It allows a single unit (one pint) of donatedIt allows a single unit (one pint) of donated
blood to benefit more than one patientblood to benefit more than one patient
 Red blood cells and platelets are the mostRed blood cells and platelets are the most
frequently transfused blood componentsfrequently transfused blood components

15. Packed red cellsPacked red cells
 The red cells from a donor unit, dilutedThe red cells from a donor unit, diluted
with plasma to a hematocrit of aboutwith plasma to a hematocrit of about
75%.75%.
 Volume is about 200 mL.Volume is about 200 mL.
 Storing red cells (just above freezing)Storing red cells (just above freezing)
allows survival for 42 daysallows survival for 42 days
– but unfortunately decreases 2,3-DPGbut unfortunately decreases 2,3-DPG
– ruins the platelets and neutrophils.ruins the platelets and neutrophils.

16. Packed red cellsPacked red cells
 Red blood cells contain hemoglobinRed blood cells contain hemoglobin
– carries oxygen throughout the body.carries oxygen throughout the body.
– Essentially provides oxygen-carryingEssentially provides oxygen-carrying
capacitycapacity
 Product of choice for most clinicalProduct of choice for most clinical
situations situations

17. Packed red cellsPacked red cells
 Recent advances have made itRecent advances have made it
possible to store red blood cells for uppossible to store red blood cells for up
to 42 days. to 42 days.
 IndicationsIndications
– acute trauma before surgeryacute trauma before surgery
– people with anemia who are havingpeople with anemia who are having
surgerysurgery

18. Packed red cellsPacked red cells
 fastest way to increase the oxygen-fastest way to increase the oxygen-
delivering capacity of the blood.delivering capacity of the blood.
 A unit of whole blood or packed redA unit of whole blood or packed red
cells willcells will raise the hematocrit by 3%raise the hematocrit by 3%
and theand the hemoglobin by 1-1.5 gm/dLhemoglobin by 1-1.5 gm/dL

19. Frozen red cellsFrozen red cells
 reduces the risk of infusing antigens,reduces the risk of infusing antigens,
or foreign bodies, that the body mightor foreign bodies, that the body might
regard as potentially dangerousregard as potentially dangerous
– Previously sensitized patientsPreviously sensitized patients
 Not available for use in emergencyNot available for use in emergency
situationssituations
 Rbc viability is improvedRbc viability is improved
 ADP and 2,3 DPG maintainedADP and 2,3 DPG maintained

20. Platelet concentratesPlatelet concentrates
 Component: platelets, 50 ml plasmaComponent: platelets, 50 ml plasma
 cellular components that help in thecellular components that help in the
clotting process. clotting process.
 Platelets are stored for up to five daysPlatelets are stored for up to five days
at room temperature.at room temperature.

21. Platelet concentratesPlatelet concentrates
 IndicationIndication
– used if there is a platelet disorderused if there is a platelet disorder
– when massive blood loss has occurredwhen massive blood loss has occurred

22. Platelet concentratesPlatelet concentrates
 Platelets must be stored at roomPlatelets must be stored at room
temperature, so are good only for 5 days ortemperature, so are good only for 5 days or
less.less.
 One unit will usually raise the platelet countOne unit will usually raise the platelet count
5-10k/microliter.5-10k/microliter.
 Check one hour after transfusion.Check one hour after transfusion.
– If the platelet count does not increase asIf the platelet count does not increase as
expected (“refractoriness”), suspect DIC orexpected (“refractoriness”), suspect DIC or
immune platelet destruction (anti-HLA).immune platelet destruction (anti-HLA).

23. Fresh frozen plasmaFresh frozen plasma
 From freshly donated bloodFrom freshly donated blood
 Source of vit k- dependent clottingSource of vit k- dependent clotting
factorsfactors
 Only source of factor VOnly source of factor V

24. Fresh Frozen PlasmaFresh Frozen Plasma
 IndicationIndication
– For coagulopathy and deficient clottingFor coagulopathy and deficient clotting
factorsfactors
 1 unit FFP = 3% increase in CF levels1 unit FFP = 3% increase in CF levels
 At least 30% to ensure adequate coagulationAt least 30% to ensure adequate coagulation

25. CryoprecipitatedCryoprecipitated
antihemophilic factorantihemophilic factor
 an antihemophilic concentratean antihemophilic concentrate
 prepared from plasma and is rich inprepared from plasma and is rich in
clotting factors clotting factors
 used in people with hemophilia, vonused in people with hemophilia, von
Willebrand's disease or other majorWillebrand's disease or other major
coagulation abnormalities to preventcoagulation abnormalities to prevent
or control bleedingor control bleeding

26. CryoprecipitatedCryoprecipitated
antihemophilic factorantihemophilic factor
 Its contents are the major portion ofIts contents are the major portion of
the Factor VIII, von Willebrand factor,the Factor VIII, von Willebrand factor,
fibrinogen, Factor XIII and fibronectinfibrinogen, Factor XIII and fibronectin
present inpresent in freshly drawn andfreshly drawn and
separated plasmaseparated plasma..

27. Replacement therapyReplacement therapy
 Serologic compatibilitySerologic compatibility
– A, B, O and Rh groupsA, B, O and Rh groups
 CrossmatchingCrossmatching
– Donors’ red cell and Recipients’ seraDonors’ red cell and Recipients’ sera
 Major crossmatchMajor crossmatch

28. Serologic compatibilitySerologic compatibility

29. Rh groupsRh groups
 Rh negative recipients should beRh negative recipients should be
transfused with Rh negative bloodtransfused with Rh negative blood
 Rh negative groupRh negative group
–– 15% of the population15% of the population
– Limited supplyLimited supply

30.  A 50M pedestrian was hit by a car whileA 50M pedestrian was hit by a car while
crossing Commonwealth Ave. Hecrossing Commonwealth Ave. He
sustained blunt trauma to the pelvis andsustained blunt trauma to the pelvis and
an open femoral fracture on the L. At thean open femoral fracture on the L. At the
ER, BP 90/50 HR 110 RR 28 with anER, BP 90/50 HR 110 RR 28 with an
estimated blood loss of 1L.estimated blood loss of 1L.
 The initial resuscitation fluid isThe initial resuscitation fluid is
– A. Whole bloodA. Whole blood
– B. packed RBCB. packed RBC
– C. Plain Lactated RingersC. Plain Lactated Ringers
– D. DextranD. Dextran

31.  After 2L of crystalloids, the BP 90/60After 2L of crystalloids, the BP 90/60
HR 120 RR 32. The SROD decided toHR 120 RR 32. The SROD decided to
give blood. What is the best blood productgive blood. What is the best blood product
to administer?to administer?
– A. Fresh Whole BloodA. Fresh Whole Blood
– B. packed RBCB. packed RBC
– C. plasma expandersC. plasma expanders
– D. plateletsD. platelets

32. Parameter Class I Class II Class III Class IV
blood loss in
mL
<= 750 mL 750 − 1,500
mL
1,500 −
2,000 mL
>= 2,000
mL
blood loss
as % TBV
<= 15% 15 − 30% 30 − 40% >= 40%
pulse > 100 > 100 > 120 >= 140
blood
pressure
normal normal decreased decreased
capillary
refill
normal delayed delayed delayed
respirations 14 − 20 20 − 30 30 − 40 > 35
urine output >= 30
mL/h
20 − 30
mL/h
5 − 10 mL/h minimal
mental
status
slightly
anxious
mildly
anxious
anxious and
confused
confused
and
lethargic

33.  A CT scan of abdomen was done withA CT scan of abdomen was done with
findings of Grade 2 renal injury, L withfindings of Grade 2 renal injury, L with
incomplete fracture, L iliac. He underwentincomplete fracture, L iliac. He underwent
ORIF, L femur and placed on completeORIF, L femur and placed on complete
bed rest. He was transfused 2 ‘u’ WB andbed rest. He was transfused 2 ‘u’ WB and
4 ‘u’ pRBC.4 ‘u’ pRBC.
 What are the possible complications ofWhat are the possible complications of
blood transfusion?blood transfusion?

34. Risks from a unit ofRisks from a unit of
ordinary red cellsordinary red cells
 Non-hemolytic febrile transfusionNon-hemolytic febrile transfusion
reaction:reaction: 1-5%1-5%
 Minor allergic:Minor allergic: 1-2%1-2%
 Real anaphylaxis:Real anaphylaxis:
– maybe 1 in ~20,000; fatality rate unknownmaybe 1 in ~20,000; fatality rate unknown

35. Transfusion reactionsTransfusion reactions
 Hemolytic ReactionsHemolytic Reactions
 Allergic ReactionsAllergic Reactions
 Febrile ReactionsFebrile Reactions
 Bacterial ContaminationBacterial Contamination
 Circulatory OverloadCirculatory Overload
 HypothermiaHypothermia

36. Transfusion reactionsTransfusion reactions
 AlloimmunizationAlloimmunization
 Graft Versus Host DiseaseGraft Versus Host Disease
(GVHD)(GVHD)
 Transfusion related acute lungTransfusion related acute lung
injury (TRALI)injury (TRALI)

37. Allergic / urticarialAllergic / urticarial
transfusion reactionstransfusion reactions
 most common usually due to allergiesmost common usually due to allergies
to specific proteins in the donor’sto specific proteins in the donor’s
plasmaplasma
 can be avoided with futurecan be avoided with future
transfusions by pretreatment withtransfusions by pretreatment with
antihistamines or steroids.antihistamines or steroids.

38. Allergic / urticarialAllergic / urticarial
transfusion reactionstransfusion reactions
 Some get “hay fever / hives /Some get “hay fever / hives /
wheezing” from transfusionswheezing” from transfusions
– you can continue the transfusion whenyou can continue the transfusion when
they are betterthey are better
– and in the future, pre-treat with anand in the future, pre-treat with an
antihistamine.antihistamine.

39. Allergic / urticarialAllergic / urticarial
transfusion reactionstransfusion reactions
 For severe (anaphylaxis), RBC’s andFor severe (anaphylaxis), RBC’s and
platelets are washed to remove allplatelets are washed to remove all
plasma indicated.plasma indicated.
– Very fast, spectacular illness afterVery fast, spectacular illness after
transfusion only a few mL.transfusion only a few mL.
– IgA deficiency should be considered inIgA deficiency should be considered in
the case of anaphylactic reactions.the case of anaphylactic reactions.

40. Hemolytic ReactionsHemolytic Reactions
 transfusion of an incompatible bloodtransfusion of an incompatible blood
component.component.
 Most are due to naturally occurringMost are due to naturally occurring
antibodies in the ABO antigen systemantibodies in the ABO antigen system
and Rh groupsand Rh groups
 may cause hemoglobin induced renalmay cause hemoglobin induced renal
failure and a consumptivefailure and a consumptive
coagulopathy (DIC).coagulopathy (DIC).

41. Immediate hemolyticImmediate hemolytic
transfusion reactiontransfusion reaction
 1 in ~25,000 units; fatality rate 10%1 in ~25,000 units; fatality rate 10%
 A disaster, almost always preventable.A disaster, almost always preventable.
 Most often due toMost often due to ABO mismatch dueABO mismatch due
to a clerical errorto a clerical error (i.e., the wrong blood(i.e., the wrong blood
and/or the wrong recipient).and/or the wrong recipient).

42. Clinical presentationClinical presentation
 fever, hypotension, nausea, vomiting,fever, hypotension, nausea, vomiting,
tachycardia, dyspnea, chest or backtachycardia, dyspnea, chest or back
pain, flushing and severe anxietypain, flushing and severe anxiety
 pain at the infusion sitepain at the infusion site
 Post-op site:Post-op site: diffuse bleedingdiffuse bleeding
hypotensionhypotension

43. Intravascular destruction of RBCIntravascular destruction of RBC
HemoglobinemiaHemoglobinemia
free hemoglobin in the serumfree hemoglobin in the serum
HemoglobinuriaHemoglobinuria may be noted and, may be themay be noted and, may be the firstfirst
sign of hemolysissign of hemolysis
Clinical presentationClinical presentation

44. Renal toxicityRenal toxicity
Precipitation of free hemoglobin in thePrecipitation of free hemoglobin in the
tubulestubules
Acute tubular necrosisAcute tubular necrosis

45. DICDIC
In the circulation, Ag-Ab complexesIn the circulation, Ag-Ab complexes
Activates complement system,Activates complement system,
factor XIIfactor XII
DICDIC

46. TreatmentTreatment
 Stop the transfusionStop the transfusion
 Keep the vein open by running in salineKeep the vein open by running in saline
 Draw your post-transfusion samplesDraw your post-transfusion samples
 check the urine for hemoglobincheck the urine for hemoglobin
 notify the blood banknotify the blood bank
 Save the untransfused blood.Save the untransfused blood.
 Give mannitol to keep the kidneys openGive mannitol to keep the kidneys open
 monitor for DIC.monitor for DIC.
 fluids, diuresis and transfusion support for bleedingfluids, diuresis and transfusion support for bleeding

47. patient’s identificationpatient’s identification
checked..checked..
 repeat crossmatch, bacterial culturerepeat crossmatch, bacterial culture
 most errors are clerical or due tomost errors are clerical or due to
misidentification of a patient at the bedside.misidentification of a patient at the bedside.
 mislabelled specimen sent to the blood bankmislabelled specimen sent to the blood bank
 A fatal hemolytic transfusion reaction occursA fatal hemolytic transfusion reaction occurs
about once in 100,000 transfusionsabout once in 100,000 transfusions

48. DO NOT ASSUME IT IS SOMEONEDO NOT ASSUME IT IS SOMEONE
ELSE'S RESPONSIBILITY TOELSE'S RESPONSIBILITY TO
CHECK!CHECK!

49. Laboratory criteriaLaboratory criteria
 Free hemoglobin > 5mg/dlFree hemoglobin > 5mg/dl
 Serum haptoglobulin of > 50 mg/dlSerum haptoglobulin of > 50 mg/dl
 Serologic criteriaSerologic criteria
– INCOMPATIBILITY OF THE DONORINCOMPATIBILITY OF THE DONOR
THE RECIPIENTTHE RECIPIENT
 Positive Coombs’ testPositive Coombs’ test

50. Delayed hemolyticDelayed hemolytic
transfusion reactionstransfusion reactions
 1 in ~6000; fatality rate 0.1%1 in ~6000; fatality rate 0.1%
 previously sensitized to an antigenpreviously sensitized to an antigen
through transfusion or pregnancythrough transfusion or pregnancy
 can result in symptomatic orcan result in symptomatic or
asymptomatic hemolysis several daysasymptomatic hemolysis several days
(2-10 days) after a subsequent(2-10 days) after a subsequent
transfusiontransfusion

51. Delayed hemolyticDelayed hemolytic
transfusion reactionstransfusion reactions
 Not preventable.Not preventable.
 A new antibody or anamnesticA new antibody or anamnestic
response has probably developed.response has probably developed.

52. Clinical presentationClinical presentation
 Extravascular hemolysis, mild anemia,Extravascular hemolysis, mild anemia,
indirect hemoglobinemiaindirect hemoglobinemia
 These present with flu-like symptomsThese present with flu-like symptoms
recurrent anemia and jaundicerecurrent anemia and jaundice

53. Delayed hemolyticDelayed hemolytic
transfusion reactionstransfusion reactions
 Most frequent: Transfusion of RhMost frequent: Transfusion of Rh
positive red blood cells to an Rhpositive red blood cells to an Rh
negative woman of childbearing agenegative woman of childbearing age
can result in sensitization andcan result in sensitization and
hemolytic disease of the newborn inhemolytic disease of the newborn in
future pregnancies.future pregnancies.

54. Febrile nonhemolyticFebrile nonhemolytic
transfusion reactiontransfusion reaction
 Defined to be a rise in temperature of 1Defined to be a rise in temperature of 1 °°CC
or more and >=38or more and >=38 °°C, within 24 hours ofC, within 24 hours of
transfusiontransfusion
 without evidence of a hemolytic transfusionwithout evidence of a hemolytic transfusion
reaction.reaction.
 due to cytokines in the blood itself and/ordue to cytokines in the blood itself and/or
produced in the patient from sensitivity toproduced in the patient from sensitivity to
the HLA molecules on platelets and whitethe HLA molecules on platelets and white
cells.cells.

55. Febrile transfusionFebrile transfusion
reactionsreactions
 usually occur due to sensitization tousually occur due to sensitization to
antigens on cell components,antigens on cell components,
particularly leukocytes.particularly leukocytes.
 chills and a temperature risechills and a temperature rise
 60-90 mins after transfusion60-90 mins after transfusion

56. Bacterial contaminationBacterial contamination
 RareRare
 Acquired from contaminated collection bagsAcquired from contaminated collection bags
 Poor cleaning of donor’s skinPoor cleaning of donor’s skin
 reactions are quite severe with high feverreactions are quite severe with high fever
 rigors and/or other systemic symptoms suchrigors and/or other systemic symptoms such
as hypotension, nausea or vomiting.as hypotension, nausea or vomiting.

57. Bacterial contaminationBacterial contamination
 Gram – organisms, Pseudomonas sp.,Gram – organisms, Pseudomonas sp.,
Coliforms and YersiniaColiforms and Yersinia
 Pseudomonas sp can grow at 4Pseudomonas sp can grow at 4°C°C
– Are the most commonAre the most common
– Don’t transfuse theDon’t transfuse the greengreen oror purplepurple units.units.

58. Bacterial contaminationBacterial contamination
 Platelets (kept at room temperaturePlatelets (kept at room temperature
during their 5-day shelf life) are a greatduring their 5-day shelf life) are a great
culture mediumculture medium
– especially for skin staphylococci from theespecially for skin staphylococci from the
venipuncturevenipuncture

59. Bacterial contaminationBacterial contamination
 Transfusion should be stopped andTransfusion should be stopped and
the bag sent for gram stain andthe bag sent for gram stain and
culture.culture.
 The Blood Center should be notified.The Blood Center should be notified.
 The patient should have blood culturesThe patient should have blood cultures
obtained and, if appropriate, IVobtained and, if appropriate, IV
antibiotic therapy begunantibiotic therapy begun

60. Transfusion Related AcuteTransfusion Related Acute
Lung Injury (TRALI)Lung Injury (TRALI)
 ““noncardiogenic pulmonary edema”noncardiogenic pulmonary edema”
 Defined to be ARDS within 6 hours ofDefined to be ARDS within 6 hours of
a transfusion with no other clear causea transfusion with no other clear cause
 occurs when donor plasma containsoccurs when donor plasma contains
an antibody, usually against thean antibody, usually against the
patient's HLA or leukocyte specificpatient's HLA or leukocyte specific
antigens.antigens.

61. Transfusion Related AcuteTransfusion Related Acute
Lung Injury (TRALI)Lung Injury (TRALI)
 1 in 1000; fatality rate <1% with estimates1 in 1000; fatality rate <1% with estimates
varying widelyvarying widely
 The cause is apparently antibodies in theThe cause is apparently antibodies in the
donor plasma against the patient’sdonor plasma against the patient’s
neutrophils (which, in the sick, areneutrophils (which, in the sick, are
marginated in the lung vessels).marginated in the lung vessels).
 The donor antibodies cause theseThe donor antibodies cause these
neutrophils to release toxic products andneutrophils to release toxic products and
thus produce ARDS.thus produce ARDS.

62. Clinical presentationClinical presentation
 dyspnea, hypotension and feverdyspnea, hypotension and fever
typically begin 30 minutes to 6 hourstypically begin 30 minutes to 6 hours
after transfusionafter transfusion
 chest x-ray shows diffuse non-specificchest x-ray shows diffuse non-specific
infiltrates , “white out”infiltrates , “white out”

63. TreatmentTreatment
 Therapy is primarily supportiveTherapy is primarily supportive
 Ventillatory support may be requiredVentillatory support may be required
for several days before resolution..for several days before resolution..
 The Blood Center should be notifiedThe Blood Center should be notified
so that the donor may be tested forso that the donor may be tested for
antibodies against the patientantibodies against the patient

64. Electrolyte toxicity (i.e.,Electrolyte toxicity (i.e.,
potassium)potassium)
 A real danger for newbornsA real danger for newborns
– one may prefer washed red cells.one may prefer washed red cells.
 If hemolyzed blood is administeredIf hemolyzed blood is administered
(i.e., the blood was left on the radiator(i.e., the blood was left on the radiator
or the warmer was too hot), the resultor the warmer was too hot), the result
will bewill be catastrophiccatastrophic..

65. HypothermiaHypothermia
 Red cells and fresh frozen plasma areRed cells and fresh frozen plasma are
chilly.chilly.
 An extra blanket is much safer than anAn extra blanket is much safer than an
electric warming coilelectric warming coil
– even “the special warmers for blood thateven “the special warmers for blood that
don’t go over 104o F / 40o C.don’t go over 104o F / 40o C.

66. OvertransfusionOvertransfusion
 Rapid infusion of bloodRapid infusion of blood
– Plasma expanders, iv fluidsPlasma expanders, iv fluids
– Regulate BT 2-4 hrs each bagRegulate BT 2-4 hrs each bag
– CVPCVP
– diuresisdiuresis

67. Transmission ofTransmission of
diseasesdiseases
 Malaria, Chagas’, syphilisMalaria, Chagas’, syphilis
– Transmitted BTTransmitted BT
 CMVCMV
 Hepatitis C and HIV-1Hepatitis C and HIV-1
– Dramatically decreasedDramatically decreased
 Better antibody and nucleic acid screeningBetter antibody and nucleic acid screening
– 1 per 1,000,000 units1 per 1,000,000 units
 Hepatitis BHepatitis B
– 1 per 100,000 units1 per 100,000 units

68. Transmission ofTransmission of
diseasesdiseases
 Hepatitis AHepatitis A
– Very rare, no asymptomatic carrier stateVery rare, no asymptomatic carrier state
 ““Pathogen in-activation system”Pathogen in-activation system”
– Reduces infectious levels of all virusesReduces infectious levels of all viruses
and bacteria transmissible by transfusionand bacteria transmissible by transfusion

69. Pathogen InactivationPathogen Inactivation
TechnologyTechnology
 for platelets and plasmafor platelets and plasma use the smalluse the small
molecule amotosalen HClmolecule amotosalen HCl which penetrateswhich penetrates
cells and pathogens and targets DNA andcells and pathogens and targets DNA and
RNA. RNA.
 Once docked inside DNA and RNA,Once docked inside DNA and RNA,
amotosalen is activated by ultraviolet lightamotosalen is activated by ultraviolet light
to form a chemical crosslink that locks-upto form a chemical crosslink that locks-up
the strands of nucleic acid,the strands of nucleic acid, blockingblocking
replicationreplication. .
 for red cells uses a different moleculefor red cells uses a different molecule (S-(S-
303)303) that forms crosslinks when activatedthat forms crosslinks when activated
by a change in pH. by a change in pH.

70. Pathogen InactivationPathogen Inactivation
TechnologyTechnology
 Treated pathogens areTreated pathogens are
inactivated by the process andinactivated by the process and
can no longer multiply andcan no longer multiply and
cause disease.cause disease.

71. Pathogen InactivationPathogen Inactivation
TechnologyTechnology

72. Indications for bloodIndications for blood
replacementreplacement
 Improve in Oxygen-carrying capacityImprove in Oxygen-carrying capacity
 Volume replacementVolume replacement
 Replacement of clotting factorsReplacement of clotting factors

73. What are the indications for RBCWhat are the indications for RBC
transfusion in the critically ill surgicaltransfusion in the critically ill surgical
patient?patient?
 No single measure can replace good clinicalNo single measure can replace good clinical
judgement as the basis for decision-makingjudgement as the basis for decision-making
regarding perioperative transfusionregarding perioperative transfusion
 Mild-to-mod anemia does not contribute toMild-to-mod anemia does not contribute to
perioperative morbidityperioperative morbidity

74. .... indications for RBC transfusionindications for RBC transfusion
 ““Universal trigger”Universal trigger”
– 70g/dL for a healthy low risk patient70g/dL for a healthy low risk patient
– 10g/dL for patients with cardiopulmonary10g/dL for patients with cardiopulmonary
diseasedisease
 Wound healing and postop infection is notWound healing and postop infection is not
influenced by normovolemic anemiainfluenced by normovolemic anemia
 Transfusion should not be consideredTransfusion should not be considered
substitute for good surgical and anestheticsubstitute for good surgical and anesthetic
techniquetechnique

75. Volume replacementVolume replacement
 Most common indication for BloodMost common indication for Blood
transfusiontransfusion
– Acute blood lossAcute blood loss
 Measures of hgb and hctMeasures of hgb and hct
– Misleading in acute bleedingMisleading in acute bleeding
– Normal in spite of severely contractedNormal in spite of severely contracted
blood volumeblood volume

76. Blood loss of 1L in aBlood loss of 1L in a
healthy adulthealthy adult
 Venous hct falls byVenous hct falls by
– 3% in the first hour3% in the first hour
– 5% at 24 hours5% at 24 hours
– 6% at 48 hours6% at 48 hours
– 8% at 72 hours8% at 72 hours

77.  The theoretical “The theoretical “transfusion triggertransfusion trigger,” or,” or
the critical point at which a physicianthe critical point at which a physician
decides to transfuse a patientdecides to transfuse a patient

78. RBC InfusionRBC Infusion
 Rarely for Hgb>10g/dLRarely for Hgb>10g/dL
Usually for Hgb <7g/dLUsually for Hgb <7g/dL
Decision based on risk forDecision based on risk for
complications related to inadequatecomplications related to inadequate
oxygenationoxygenation

79. Platelet InfusionPlatelet Infusion
 Rarely for PLT>100,000Rarely for PLT>100,000
Usually for PLT<50,000Usually for PLT<50,000
For PLT between 50,000 and 100,000For PLT between 50,000 and 100,000
decision based on assessment of riskdecision based on assessment of risk

80. FFP InfusionFFP Infusion
 Microvascular bleeding present andMicrovascular bleeding present and
PT or PTT is 1.5 times normalPT or PTT is 1.5 times normal
 In the absence of lab results: AfterIn the absence of lab results: After
transfusion of 1 total blood volumetransfusion of 1 total blood volume

81. Transfusion indicationsTransfusion indications

82. PACKED RED CELLSPACKED RED CELLS
 Hemoglobin less than 7 gm/dLHemoglobin less than 7 gm/dL
 Preoperative hemoglobin less than 9 gm/dLPreoperative hemoglobin less than 9 gm/dL
and operative procedures or other clinicaland operative procedures or other clinical
situations associated with major predictablesituations associated with major predictable
blood lossblood loss
 Symptomatic anemia in a normovolemicSymptomatic anemia in a normovolemic
patientpatient
 Acute loss of at least 15% of estimatedAcute loss of at least 15% of estimated
blood volume with evidence of inadequateblood volume with evidence of inadequate
oxygen delivery following volumeoxygen delivery following volume
resuscitationresuscitation

83. FRESH FROZENFRESH FROZEN
PLASMAPLASMA
 PT or PTT greater than 1.5 times the meanPT or PTT greater than 1.5 times the mean
of the reference range (PT>16, PTT>39) inof the reference range (PT>16, PTT>39) in
a non-bleeding patient scheduled toa non-bleeding patient scheduled to
undergo surgery or invasive procedureundergo surgery or invasive procedure
 Massive transfusion (more than 1 bloodMassive transfusion (more than 1 blood
volume or 10 units) and coag tests are notvolume or 10 units) and coag tests are not
yet availableyet available
 Emergency reversal of coumadinEmergency reversal of coumadin
anticoagulationanticoagulation
 Coagulation factor deficiencyCoagulation factor deficiency

84. PLATELETSPLATELETS
 Platelet count less than 20,000 in a non-bleedingPlatelet count less than 20,000 in a non-bleeding
patient with failure of platelet productionpatient with failure of platelet production
 Platelet count less than 50,000 and impendingPlatelet count less than 50,000 and impending
surgery or invasive procedure, patient activelysurgery or invasive procedure, patient actively
bleeding, or outpatientbleeding, or outpatient
 Patients during or after open heart surgery or intra-Patients during or after open heart surgery or intra-
aortic balloon pump with diffuse bleedingaortic balloon pump with diffuse bleeding
 Massive transfusion (more than 1 blood volume orMassive transfusion (more than 1 blood volume or
10 units) when platelet counts are not available10 units) when platelet counts are not available
 Qualitative platelet defect (bleeding time greaterQualitative platelet defect (bleeding time greater
than 9 minutes) with bleedingthan 9 minutes) with bleeding

85. Platelet concentratesPlatelet concentrates
 Transfusion Guidelines:Transfusion Guidelines:
– Platelet count < 20,000/mm3Platelet count < 20,000/mm3
– Platelet count <50,000/mm3Platelet count <50,000/mm3 if withif with
microvascular bleedingmicrovascular bleeding
– Complicated surgeries with >10 units of bloodComplicated surgeries with >10 units of blood
transfused, with signs of microvascular bleedingtransfused, with signs of microvascular bleeding
– Documented platelet dysfunction(prolonged BT,Documented platelet dysfunction(prolonged BT,
abnormal plt function tests)abnormal plt function tests)

86. CRYOPRECIPITATECRYOPRECIPITATE
 Fibrinogen less than 100 mg/dLFibrinogen less than 100 mg/dL
 Fibrinogen less than 120 mg/dL with diffuseFibrinogen less than 120 mg/dL with diffuse
bleedingbleeding
 Von Willebrand disease or hemophiliaVon Willebrand disease or hemophilia
unresponsive to desmopressin (DDAVP)unresponsive to desmopressin (DDAVP)
and no appropriate factor concentratesand no appropriate factor concentrates
availableavailable
 Uremic bleeding if desmopressin isUremic bleeding if desmopressin is
ineffectiveineffective
 Factor XIII deficiencyFactor XIII deficiency

87. major indication formajor indication for
whole blood transfusionwhole blood transfusion
 some cases of cardiac surgerysome cases of cardiac surgery
 massive hemorrhage when more thanmassive hemorrhage when more than
10 units of red blood cells are required10 units of red blood cells are required
in any 24-hour periodin any 24-hour period

88. Massive transfusionMassive transfusion
 Death by exsanguination has beenDeath by exsanguination has been
described as the loss of 150 mL ofdescribed as the loss of 150 mL of
blood per minute, which results in lossblood per minute, which results in loss
of half the blood volume in 20 minutesof half the blood volume in 20 minutes
 It has also been classified as bloodIt has also been classified as blood
loss of more than 5,000 mLloss of more than 5,000 mL
 10 units of blood transfused within 2410 units of blood transfused within 24
hourshours

89. Massive transfusionMassive transfusion
 replacement of one entire blood volumereplacement of one entire blood volume
within 24 hourswithin 24 hours
 50% blood volume replacement within 350% blood volume replacement within 3
hourshours
 transfusion of more than 20 units oftransfusion of more than 20 units of
erythrocyteserythrocytes
 requiring 4 units of blood within an hour withrequiring 4 units of blood within an hour with
anticipation of ongoing usageanticipation of ongoing usage

90. Massive transfusionMassive transfusion
 Most MTPs call for the use ofMost MTPs call for the use of
uncrossmatched type O negative (O-)uncrossmatched type O negative (O-)
blood as the first-line infusionblood as the first-line infusion
preference.preference.

91. O negative bloodO negative blood
 universality and timely availability fromuniversality and timely availability from
hospital blood bankshospital blood banks
 when used during massivewhen used during massive
exsanguination is potential problemsexsanguination is potential problems
with crossmatching and incompatibilitywith crossmatching and incompatibility
later in the patient’s hospital staylater in the patient’s hospital stay
– more than 4 unitsmore than 4 units

92. O+ bloodO+ blood
 It has been shown to be generally safeIt has been shown to be generally safe
and can help prevent blood shortagesand can help prevent blood shortages
 administer to men andadminister to men and
postmenopausal womenpostmenopausal women
 To woman of childbearing age canTo woman of childbearing age can
result in sensitizationresult in sensitization

93. Massive transfusionMassive transfusion
complicationscomplications
 Coagulopathy is caused by a dilutionalCoagulopathy is caused by a dilutional
effect on the host's clotting factors andeffect on the host's clotting factors and
platelets, as well as the lack ofplatelets, as well as the lack of
platelets and clotting factors in packedplatelets and clotting factors in packed
red blood cells.red blood cells.
 Volume overloadVolume overload
 HypothermiaHypothermia

94. Massive transfusionMassive transfusion
complicationscomplications
 HyperkalemiaHyperkalemia may be caused by lysis ofmay be caused by lysis of
stored red cellsstored red cells
 Metabolic acidosisMetabolic acidosis and hypokalemia may beand hypokalemia may be
caused by the transfusion of a large amountcaused by the transfusion of a large amount
of citrated cells.of citrated cells.
 Hypocalcemia due to citrate toxicityHypocalcemia due to citrate toxicity maymay
occur in those with hepatic failure,occur in those with hepatic failure,
congestive heart failure (CHF), or other low-congestive heart failure (CHF), or other low-
output states.output states.
– It is increasingly uncommon with the use ofIt is increasingly uncommon with the use of
component therapy.component therapy.

95. Massive transfusionMassive transfusion
complicationscomplications
 Use of blood from multiple donorsUse of blood from multiple donors
increases the risk of hemolyticincreases the risk of hemolytic
reactions as a consequence onreactions as a consequence on
incompatibilityincompatibility

96. Transfusion optionsTransfusion options
 Type-specific, non-cross-matched bloodType-specific, non-cross-matched blood
 May be used in emergenciesMay be used in emergencies
 O-negative, type-specific is equally safeO-negative, type-specific is equally safe
– Also called the “Also called the “universal t ransf usion productuniversal t ransf usion product ””
 Hemoglobin solutionsHemoglobin solutions
 Autologous tansfusionAutologous tansfusion
 hemodilutionhemodilution

97. Methods ofMethods of
administering bloodadministering blood
 Rate depends on patient’s statusRate depends on patient’s status
 IntravenousIntravenous
 IntraperitonealIntraperitoneal
– 90% enters the circulation90% enters the circulation
– Absorbtion for atleast a weekAbsorbtion for atleast a week
 Medullary cavityMedullary cavity

98. Methods ofMethods of
administering bloodadministering blood

99. Special concernSpecial concern
 Jehovah’s Witnesses cannot accept donorJehovah’s Witnesses cannot accept donor
packed red cells, platelets, white cells orpacked red cells, platelets, white cells or
plasma, and cannot accept autologous orplasma, and cannot accept autologous or
cell-cycled intraoperative transfusion.cell-cycled intraoperative transfusion.
 The sect leadership used to be militantlyThe sect leadership used to be militantly
anti-immunization, anti-germ theory, andanti-immunization, anti-germ theory, and
anti-transplantation as wellanti-transplantation as well

100. Blood transfusionBlood transfusion
therapytherapy
Raymund AG Ong, MD FPCS FPALESRaymund AG Ong, MD FPCS FPALES
Department of SurgeryDepartment of Surgery
FEU-NRMF Medical CenterFEU-NRMF Medical Center