Key Points in Blood and Blood Products Transfusion

Practice

Siti Rohayah SulaimanDepartment of Anaesthesia & Intensive Care,

HRPB, Ipoh

Overviewblood components

blood grouping

transfusion indication

administration of blood components

transfusion complication/reactions

summary

Blood Components

Packed red blood cells (PRBC)

Platelets

Fresh Frozen Plasma (FFP)

Cryoprecipitate (CP)

Cryo poor plasma (CPP)

1 unit of blood theoretically gives;

1 PRBC

1 FFP

1 random donor unit platelet

Storage Condition

PRBC : 4-6’C, shelf life 35 days

FFP/CPP : -40’C, shelf life 1 year

Cryoprecipitate : -40’C, shelf life 1 year

Platelet : 22-24’C on platelet agitator, shelf life 5 days

Blood Grouping:ABO & Rh Compatibility

4 types of blood group

O, A, B, AB

Group O - universal donor, but can only receive O

Group AB - universal recipient, but can only donate to AB

Rh -ve/Rh tve

Rh tve can receive Rh -ve blood, but Rh -ve can't receive Rh the blood

Blood & Blood Products Transfusion in Critically Ill

RBC transfusion>40% - receive RBC transfusion in ICU, 90% for stable anaemia

PRBC indications in ICU;

Acute haemorrhage with haemodynamic instability

Acute anaemia with evidence of inadequate O2 delivery - restless, obtundation, lactate acidosis, cool peripheries

Transfusion threshold Hb < 7-8 g/dL - depending on patient

based on Transfusion Requirement in Critical Care (TRICC) trial

833 critically ill patient, liberal (Hb<10 gm/dL) vs restrictive (Hb <7 gm/dL)

exceptional in acute myocardial ischaemia (Hb < 10 g/dL)

restrictive strategy reduce hospital mortality

2014 metanalysis - confirm TRICC trial finding

liberal transfusion Hb > 8 gm/dL, increase risk of nosocomial infection

co-morbic heart disease Hb <8.7 gm/dL, maintain Hb near 10 gm/dL in acute MI

NEJM, 2013 - Transfusion for acute UGIT bleeding

921 patients with UGIT bleed

randomly assigned RBC transfusion Hb<7 gm/dL vs Hb < 9 gm/dL

patients in lower trigger group, Hb<7 gm/dL had higher survival at 6 weeks, less ongoing bleeding & fewer complication

Potential efficacy of transfused RBC

circulatory (volume) effect

more immediate effect

not recommended as volume expander

rheological effect - blood flow/viscosity

important in maintaining microvascular circulation in severe haemodilution

improved oxygen transportation

improved Hb ~ 1 g/dL per unit RBC

not necessarily improved O2 delivery/consumption at tissue level

Platelet transfusionsProphylaxis

platelet <10x109/L without risk factors for bleeding

platelet <20x109/L with risk for bleeding

to maintain platelet > 50x109/L - for surgery/invansive procedure

Bleeding patient

any bleeding pt dt thrombocytopenia

platelet < 50x109/L in massive bleeding or transfusion

Plasma Transfusionportion of WB that remain after RBC & platelet removed

replacement of single factor deficiencies if specific factor not available

immediate reversal of warfarin induced anticoagulation - in active bleeding/urgent surgical procedure

indication in critically ill less established

active bleeding in setting of known or strongly suspected coagulation abnormalities

Massive transfusion of PRBC

prior to invasive surgical procedures with high risk of bleeding complications

invasive procedures with low risk of bleeding, INR > 2

Cryoprecipitate Transfusion

contain factor VIII, fibrinogen, von Willebrand, factor XIII & fibronectin

treatment of haemophilia, congenital/acquired hypofibrinogemia

liver disease, DIC, hyperfibrinolysis, massive transfusion

Safe & Effective Transfusiondefine indication & benefit

accurate pt identification for blood group and compatibility

identification & careful management of high risk pt

appropriate handling, administration & monitoring

infusion should not be associated with preventable ill effect

inform patient/relatives

aware of possible transfusion related complications

early diagnosis & intervention in adverse events of transfusion

documentation

Administration of blood component

must be checked against patient’s information detail

blood request form

case notes

wristband

Patient monitoring during transfusion

Vital signs - T, BP, PR - before, during and after transfusion

Closely observed during 1st 5-10 min of transfusion

RBC - 1st 50 mls - should transfused slowly

Unconscious patients - vital signs should be check at 15 min interval during transfusion

Periodically observed during transfusion for any acute transfusion reaction

Time limit for infusion of blood componentsRBC

risk of bacteria contamination at room T

start transfusion within 30 min after removing from blood refrigerator

should complete transfusion within 4 hrs

Platelet

keep at T 22-24, never keep in refrigerator

infusion should start as soon as received from blood bank and complete within 30 min

Plasma

start as soon as thawed

should complete as tolerated

Blood administration sets

all blood component - infused using administration set with integrated filter 170 micrometer, to trap any large aggregate

platelet - used new administration set

Blood warmers

reduce incidence of cardiac arrest/arrythmias dt massive transfusion of cold blood component

limited to multiple rapid transfusion >50 mls/kg/hr in adults, 15 mls/kg/hr in children, exchange transfusion

no evidence beneficial in slow infusion

should not be warm by placing in hot water, under running tap,

ComplicationsImmunologic reactions

Acute haemolytic reactions - 0.016%, ABO incompatibility, fatal.

pain at infusion site, fever, chills, back/substernal pain, dyspnea, changes in mental status, hypotension, cyanosis, bleeding

unconscious pt - unexplained hypotension, haematuria, bleeding

Delayed haemolytic reaction - more common (0.025%), mild, 35% undetected

Febrile nonhaemolytic reaction - 7% of RBC transfusion, dt anti leukocytes antibody, self limited

Allergic reaction - dt antigen to which patient has preexisting antibodies.

from mild urticaria to anaphylaxis

ComplicationsVolume overload

volume expansion, may lead to APO esp in cardiac and renal failure patient

Hypothermia

rapidly transfused cold blood product in acute bleeding, reduce core body T 32-35 C

cardiac arrest, arrythmias

Coagulopathy

in significant PRBC transfusion, early resuscitation with colloids/crystalloids

haemodilution, acidosis

replacement of blood product 1:1:1 ratio

ComplicationsCitrate toxicity

present in stored blood products

cause metabolic alkalosis and reduced plasma ionised calcium

Tranfusion related acute lung injury (TRALI)

alloreactive plasma antibodies/biologically active lipids, cause agglutination & activation of leukocytes —> ALI, APO

mild increase in O2 requirements to severe ARDS

Post transfusion purpura

rare disorder, thrombocytopenia develop after 7-10 days post transfusion

Transfusion Reaction

Transfusion Reaction

SummaryTransfusion of blood & blood products common in ICU

> 40% of patients receive one or more RBC transfusion while in ICU

Evidence indicates that a great numbers of patients being transfused RBC may not having benefit from transfusion - in improving clinical outcomes

Challenge lies in identifying patient at risk of complication from anaemia and transfusing them without exposing other patient to unwarranted risk of inappropriate transfusion

Indication for platelet and plasma transfusion not as clear as RBC transfusion

Better and safe transfusion practice should not be view as option, but necessity to ensure benefit than giving harm