Blood Component Transfusion

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Blood Component Transfusion

• Christine Wyrick, MD

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Blood Transfusions

• As an anesthesiologist in the OR, you are
  directly responsible for
• Saving a patients life with blood
• Adverse events that may occur with transfusion

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Available Blood Components

• Packed Red Blood Cells (PRBCs)
• Whole Blood (on PMH 3rd floor)
• Fresh Frozen/Thawed Plasma
• Platelets
• Cryoprecipitate

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Why Transfuse?

• Patients tissues are starved of oxygen (from low
  hemoglobin)need red blood cells
• Patients blood wont clotneed platelets or
  coagulation factors

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Oxygen Delivery

• Arterial O2 content
• 1.34(Hbg)(sat) 0.008 pAO2

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Packed Red Blood Cells

• One unit 300-350cc volume with HCT 55-60
• Stored at 1-6C for up to 35 days
• Once at room temperature, must be used within 4
  hours
• Each unit raises hemoglobin by 1 g/dL, HCT by 3

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PRBCs Indications

• Research shows
• In patients without cardiovascular disease,
  hemoglobin values 7 g/dL are safe
• In the patient experiencing the Acute Coronary
  Event, hemoglobin should be kept above 10 g.

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PRBCs The Gray Area

• Patients with cardiovascular disease but without
  active ischemia--conflicting evidence regarding
  threshold for transfusion

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PRBCs The Gray Area

• The 70-year old blind dialysis-dependent double
  amputee diabetic, hemodynamically unstable,
  undergoing a Whipple, hemoglobin of 9?
• TRANSFUSE

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PRBCs The Gray Area

• The 55 yo, stable angina, railroad track vitals
  during ankle ORIF, hemoglobin of 8?
• Hold off on giving blood (but why is their
  hemoglobin that low?)

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PRBCs Other Considerations

• Free flaps--need healthy blood supply
• Sickle Cell Disease--red cells dont work well
• Burn patients--higher O2 requirements
• Neurosurgical patients in vasospasm--balance O2
  delivery and blood viscosity

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PRBCs Official PHHS Guidelines

• Hypovolemia due to blood loss
• gt20 fall in BP
• HR gt100
• EBL gt1000cc or 15 patients blood volume
• Oliguria
• Orthostatic BP/HR changes

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PRBCs Bottom Line

• Treat the patient, not the number
• Take into account past medical history, starting
  H/H, hemodynamic stability, and the rate of blood
  loss

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Whole Blood

• Contains clotting factors along with RBCs
• Some decrease in levels of factors V and VIII
  with time, but these are still usually adequate
• Platelets are inactivated by cold storage

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Whole Blood

• Only available on 3rd floor (OB), only in types O
  and A
• About 450cc, HCT 40-45
• Transfusion indications similar to those for
  PRBCs

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Thawed Plasma/Fresh Frozen Plasma

• Consists of donated plasma after removal of RBCs
• Volume about 250cc
• Contains all clotting factors
• At PMH, plasma is not stored frozen, so factor
  VIII levels are decreased

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Plasma Transfusion Indications

• Patient is bleeding and has a clotting factor
  deficiency (INR 1.6) or coagulopathy of
  Uncertain Origin
• Reversal of warfarin in emergencies
• TTP with plasmapheresis
• Heparin resistance

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Plasma Transfusion--Nonindications

• Volume expansion (without coagulopathy)--use
  crystalloid/albumin
• Heparin reversal--use protamine
• Isolated factor deficiencies or vonWillebrand
  disease
• Patient is not bleeding

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Plasma Transfusion in the Non-bleeding Patient

• If the patient isnt bleeding and wont have a
  reason to (ie, not pre-op)
• Take a deep breath
• Try some vitamin K
• Think about diagnosis

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Platelets

• Come either pooled (from several people donating
  whole units of blood) or from single donor
  (apheresis platelets)
• Each bag of 250cc raises count by 25-50K
• Kept at room temperature

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Platelet Transfusion

• Platelets are in short supply, so use is
  restricted
• Prophylaxis lt10K
• Most invasive procedures and/or bleeding patient
  lt50K
• Invasive procedure/bleeding and dysfunctional
  platelets lt100K
• Neurosurgery lt100K

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Cryoprecipitate

• When FFP is thawed, some plasma components
  precipitate
• Each bag is 10 pooled units and is about
  150cc
• Kept at room temperature
• Contains fibrinogen, factors VIII and XIII and vWF

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Cryoprecipitate Transfusion Indications

• Low (lt100 mg/dL) or dysfunctional fibrinogen with
  bleeding or patient needing procedure
• vonWillebrand disease
• Uremic bleeding (if DDAVP doesnt work)
• t-PA reversal

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Adjuncts to Transfusion

• DDAVP and factor concentrates
• Factor concentrates are expensive, but have
  advantages
• Useful in specific factor deficiencies
• Do not contribute to volume overload

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Desmopressin

• AKA DDAVP
• Synthetic analogue of vasopressin
• Causes endothelial cell release of factor VIII
  and vWF, enhances platelet function in uremia
• Can use in Jehovahs Witnesses

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Prothrombin Complex Concentrate

• PCC, Profilnine
• Virally-inactivated pooled plasma product
• Contains factors II, VII, IX, and X
• For warfarin reversal--expensive, but low-volume,
  low risk of reactions

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Prothrombin Complex Concentrate

• Has been associated with arterial and venous
  thrombosis
• Unlike FFP, does not contain proteins C and S
• Included in Trauma Coumadin Protocol here at
  Parkland

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Factor VII Concentrate

• NovoSeven
• Recombinant Factor VIIa
• Very expensive
• Used for massive trauma, head bleeds, cardiac
  surgery
• OK for JWs

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Artificial Oxygen Carriers

• Not blood products
• Hemoglobin or perfluorocarbon-based molecules
• None approved for use in the US

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Complications of Transfusion

• Infection
• Transfusion reactions
• Volume overload
• Immunosuppression

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Infectious Complications

• Hepatitis B 1200,000
• HIV and HCV 12,000,000
• HTLV I and II 13,000,000
• CMV 1-17
• Leukoreduction nearly eliminates this risk

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Infectious Complications

• Bacterial
• Most common with platelets since they are never
  refrigerated (and often pooled)
• Incidence as high as 0.1
• Can cause sepsis (most commonly staph/strep)
• All platelet donations are now routinely screened
  for bacteria

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Transfusion Reactions

• Acute hemolytic reactions
• Rare, but life-threatening
• Usually ABO incompatibilities between donor and
  patient due to human error
• Pre-existing antibodies cause massive
  inflammatory response and hemolysis

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Acute Hemolytic Reactions

• Cytokine response--hypotension, tachycardia,
  fever, DIC
• Hemolysis--hemoglobinuria and possible renal
  failure
• May result in total hemodynamic collapse

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Acute Hemolytic Reactions

• Incidence about 177,000
• Stop transfusion immediately if suspected
• Supportive treatment
• Primary prevention--check all blood products

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Delayed Hemolytic Reactions

• Patient has antibodies to more minor RBC antigens
  (Rh, Kell, Kidd, Lewis, etc) from prior exposure
• Hematocrit starts falling 5-10 days after
  transfusion
• May have symptoms, but rarely severe or
  life-threatening

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Febrile Nonhemolytic Reaction

• Increase of gt1C within one hour following
  transfusion
• Usually from reaction of recipient HLA antibodies
  with donor leukocytes
• Risk increases with pooled products (platelets),
  decreases with leukoreduction
• Treat symptomatically--can be severe

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Allergic Reactions

• Common, up to 3 of plasma infusions
• IgE antibodies to proteins in donors plasma
• Usually urticarial, rarely see anaphylaxis

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Transfusion-Related Acute Lung Injury

• TRALI--ARDS from transfusions
• Donor antibodies react against recipient
  leukocytes in the alveoli, causing degranulation,
  bilateral pulmonary edema, and hypoxia

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TRALI

• Onset is 1-2 hours after transfusion, presents
  within 4-6 hours by definition
• Fever, hypotension, hypoxia, dyspnea, pink foam
  from endotracheal tube
• CXR shows bilateral diffuse infiltrates
• Normal heart function
• No other discernable cause

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TRALI

• Treatment is supportive
• Most patients recover in 2-3 days, but may need
  ventilatory support
• Notify blood bank for testing of donor units

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Volume Overload

• Not uncommon when an elderly or CHF patient
  receives multiple transfusions
• Consider invasive monitoring if massive
  transfusions required in the CHF patient

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Immunosuppression

• Blood transfusions induce immune tolerance
• May increase post-operative infection rates,
  increase cancer recurrence rates
• Leukoreduction is felt to mitigate this effect

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Transfusions How To?

• Ask circulating nurse if blood is available
• If not and you think patient may need it, find
  out if blood bank has a clot (answer will be no
  for all outpatients)
• Draw one pink-top tube and send to blood bank,
  tell them how much to get ready

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Blood Typing

• Type and screen patients red cells are tested
  for ABO and Rh, screened for any unusual
  antibodies
• Type and cross a sample of the patients blood
  is mixed with the donors blood to check for
  reaction--these units are designated for your
  patient

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Blood Typing

• Plasma needs ABO matching only
• Platelets and cryo do not need to be matched

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Blood Typing

• In emergent situations, a limited number of Type
  O-negative units are kept in the blood bank
• Type O-positive units can also be given, but
  avoid if possible in pre-menopausal women

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Blood Administration

• Use a filter infusion set
• Platelets come from the blood bank with their own
  special filter
• Use a fluid warmer for PRBCs and FFP
• Dont mix blood products with LR
• Dont put platelets through pressure infusers

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Massive Transfusion Protocol (MTP)

• Details on the Transfusion Medicine website
• Blood products come in series of shipments with
  pre-determined ratios to balance PRBCs with
  other components

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MTP

• Idea is that you simply just give the stuff as it
  comes at you, until its no longer needed
• All blood components still must be checked in

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Special Considerations in MTP

• Citrate used in blood storage chelates calcium in
  the patients blood
• Potassium leaks from red cells during storage
• Lactic acid accumulates during storage
• The risk of adverse events from transfusions
  increases as the number of transfused units
  increases

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Conclusion

• Blood transfusions can save your patient
• Blood transfusions can (rarely) kill your patient
• Keep in mind that YOU give the blood, not the
  surgeon, but keep communications open