Blood Transfusion

Department of Anesthesiology & Reanimation School of Medicine, Padjadjaran University/

Hasan Sadikin General Hospital Bandung

Introduction

Blood transfusion :Transfer of Blood/ Blood component fromdonor’s blood to receiver’s circulation

Goals :- Improve circulation volume- Improve Hb level- Improve coagulation mechanism

Cautions :- Appropriate indications- Appropriate techniques- Observations of sign of complications- Prevention and therapy for complications

Type of Blood/Blood Component for transfusion

1. Whole Blood

* Fresh Blood, storing time 4-6 hours advantages :

- complete caogulation factors- good blood cell functions

disanvantages :- impractical supply- risk of infections transmission i.e lues, CMV

* New blood, storing time 3-4 daysadvantages :

- easy suppliyng

disadvantages :- coagulation factors, especially factor V and VIII

almost depleted ( high Hb affinity to O2

decreased O2 release from Hb to tissue)- High concentration of K+, amonium and lactic

acid

2. Red blood cell

advantages :a. plasma is not given. Avoid circulation overloadb. hematocrit level could be tailoredc. hepatitis (infections) hazard avoidedd. advantages in patients with renal diseasee. allergic reactions decreasedf. autoimmun bodies reactions decreasedg. anticoagulant free

disadvantages :a. possible infections hazard during preparationb. short storing period, 4-6 hours.

Packed Red Cell-made by separating/extracting plasma in closemethode until hematocrit level 70 – 80 %

Red Cell Suspensions- made by mixing RBC’s concentrate with solvent onequal volume

Washed Red Cell-made by washing RBC concentrate 2-3 times withphysiologic NaCl solution :a. PNH (Paroxysmal Nocturnal Hb-uria)b. Acquired Haemolytic Anemiac. Exchange transfusiond. Transfusion on renal transplant.

3. Thrombocyt

given to patients with thrombocyt deficits due to primary diseaseor secondary due to bleeding.

Type of thrombocyt :1. Platelet Rich Plasma (PRP)

PRP made by separating plasma from fresh blood

2. Platelet’s ConcentrateMade by centrifuging PRP and separating its thrombocytconcentrate

Storing :a. In 40 Celcius - good haemostatic, short life spanb. In 180 Celcius - poor hemostatic, better life span

Storing time 48 – 72 hours

4. Plasma

a. restore blood volume and circulationb. replace and enhance blood proteinsc. replace and improve spesific plasma factor

* Liquid plasmamade by separating plasma from whole blood on packed red cellpreparation process

* Dry plasmamade by drying liquid plasma

Advantages :- long storing time (3 years)- easy transport- room temperature storage- no risk of lues infections- independent of blood group

Disadvantages :- higher risk of hepatitis infection due to collected from various donors.

* Fresh Frozen Plasma

made by separating plasma from fresh whole blood andimmediately freezed at minus 600 Celcius (CO2 ice)

storage :- at temp. minus 300 C for 1 year- at temp. minus 200 C for 6 months

ideally given on :- bleeding cases- as fresh whole bood replacement if mixed with packed

red cell

* Cryoprecipitate

made by freezing fresh frozen plasma at minus 600 Cand liquified at 4-6 C

advantages :contains much amount of factor VIII and factor I(fibrinogen). A bag of cryoprecipitate contains 130units of Anti Hemophylic Factor (AHF)

Complications of Transfusion

1. Hemolytic ReactionRed blood cell destructions occur producing free Hb inplasma due to blood group incompatibility. If free Hblevel more than 25 %, Hb uria occur.

Acute :-occur immediately when transfusion.50 cc of incompatible blood enough to precipitate thereactions

sign :- hot sensation along the veins- specific lumbal pain- ‘depressed chest’ feeling, dyspneu- headache, flushing face- raised body temp., nausea & vomitting- during anesthesia :

tachypneu, hypotension, small pulse pressure, shock.Diffuse bleeding from operative wound.

Laboratory :- Hb-uria- Peripheral blood preparate hemolytic sign- Blood bilirubine- Free Hb in plasma- methemoglobine

Delayed :

Occur on patients who recieved frequent transfusionor women who previously had delivered baby.Reactions occur after several hours or days aftertransfusion and commonly after transfusion ofsecond bag or more.

Therapy :

- stop transfusion, change transfusion set- treat shock- shock position- plasma expander infusion- vasopressor- sodium bicarbonate- oxygenation- lasix / 20 % manitol- corticosteroids- report to blood bank

* send back transfused blood* send sample of patients blood* patients urine

- control Hb level* thrombocyt* fibrinogen

- give compatible fresh blood

2. Non Hemolytic Reactions

1. Allergy- antigen in donor’s blood will bound with it’s

antibody in recipient’s serum- antibody which present in donor’s blood which

passively transfered by transfusion to recipient

therapy :give antihistamine and corticosteroid on severereactions.

2. Pyrogen reactionssign :- febrile (38-400 C)- shivering, headache, pain on the whole body, restless untill

convulsions

3. Bacterial containation reactions- bacterial contamination could occur during blood

collecting.

Sign :- febrile, headache, shivering, vomitting, stomachache,

diarrhea to shock.These sign occur during or immediately after transfusion

Therapy :- stop transfusion- treat shock (plasma expander, vasopressor, oxygen etc)

4. Overload

occur due to transfusion of relatively too highvolume in a short period.For these reason, whole blood should be givencautiously on some circumstances :

- anemia- decreased cardiac reserve- renal disease- oedema

sign :

- headache, precardial pain, coughing, dyspneu,heavy feeling on both arms, pulmonary rhales and‘elevated’ neck veins

therapy :

For patients with overloading tendency :- Infusion drips as slow as possible

(adult 12-30 drips/min, children 6-8 drips/min)- diuretics before transfusion- only blood component is given- close observation during transfusion

5. Heart rhythm disturbances

mostly occur on rapid and massive transfusion of :- cold blood- elevated K+ level- citrate toxicity

general therapy :- slowing transfusion rate

specific therapy:- blood heated to body temperature- better if switch to fresh blood

6. Acidosis

On patients with acidosis tendency (i.e. renalfailure, ileus, septic conditions) administeringstored blood will worsening those condition, sodid massive transfusion.

Therapy :-correction of acidosis with sodium bicarbonate

7. Kalium toxicity

due to elevated K+ level in blood which stored more than10 days

sign:- ECG changes- Cardiac arrest danger

Prevention :- administer fresh blood

therapy :- enforce diuresis- Glucose 5 % infusion + regular insuline 8-12 units

8. Citrate toxicity

especially on massive transfusion (>2 liters) on patients withpoor hepatic function, where citrate will bound to Ca++ ion.

Sign :- tetany, tremor, ECG disturbances to cardiac arrest

therapy :- Ca gluconate i.v or CaCl2 1 gram every 1000 ml of blood transfused

9. Coagulation disorder

especially on massive transfusion with storedblood, due to reduced thrombocyt and othercoagulation factors.

Therapy :- administering 1 unit of FFP or

cryoprecipitate for every 5 unit of wholeblood.

10. Hyperammonium

- amonium blood level increase after 5-7 days andreach maximal level after 3 weeks of storage

therapy :- administering fresh blood.

11. Air embolism

due to technical error, especially on transfusionwith ‘pressured’ bag

therapy :- positioning the patient laterally to cardiac side- shock positioning

12. Transmission of disease

* Hepatitissign & symptoms appear 2-3 months after transfusion

sign :icterus, hepatomegaly, spleenomegaly

therapy :-immuniglobuline, diet to improve hepatic functions

prevention :Donor is not accepted before 5 years of convalescenceperiod

* Malariasign appear after 1-10 days afer transfusion

prevention :Donor is not accepted under 2 years from last attack.

therapy :- antimalarial drugs

* Syphylissign appear 9-10 weeks post transfusion and manifestas stage II skin lesions.

Methods for estimating blood loss

1. Measuring Gauze’s WeightBlood loss equal to gauze weight difference before and after used(1 gram equal to 1 ml blood)

2. Calori meterUsed gauze washed with standardized water and ammonium

3. Visual EstimationCould be done by an experts. Blood clot of “a fist size” equal to about½ liter of blood.

4. Measuring blood on suction apparatusSometimes difficult due to other liquid mixing or suction rinsing withwater.

5. Patients clinical conditionsDifficult due to anesthetic drug alter clinical response to bleeding

Transfusion techniques

1. Infusion set preparation

Infus set must be equipped with filterInfusion needle gauge should be appropriate tointended rate of transfusion a. easily damage venous wall, causing swollen tissue b. commonly use on babies,easy fixation c. plastic catheter with stylet inside, if already inserted, will not damage the vein easily

3. Inserting infusion seta. notify the patient if an infusion will be insertedb. If possoble, choose a large- straight vein which not

locate on ajointc. Stagnate the veind. Do not attemp/reattemp on acollapsed veine. Fixation

Better if on three locations- on the root of the catheter- on rubber plastic junction- on transparant plastic hose

f. Use splint g. On emergency conditions could inserted > 1 infusion h. Build patients cooperation, on conscious patients i. on emergency condition j. all procedure must be done under sterile conditions

3. Blood bag preparation

a. Must be carefull !patient’s identity, blood group, cross-matchresult, bag label number, blood plasma colour,any blood clot

b. Do not shake blood bagc. Before transfused, blood should be warmedd. Blood must keep refrigerated before usee. Blood bag which already perforated, must

immediately transfused

4. On transfusing blood

a. Note! Blood pressure, heart rate, respirationand patinet’s temperature

b. Before transfusing blood, give NaCl infusionc. If blood drips stagnant, change transfusion setd. During first 15 minutes, patients should be

carefully monitorede. During transfusion, blood pressure &

respiration must be monitored

5. Rate of transfusiona. On massive bleeding, administer blood as fast

as possible (1500 ml in 15 minutes)b. On normovolemic patients :

adult : 500 ml / 5-6 hourschildren : depend on body weight and age

6. Tricks for enhancing blood transfusiona. Put blood bag as high as possibleb. Insert big bore catheterc. Give pressure to blood bagd. Injecting blood on the catheter