A 36 year old shopkeeper presented with 2 months history of weakness, shortness of breath on exertion and pain upper abdomen

off & on. Except for pallor the physical examination was unremarkable. Investigations revealed Hb 7 g/dl and low serum ferritin. One year ago he had similar illness and was given 2 unit of blood transfusion by a General Practitioner. He gave hisotry of fever and chills during the blood transfusion that settled with some injections. What would you suggest the patient?
a. Two unit of leuco- poor blood to avoid febrile reaction b. Two units of whole blood c. Patient does not need transfusion because the risks outweigh the benefit

What is the next course of action?

PREPARATION OF BLOOD COMPONENTS

Platelet Concentrate

Platelet-rich Plasma Whole Blood

1st Spin

2nd Spin

FFP for Clinical use FFP for Fractionation

Fresh Plasma

Rapid freezing & Thawing at 40C

Red Cell Concentrate

Cryoprecipitate

Cryosupernatant

Blood Products
RED CELL PRODUCTS
Red cell concentrate, Leuco-reduced red cells, Washed RCC, Frozen RCC ,Reduced volume packs (Paediatric use)

PLASMA PRODUCTS
FFP, Cryoprecipitate, Cryosupernatant, Single donor plasma (Apheresis)

PLATELET PRODUCTS
Random donor platelets Single donor platelets

AUTOLOGOUS BLOOD STEM CELLS

Haemotherapy -The Decision

Guidelines Clinical judgment
Blood & blood components must be administered only when absolutely indicated & when other forms of therapy are ineffective Therapeutic benefit outweighs potential risks & adverse effects

Guidelines
Haemoglobin level
Hb > 10 g/dl: Hb < 7 g/dl: Hb < 8- 9 g/dl: Transfusion unjustified Transfusion may be required Transfusion if risk factors present

Blood Volume Loss

15% ( 750 ml ) No need of transfusion disease or if blood loss continues 30-40%(1500-2000 ml) RCC Transfusion 40% (> 2000 ml) RCC / whole blood transfusion 15-30% (800-1500 ml) If preexisting anaemia or CVS

INDICATIONS FOR RCC

Objective: to improve oxygen carrying capacity Bone marrow failure Inherited RBC disorders -thalassaemia major , sickle cell anaemia Acquired RBC disorders Severe haemolytic anaemia Chronic renal failure

FRESH BLOOD
No acceptable definition Indications Haemorrhagic shock, severe pulmonary disease, premature infants, cardiac surgery in small children Special Situations: Blood < 7 days old (normal 2,3 DPG) Blood < 48 hours old (normal potassium)

WHOLE BLOOD
Indications: Active bleeding with >25% loss Liver transplantation, massive blood transfusions Exchange Transfusion Use on decline Wastage of resources Difficult to balance community needs

Preparation of FFP
Preparation - From whole blood within 6 hrs of collection by centrifugation & rapid freezing to 300 C or less - ~ 200 ml - All coagulation factors, FVIII >70%, Fibrinogen : 250 - 400 mg Storage Shelf Life Thawing - 300C or lower - 1 year - At 370C in thawing bath within 15 - 30 minutes

Volume Contents

INDICATIONS of FFP
Coagulation Defects with evidence Active bleeding PT Defects Vitamin K deficiency Liver disease Immediate reversal of warfarin effect DIC Massive transfusion > 1.5 times the control PTTK > 1.5 times the control

Administration of FFP
Administration - Within 2 hrs of thawing If delay store at 40C (< 24 hrs) Must not be refrozen Compatibility Dosage - ABO compatible AB plasma universal donor - 10-15 ml / kg.

Rate of Infusion - In Less than 4 hrs

Inappropriate Use
Volume expander Nutritional support Treatment of immune deficiency states

Preparation of Cryoprecipitate
Preparation: By thawing FFP unit at 40C & rapid freezing to 300C or below within 2 hrs of its preparation Volume Contents Storage : : : 20 ml FVIII, vWF, Fibrinogen, Fibronectin FXIII Stored at 300C 12 months In water bath at 370C for 15 min

Shelf Life : Thawing :

Indications of Cryoprecipitate
Congenital Hemophilia A Von Willebrands disease Factor XIII deficiency Hypofibrinogenaemia Acquired DIC Uraemic bleeding Streptokinase therapy

Indications of Platelet Transfusion

Thrombocytopenia
Failure of Platelet Production Increased Destruction

Platelet Count & Bleeding

Platelet Count > 50,000/l: Bleeding unlikely due to thrombocytopenia 10,000- 50,000/l: Risk of haemorrhage during haemostatic challenge 5000-10,000/l: Increased risk of spontaneous haemorrhage <5000/l: Risk of severe life threatening haemorrhage

Massive Transfusion
Replacement of one or more blood volumes within 24 hours ( > 10 units red cells) Indications: Major trauma ( # femur, pelvis ) Massive GIT haemorrhage Post partum haemorrhage Ruptured aortic aneurysm Vascular Surgery

Massive Transfusion Adverse Reactions

Hypothermia Dilutional thrombocytopenia Dilutional Coagulopathy Citrate toxicity Acid base imbalance

Massive Transfusion Treatment of adverse effects

Crystalloids, colloids, whole blood / RCC, Blood warming Platelet concentrates if platelets < 50,000 / l FFP if PT / APTT > 1.5 normal range Cryoprecipitate if fibrinogen < 100 mg/dl

ADVERSE REACTIONS TO TRANSFUSION

it transfusions

cal analysis

History of complications Over the Years

ABO 1900 1940 1945 1949 1972 1984 1984 1989 + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Rh MP Syph HBV CMV HIV HCV

And the story goes on, we solved one problem , only to face another situation ---------

Definition

Any unexpected or unfavorable sign or symptom that occurs during or shortly after transfusion should be considered to have been caused by blood / blood component unless proven otherwise SHOT

Transfusion Reactions
Acute
Immunologic Nonimmunologic Bacterial contamination Circulatory overload

Delayed
Immunologic Nonimmunologic

Haemolytic

Haemolytic

Haemosiderosis

Febrile non haemolytic Allergic

Post transfusion purpura Diseases Transmission

Non cardiogenic Physical/chemical Pulmonary haemolysis

TA- GVHD

Acute Haemolytic Reactions

Incidence: 1:33,000 Aetiology
Red Cell incompatibility -DUE TO CLERICAL MISTAKES Interaction of transfused red cells with preformed antibodies

Intravascular Haemolysis Neuroendocrine response Complement activation Coagulation effects Cytokine effects

Clinical Features
Anxiety, Chills, fever Pain along infusion line Hypotension Haemoglobinuria (back pain) Renal failure DIC oozing from surgical site Uncontrolled hypotension

Under GA patients

DIFFERENTIAL DIAGNOSIS
Consider most serious and potentially fatal
a. Acute Hemolytic Transfusion reaction

b. Anaphylaxis c. Transfusion induced sepsis

d. TRALI e. f. Treatment related fever Disease related fever

Immediate Actions
Stop Transfusion Maintain I/V Line Check for clerical errors -Check all labels ,forms, and patients identification Report to the blood bank with all the clinical details

Samples Required
Blood Bag Blood in EDTA Blood in citrate Clotted Blood Urine

Principles of Management
Urine out put > 100 ml/hr for 18-24 hrs Monitor Vital signs & CVP Diuresis Ionotropic support DIC management

Non-Hemolytic Febrile Transfusion Reactions (NHFTR)

Antibodies to HLA Class I antigens Fever & Chills Management Prevention Leuco depletion Washed RCC

Prevention of NHFTR

Delayed Haemolytic Transfusion Reactions

Anamnestic (secondary) response to red cells antigens Generally asymptotic Patients reports back after 10-12 days after discharge Mild jaundice, ill health during this period at home Attributed to drugs/surgery/ underlying disease etc Mild fall in Hb, jaundice Coombs test positive Due to Rh, Kidd, Duffy, Kell etc

CAUSES OF ANAPHYLACTIC REACTIONS

IgA deficient individuals Preexisting antibodies to other serum proteins Complement derived anaphylatoxins Drugs and other soluble antigens Preformed histamine, serotonin

Clinical Features
Apprehension Chest Pain Facial flushing Generalized urticaria, pruritis Laryngeal or facial oedema Bronchospasm, wheezing, dyspnoea Hypotension, loss of consciousness

Management & Prevention

ANTI HISTAMINE STEROIDS EPINEPHRINE WASHED RED CELLS PLASMA FROM IgA DEFICIENT DONORS

Bacterial Contamination
Sources Bacteraemia at the time of donation Inadequate arm cleaning / preparation During storage - minor leaks Species Yersinia, Citrobacter, Enterobacter, Pseudomonas, Listeria Preformed Endotoxins Signs & Symptoms Fever, shock, haemoglobinuria Management I/V antibiotics, treatment of hypotension & DIC

TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)

Mediator Donor/Recipient WBC (HLA) antibodies (leucoagglutinins) WBC aggregates in lungs activation of complement Signs & Symptoms ARDS, Fever, Chills, Cyanosis, hypotension, Non productive cough Pulmonary infiltrates Management Vigorous ventilator support & steroids

Transfusion Induced Purpura

Mediators Anti platelet antibodies Signs & symptoms Thrombocytopenia & bleeding Management I/V immunoglobulins, plasma exchange, steroids Transfusion of platelet from donors who lack the specific antigen

TA - GVHD
Etiology Donor lymphocytes transfused to immuno-compromised patients Signs & Symptoms Rash, diarrhea, hepatitis, pancytopenia, fever Treatment & outcome Prevention