Blood Blood TransfusionTransfusion

Presented by:Presented by:

Dr. Dhritiman Dr. Dhritiman ChakrabartiChakrabarti

An adult human has about 4–6 liters of blood An adult human has about 4–6 liters of blood circulating in the body. Among other things, circulating in the body. Among other things, the primary function of blood is to transport the primary function of blood is to transport oxygen to various parts of the body.oxygen to various parts of the body.

Blood consists of several types of cells Blood consists of several types of cells floating around in a fluid called Plasmafloating around in a fluid called Plasma..

The Red Blood CellsThe Red Blood Cells contain Hemoglobin, a contain Hemoglobin, a protein that binds oxygen. Red blood cells protein that binds oxygen. Red blood cells transport oxygen to, and remove carbon transport oxygen to, and remove carbon dioxide from, the body tissues.dioxide from, the body tissues.The White Blood CellsThe White Blood Cells are the cells primarily are the cells primarily responsible for immunity.responsible for immunity.

The PlateletsThe Platelets help in hemostasis. help in hemostasis.The PlasmaThe Plasma contains ions and various kinds contains ions and various kinds of proteins serving diverse functions.of proteins serving diverse functions.

DefinitionsDefinitions A Blood Transfusion is the infusion of whole blood A Blood Transfusion is the infusion of whole blood

or a blood component such as plasma, red blood or a blood component such as plasma, red blood cells, or platelets into the patient’s venous cells, or platelets into the patient’s venous circulation. circulation.

A blood transfusion is given because of red blood A blood transfusion is given because of red blood cell loss, such as with hemorrage or when the body cell loss, such as with hemorrage or when the body is not adequately producing cells such as platelets. is not adequately producing cells such as platelets. The person receiving the blood is the Recipient. The The person receiving the blood is the Recipient. The person giving the blood is the Donor.person giving the blood is the Donor.

An Individual’s blood is commonly classified into An Individual’s blood is commonly classified into one of the four main groups one of the four main groups (A, B, AB, and O). (A, B, AB, and O). The surface of an individual’s red blood cells The surface of an individual’s red blood cells contains a number of proteins known as contains a number of proteins known as AntigensAntigens that are unique for each person. Many blood that are unique for each person. Many blood antigens have been identified, but the antigens A, antigens have been identified, but the antigens A, B, and Rh are the most important in determining B, and Rh are the most important in determining blood group or type. Because antigens promote blood group or type. Because antigens promote agglutination or clumping of blood cells, they also agglutination or clumping of blood cells, they also known as known as Agglutinogens.Agglutinogens.

Blood Groups 

The The A A antigen or agglutinogen is present on antigen or agglutinogen is present on the RBCs of people with blood group the RBCs of people with blood group AA , the , the BB antigen is present in people with blood antigen is present in people with blood group group BB, and both , and both AA and and BB antigens are found antigens are found on the RBC surface in people with group on the RBC surface in people with group ABAB blood. Neither antigen is present in people blood. Neither antigen is present in people with group with group OO blood . blood .

Preformed antibodies to RBC antigens are Preformed antibodies to RBC antigens are present in the plasma; these antibodies are present in the plasma; these antibodies are often called often called AgglutininsAgglutinins. People with blood . People with blood group group AA have have B B antibodies (Agglutinins ), antibodies (Agglutinins ), AA antibodies are present in people with blood antibodies are present in people with blood group group BB , and people with blood group , and people with blood group OO have have antibodies to both antibodies to both AA and and BB antigens . People antigens . People with group with group ABAB blood do not have antibodies blood do not have antibodies to either to either AA or or BB antigens . antigens .

If a person with type O blood is transfused If a person with type O blood is transfused with blood from a person with either group A with blood from a person with either group A or group B blood, there would be destruction or group B blood, there would be destruction of the recipient’s red blood cells because his of the recipient’s red blood cells because his or her anti-A or anti-B agglutinins would react or her anti-A or anti-B agglutinins would react with the A or B antigens in the donor’s red with the A or B antigens in the donor’s red blood cells.blood cells.

This example shows why individuals with This example shows why individuals with type AB blood are often called type AB blood are often called Universal Universal RecipientsRecipients (because people in this blood (because people in this blood group have no agglutinins for either A or B group have no agglutinins for either A or B antigens) and group O people are often called antigens) and group O people are often called Universal DonorsUniversal Donors (because they have neither (because they have neither A nor B antigens).A nor B antigens).

The Rh factor is an inherited antigen in human blood. The Rh factor is an inherited antigen in human blood.

Blood that contains the Rh factor is known as Rh-positive, Blood that contains the Rh factor is known as Rh-positive, when it is not present the blood is said to be Rh-negative. when it is not present the blood is said to be Rh-negative. Rh blood does not naturally contain Rh antibodies. If Rh-Rh blood does not naturally contain Rh antibodies. If Rh-positive blood is injected into an Rh-negative person, the positive blood is injected into an Rh-negative person, the recipient develops Rh antibodies. Subsequent transfusion recipient develops Rh antibodies. Subsequent transfusion with Rh-positive blood may cause serious reactions with with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells.clumping and hemolysis of red blood cells.

  

Rhesus (RH) Factor 

Other Blood GroupsOther Blood Groups

In addition to the ABO antigens and Rh antigens, In addition to the ABO antigens and Rh antigens, many other antigens are expressed on the RBC many other antigens are expressed on the RBC surface membrane.surface membrane.

The International Society of Blood Transfusion The International Society of Blood Transfusion currently recognizes 30 blood-group systems currently recognizes 30 blood-group systems (including the ABO and Rh systems). (including the ABO and Rh systems).

For Eg. MNS, Kell, Kidd, Duffy, Lewis etc.For Eg. MNS, Kell, Kidd, Duffy, Lewis etc. These are mostly involved in Delayed Hemolytic These are mostly involved in Delayed Hemolytic

Transfusion reactions.Transfusion reactions.

Typing and Cross MatchingTyping and Cross Matching

Before any blood can be given to a patient, it Before any blood can be given to a patient, it must be determined that the blood of the must be determined that the blood of the donor is compatible with the patient. The donor is compatible with the patient. The laboratory examination to determine a laboratory examination to determine a person’s blood group and Rh factor is called person’s blood group and Rh factor is called Blood Typing.Blood Typing.

The process of determining compatibility The process of determining compatibility between blood specimens isbetween blood specimens is CrossmatchingCrossmatching.. RBCs from the donor blood are mixed with RBCs from the donor blood are mixed with serum from the recipient, a reagent (Coombs’ serum from the recipient, a reagent (Coombs’ serum) is added, and the mixture is examined serum) is added, and the mixture is examined for visible agglutination. If no antibodies to the for visible agglutination. If no antibodies to the donated RBCs are present in the recipient’s donated RBCs are present in the recipient’s serum, agglutination does not occur and the serum, agglutination does not occur and the risk of transfusion reaction is small. risk of transfusion reaction is small.

Selection of Blood DonorsSelection of Blood Donors

Blood donors must be selected with care. Not only must the Blood donors must be selected with care. Not only must the donor’s blood be accurately typed, but it is also important to donor’s blood be accurately typed, but it is also important to determine that the donor is free from diseases. determine that the donor is free from diseases.

The primary tests recommended by WHO are the following:The primary tests recommended by WHO are the following:

1.1. Surface antigen for hepatitis B( HbsAg)Surface antigen for hepatitis B( HbsAg)

2.2. Antibody to Hepatitis CAntibody to Hepatitis C

3.3. HIV antibody (Subtypes 1 & 2)HIV antibody (Subtypes 1 & 2)

4.4. Serology tests for SyphilisSerology tests for Syphilis

Other tests carried out depending on local need :Other tests carried out depending on local need :

1.1. Prion diseases – Creutzfeldt Jacob DiseasePrion diseases – Creutzfeldt Jacob Disease

2.2. CytomegalovirusCytomegalovirus

3.3. HIV Nucleic acid test (p24)HIV Nucleic acid test (p24)

Also mandatory that the donor should be free from Also mandatory that the donor should be free from fever a fortnight before donating blood. fever a fortnight before donating blood.

Also should be free from parasitic diseases like Also should be free from parasitic diseases like Malaria and Filariasis.Malaria and Filariasis.

Transfusion of blood and blood Transfusion of blood and blood productsproducts

Blood Conservative Strategies Blood Conservative Strategies

Preoperative Autologous DonationPreoperative Autologous Donation

– Effectiveness is limited because of less vigorous Effectiveness is limited because of less vigorous erythropoietic response and the process simply erythropoietic response and the process simply results in anemia at time of surgery.results in anemia at time of surgery.

– Benefits are the elimination of disease Benefits are the elimination of disease transmission, allergic and incompatible reactions.transmission, allergic and incompatible reactions.

– But, more expensive, sometimes wasted. But, more expensive, sometimes wasted. – Usage has declined.Usage has declined.

Acute Normovolemic HemodilutionAcute Normovolemic Hemodilution

– Patient is bled immediately before surgery.Patient is bled immediately before surgery.

– Down to haematocrit 25-30% with CVP monitoringDown to haematocrit 25-30% with CVP monitoring

– Strategy is that intraoperatively the patient will lose blood Strategy is that intraoperatively the patient will lose blood of low hematocrit value and reduce total red blood cell of low hematocrit value and reduce total red blood cell loss.loss.

– Collected blood is transfused back after surgery.Collected blood is transfused back after surgery.

– Less frequently used.Less frequently used.

Intraoperative blood salvageIntraoperative blood salvage

– Blood is salvaged intraoperatively from sites Blood is salvaged intraoperatively from sites where fresh blood has collected before the surgerywhere fresh blood has collected before the surgery

– Only applicable to clean operative sites without Only applicable to clean operative sites without bacterial, bowel or tumor cell contamination.bacterial, bowel or tumor cell contamination.

– Contemporary cell salvage devices anticoagulate Contemporary cell salvage devices anticoagulate the blood, separate the RBCs from the blood, wash the blood, separate the RBCs from the blood, wash the RBCs extensively in saline and reinfused to the the RBCs extensively in saline and reinfused to the patient in aliquots of 125 – 225ml with Hematocrit patient in aliquots of 125 – 225ml with Hematocrit of 45 – 65%.of 45 – 65%.

Transfusion of Whole blood has been largely Transfusion of Whole blood has been largely replaced by FFP and specific component replaced by FFP and specific component therapy depending on nature of deficiency.therapy depending on nature of deficiency.

Whole bloodWhole blood– Haematocrit of 35%-45%Haematocrit of 35%-45%– 300 ml of 4:1 mixture of donor plasma and a nutrient 300 ml of 4:1 mixture of donor plasma and a nutrient

citrate anticoagulant solutioncitrate anticoagulant solution– Stored at 2-6 deg C (maximum for 35 days)Stored at 2-6 deg C (maximum for 35 days)– Deterioration is rapid when kept out of refrigerator or Deterioration is rapid when kept out of refrigerator or

transport boxtransport box– Transfusion should be completed within 4 hrsTransfusion should be completed within 4 hrs– Warmer is used if large volume has to be transfused in a Warmer is used if large volume has to be transfused in a

short timeshort time– Not suitable for symptomatic or critical anemiaNot suitable for symptomatic or critical anemia

Packed Red Blood CellsPacked Red Blood Cells– Obtained from single donor Obtained from single donor

– Contains Red cells in Contains Red cells in CPDA solution (citrate, phosphate, CPDA solution (citrate, phosphate, dextrose and adenine) dextrose and adenine) with Hct of 70-75% and a total with Hct of 70-75% and a total volume of 250-275ml.volume of 250-275ml.

– Has a shelf life of 35 days at storage temp. of 1-6 deg C.Has a shelf life of 35 days at storage temp. of 1-6 deg C.

– In case Additive solution solution is added, the infusate is In case Additive solution solution is added, the infusate is of Hct 60%, Total volume 250-350ml., less citrate, longer of Hct 60%, Total volume 250-350ml., less citrate, longer shelf life of 42 days at storage temp. of 1-6 deg C.shelf life of 42 days at storage temp. of 1-6 deg C.

– Improves tissue oxygenation after hemorrhage and in Improves tissue oxygenation after hemorrhage and in anemic patientanemic patient

– One unit of PRBCs typically will raise the hematocrit by 3-One unit of PRBCs typically will raise the hematocrit by 3-4% and the blood hemoglobin concentration by 1 g/dl. 4% and the blood hemoglobin concentration by 1 g/dl.

Additive SolutionsAdditive SolutionsThree additive solutions are available Three additive solutions are available

1.1. Adsol ( AS-1 ) [Baxter Laboratories]Adsol ( AS-1 ) [Baxter Laboratories]

2.2. Nutricel (AS-3) [Medsep Corporation]Nutricel (AS-3) [Medsep Corporation]

3.3. Optisol (AS-5) [Terumo Corporation]Optisol (AS-5) [Terumo Corporation]

Red Blood Cell Transfusion GuidelinesRed Blood Cell Transfusion GuidelinesAcute and Perioperative Blood LossAcute and Perioperative Blood Loss1. Estimate blood loss1. Estimate blood loss If > 30-40% of rapid blood loss: transfuse RBCs and use If > 30-40% of rapid blood loss: transfuse RBCs and use

volume expandersvolume expanders If < 30-40% of rapid blood loss: RBCs not usually needed in If < 30-40% of rapid blood loss: RBCs not usually needed in

otherwise healthy personotherwise healthy person2. Monitor vital signs; Tachycardia and hypotension not 2. Monitor vital signs; Tachycardia and hypotension not

corrected with volume expanders: RBCs neededcorrected with volume expanders: RBCs needed3. Measure haemoglobin3. Measure haemoglobin If Hb > 10 g/dL: RBCs rarely neededIf Hb > 10 g/dL: RBCs rarely needed If Hb < 7 g/dL: RBCs usually neededIf Hb < 7 g/dL: RBCs usually needed If Hb 7-10 g/dL: RBCs may be needed, determined by If Hb 7-10 g/dL: RBCs may be needed, determined by

additional clinical conditionsadditional clinical conditions4. Hematocrit trigger point for transfusion is <21%.4. Hematocrit trigger point for transfusion is <21%.5. For cardiac disease patients, threshold goes up to Hb <10gm% 5. For cardiac disease patients, threshold goes up to Hb <10gm%

and hematocrit <30%.and hematocrit <30%.

Chronic AnaemiaChronic Anaemia1. Transfuse only to decrease symptoms and to 1. Transfuse only to decrease symptoms and to

minimize risk (generally at Hb of less than 7 minimize risk (generally at Hb of less than 7 g /dL). Do not transfuse above 7g/dL Hb g /dL). Do not transfuse above 7g/dL Hb unless patient is symptomatic.unless patient is symptomatic.

2. Treat nutritional and mild blood loss anemia 2. Treat nutritional and mild blood loss anemia with specific therapeutic agents as indicated with specific therapeutic agents as indicated (iron, folic acid, B12).(iron, folic acid, B12).

Guidelines for Paediatric TransfusionGuidelines for Paediatric Transfusion

If Hb is < 4 g/dL, transfuse.If Hb is < 4 g/dL, transfuse. If Hb is > 4 g/dL and < 5 g/dL, transfuse when signs of If Hb is > 4 g/dL and < 5 g/dL, transfuse when signs of

respiratory distress or cardiac failure are present. If respiratory distress or cardiac failure are present. If patient is clinically stable, monitor closely and treat patient is clinically stable, monitor closely and treat the cause of the anaemia.the cause of the anaemia.

If Hb is > 5 g/dL, transfusion is usually not necessary. If Hb is > 5 g/dL, transfusion is usually not necessary. Consider transfusion in cases of shock or severe Consider transfusion in cases of shock or severe burns. Otherwise, treat the cause of the underlying burns. Otherwise, treat the cause of the underlying anaemia.anaemia.

Transfuse with 10 to 15 ml/kg of PRBCs or 20 ml/kg of Transfuse with 10 to 15 ml/kg of PRBCs or 20 ml/kg of whole blood.whole blood.

In the presence of profound anaemia or very high In the presence of profound anaemia or very high malaria parasitaemia, a higher amount may be malaria parasitaemia, a higher amount may be needed.needed.

PlateletsPlatelets– Available as concentrates from single or multiple donorsAvailable as concentrates from single or multiple donors

– Manual Thrombapheresis is done either by ‘soft spin’ Manual Thrombapheresis is done either by ‘soft spin’ centrifugation or re-centrifugation of buffy coat layer.centrifugation or re-centrifugation of buffy coat layer.

– Can also be prepared from single donor by an Automated Can also be prepared from single donor by an Automated Apheresis machineApheresis machine

– Platelets have Platelets have very short shelf life, typically five days & very short shelf life, typically five days & are stored under constant agitation at 20-24 deg C.are stored under constant agitation at 20-24 deg C.

– No effective preservative solutions, lose potency very No effective preservative solutions, lose potency very quickly, best when fresh, thus very short turnover time.quickly, best when fresh, thus very short turnover time.

– One unit has about 3×10^11 platelets One unit has about 3×10^11 platelets

Indications for platelet transfusionIndications for platelet transfusion Indicated when platelets count fall 50,000/cummIndicated when platelets count fall 50,000/cumm

1.1. Chemotherapy, Radiotherapy for leukemia, multiple myelomaChemotherapy, Radiotherapy for leukemia, multiple myeloma2.2. Aplastic anemia Aplastic anemia 3.3. AIDSAIDS4.4. HypersplenismHypersplenism5.5. ITPITP6.6. SepsisSepsis7.7. Bone marrow transplant, organ transplant or surgeries such as Bone marrow transplant, organ transplant or surgeries such as

cardiopulmonary bypass. cardiopulmonary bypass. Avoided in those with heparin-induced thrombocytopenia (HIT) Avoided in those with heparin-induced thrombocytopenia (HIT)

or disseminated intravascular coagulation (DIC) or or disseminated intravascular coagulation (DIC) or Thrombotic thrombocytopenic purpura(TTP).Thrombotic thrombocytopenic purpura(TTP).

Expected Platelet Counts After InfusionExpected Platelet Counts After Infusion

Platelet count increase as well as platelet survival after Platelet count increase as well as platelet survival after transfusion is related to the dose of platelets infused and to the transfusion is related to the dose of platelets infused and to the patient's body surface area (BSA). Usually these values are patient's body surface area (BSA). Usually these values are less than what would be expected.less than what would be expected.

Expected platelet increase (per μL) = # platelets infused x CCI Expected platelet increase (per μL) = # platelets infused x CCI / BSA (m2) / BSA (m2)

The theoretical value of the CCI is 20,000/μL but clinically, The theoretical value of the CCI is 20,000/μL but clinically, the value is closer to 10,000/μL. If the CCI is less than the value is closer to 10,000/μL. If the CCI is less than 5,000/μL, patients are said to have "refractoriness" to platelet 5,000/μL, patients are said to have "refractoriness" to platelet transfusion.transfusion.

((Corrected platelet count increment (CCI) = platelet increment at Corrected platelet count increment (CCI) = platelet increment at one hr x BSA (m2) / # platelets infused x 10^11 )one hr x BSA (m2) / # platelets infused x 10^11 )

Fresh-frozen plasmaFresh-frozen plasma– Produced from a Single donationProduced from a Single donation– 200-300 ml of plasma with 40-60 ml of citrate 200-300 ml of plasma with 40-60 ml of citrate

anticoagulant nutrient mixtureanticoagulant nutrient mixture– Stored at -30 deg C (shelf life of 12 months)Stored at -30 deg C (shelf life of 12 months)– Thawed rapidly at 37 deg C Thawed rapidly at 37 deg C – Infused intravenously through a standard blood set with on-Infused intravenously through a standard blood set with on-

line filterline filter– ABO group must be compatibleABO group must be compatible– Infusion of 1 unit should be complete within 4 hr of Infusion of 1 unit should be complete within 4 hr of

thawingthawing

Indication for FFP transfusionIndication for FFP transfusion– To correct isolated plasma protein deficienciesTo correct isolated plasma protein deficiencies– To reverse oral warfarin anticoagulationTo reverse oral warfarin anticoagulation– In patient with liver disease, major hepatic In patient with liver disease, major hepatic

resection and severe liver injuriesresection and severe liver injuries– DICDIC– Bleeding diathesis after large volume blood Bleeding diathesis after large volume blood

transfusiontransfusion– TTPTTP

CryoprecipitateCryoprecipitate– Concentrate of factor VIII, VonWillebrand’s Concentrate of factor VIII, VonWillebrand’s

factor, fibrinogen and factor XIIIfactor, fibrinogen and factor XIII– Each 15 mL unit typically contains 100 IU of Each 15 mL unit typically contains 100 IU of

factor VIII, and 250 mg of fibrinogen. factor VIII, and 250 mg of fibrinogen. – The product is manufactured by slowly thawing a The product is manufactured by slowly thawing a

unit of FFP at temperatures just above freezing (1-unit of FFP at temperatures just above freezing (1-6 °C) and then centrifuged to remove the majority 6 °C) and then centrifuged to remove the majority of the plasma, and the precipitate is resuspended in of the plasma, and the precipitate is resuspended in the remaining plasma or in sterile saline the remaining plasma or in sterile saline

– Stored at -30 deg C (shelf life 12 month).Stored at -30 deg C (shelf life 12 month).– Also thawed at 37 deg C.Also thawed at 37 deg C.– Transfusion should be completed within 4 hrs.Transfusion should be completed within 4 hrs.

Indication of Cryoprecipitate transfusionIndication of Cryoprecipitate transfusion– Fibrinogen deficiency and dysfibrinogenaemiaFibrinogen deficiency and dysfibrinogenaemia– Uraemic bleedingUraemic bleeding– VonWillebrand’s diseaseVonWillebrand’s disease

Special blood componentsSpecial blood components– Irradiated componentsIrradiated components:- :- It is the only effective means of preventing Graft It is the only effective means of preventing Graft

vs. Host Disease while transfusing blood vs. Host Disease while transfusing blood components to immuno-compromised patients.components to immuno-compromised patients.

– Leuco-reduced cellular component:- Leuco-reduced cellular component:- Benefits areBenefits are1.1. Decreased alloimmunization/platelet refractoriness in Decreased alloimmunization/platelet refractoriness in

multiply transfused leukemics.multiply transfused leukemics.2.2. Prevention of febrile reactions to RBC/platelet Prevention of febrile reactions to RBC/platelet

transfusions in multiply transfused patients.transfusions in multiply transfused patients.3.3. Reduction of CMV transmission.Reduction of CMV transmission.4.4. Reduction in inflammatory mediator accumulation Reduction in inflammatory mediator accumulation

during storage – preventive strategy for TRALI.during storage – preventive strategy for TRALI.

Adverse effect of transfusion of Adverse effect of transfusion of blood and blood productsblood and blood products AcuteAcute

– AllergicAllergic– AnaphylaxisAnaphylaxis– HemolyticHemolytic– MetabolicMetabolic– Transfusion related acute lung injuryTransfusion related acute lung injury– Circulatory overloadCirculatory overload– Non-hemolytic febrile transfusion reactionsNon-hemolytic febrile transfusion reactions– Haemostatic: dilution of clotting factors and Haemostatic: dilution of clotting factors and

thrombocytopeniathrombocytopenia– Infective RisksInfective Risks

LateLate– Delayed hemolytic transfusion reactionsDelayed hemolytic transfusion reactions– Sensitization/AlloimunizationSensitization/Alloimunization– Transfusion Related Immune ModulationTransfusion Related Immune Modulation– Graft-vs-Host diseaseGraft-vs-Host disease– Transfusion iron overload (haemosiderosis)Transfusion iron overload (haemosiderosis)

Non hemolytic Febrile Transfusion Non hemolytic Febrile Transfusion ReactionsReactions– Result of alloimmunization to leucocyte and Result of alloimmunization to leucocyte and

platelet antigens ( HLA antigens)platelet antigens ( HLA antigens)– Symptoms: Rigor followed by Fever usually Symptoms: Rigor followed by Fever usually

within the start of 30-60 min of transfusionwithin the start of 30-60 min of transfusion– Managed by cessation or slowing of the Managed by cessation or slowing of the

transfusion and administration of an antipyretictransfusion and administration of an antipyretic– Pretreated with antipyretic in repeated transfusions Pretreated with antipyretic in repeated transfusions

and patient who has historyand patient who has history– If above measure fail, leucocyte-depleted cell If above measure fail, leucocyte-depleted cell

components are given.components are given.

Allergic reactionAllergic reaction– Symptoms: Urticarial rash and itch within minutes Symptoms: Urticarial rash and itch within minutes – Treatment: Treatment:

Antihistamines Antihistamines and reduction of transfusion rateand reduction of transfusion rate

AnaphylaxisAnaphylaxis – Rare, fatal, caused by antibodies to IgA in patients Rare, fatal, caused by antibodies to IgA in patients

who have extremely low levels of this who have extremely low levels of this immunoglobulin in plasma (Hereditary IgA immunoglobulin in plasma (Hereditary IgA Deficiency), who have been sensitized to IgA in Deficiency), who have been sensitized to IgA in previous transfusions.previous transfusions.

– Treatment: Termination of blood transfusion, IV Treatment: Termination of blood transfusion, IV crystalloids, Maintenance of airway, Oxygen, crystalloids, Maintenance of airway, Oxygen, Adrenalin, IV antihistamine and salbutamolAdrenalin, IV antihistamine and salbutamol

Acute haemolytic reactionAcute haemolytic reaction– Result of ABO incompatibilityResult of ABO incompatibility– Serious complicationSerious complication– Mortality is high when more than 200 ml has been Mortality is high when more than 200 ml has been

transfusedtransfused– Clinical featureClinical feature

Pain at the infusion site and along the veinPain at the infusion site and along the vein Facial burning Facial burning Chest and back painChest and back pain Fever, rigor and vomitingFever, rigor and vomiting Restlessness, breathlessness, flushing and Restlessness, breathlessness, flushing and

hypotensionhypotension Bleeding from vascular access sites and woundBleeding from vascular access sites and wound

Management Management Immediate recognitionImmediate recognition Cessation of transfusionCessation of transfusion Replacement of the blood transfusion setReplacement of the blood transfusion set Adequate hydrationAdequate hydration Forced diuresisForced diuresis Vasopressor/ Inotrope support might be requiredVasopressor/ Inotrope support might be required Further investigations Further investigations

– Re-cross matching and serological testingRe-cross matching and serological testing

– Blood unit for cultureBlood unit for culture

– Blood sample for clinical chemistryBlood sample for clinical chemistry

– Coagulation screenCoagulation screen

Transfusion Related Acute Lung InjuryTransfusion Related Acute Lung Injury– Occurs when mediators (anti HLA antibodies and anti-Occurs when mediators (anti HLA antibodies and anti-

granulocyte antibodies) present in the donor plasma granulocyte antibodies) present in the donor plasma activate leucocytes in the host.activate leucocytes in the host.

– Pulmonary microvascular occlusion by platelets, Pulmonary microvascular occlusion by platelets, leucocytes and fibrinleucocytes and fibrin

– Clinical feature (within 6 hrs of transfusion)Clinical feature (within 6 hrs of transfusion) FeverFever BreathlessnessBreathlessness Non-productive coughNon-productive cough HypoxiaHypoxia

– Chest X-ray shows typical features of ARDSChest X-ray shows typical features of ARDS– Transfusion related circulatory overload should be ruled Transfusion related circulatory overload should be ruled

out.out.– Multiparous female donors have been identified as most Multiparous female donors have been identified as most

common source in TRALI fatalities.common source in TRALI fatalities.

Treatment of TRALITreatment of TRALI1.1. Treatment is largely supportive.Treatment is largely supportive.

2.2. Monitor Oxygen saturation, Provide Monitor Oxygen saturation, Provide supplemental oxygen to maintain saturation supplemental oxygen to maintain saturation above 92%above 92%

3.3. Hypoxemia severe enough to require Hypoxemia severe enough to require Endotracheal Intubation and PPV occurs in Endotracheal Intubation and PPV occurs in 70-75% of patients.70-75% of patients.

4.4. No evidence supports the routine use of No evidence supports the routine use of Corticosteroids.Corticosteroids.

Metabolic complicationsMetabolic complications– In patients with massive blood transfusion( 1 In patients with massive blood transfusion( 1

ml/kg/min or 1 unit of blood per 5 minutes).ml/kg/min or 1 unit of blood per 5 minutes).– Metabolic consequences includeMetabolic consequences include

1.1. HypothermiaHypothermia (prevented by transfusing blood through (prevented by transfusing blood through blood warmer)blood warmer)

2.2. AcidosisAcidosis

3.3. Increased affinity of oxyhaemoglobin for Increased affinity of oxyhaemoglobin for oxygenoxygen( due to transfusion of 2,3 DPG depleted blood)( due to transfusion of 2,3 DPG depleted blood)

4.4. Citrate intoxicationCitrate intoxication( causes temporary reductions in ( causes temporary reductions in ionised calcium levels – If symptomatic treated by ionised calcium levels – If symptomatic treated by administering calcium gluconate)administering calcium gluconate)

5.5. Hyperkalemia Hyperkalemia

Haemostatic complicationsHaemostatic complications

1.1. Dilutional CoagulopathyDilutional Coagulopathy

– Stored blood is deficient in platelets and labile clotting Stored blood is deficient in platelets and labile clotting factor (factor V and VIII)factor (factor V and VIII)

– Massive transfusion induces dilution of Fibrinogen, Massive transfusion induces dilution of Fibrinogen, Clotting factor – II, V and VIII in addition to moderate Clotting factor – II, V and VIII in addition to moderate Thrombocytopenia.Thrombocytopenia.

– Treated by administering FFP or platelets as decided on Treated by administering FFP or platelets as decided on basis of laboratory evidence of coagulopathy or by clinical basis of laboratory evidence of coagulopathy or by clinical suspicion due to rapid ongoing blood loss.suspicion due to rapid ongoing blood loss.

2.2. Post Transfusion PurpuraPost Transfusion Purpura– Platelet-specific alloantibodies may cause post-transfusion Platelet-specific alloantibodies may cause post-transfusion

purpurapurpura– It is initially treated with high dose corticosteroids and It is initially treated with high dose corticosteroids and

intravenous immunoglobulinintravenous immunoglobulin– If platelets needed , have to be compatible with patient If platelets needed , have to be compatible with patient

alloantibodiesalloantibodies

Circulatory overloadCirculatory overload

1.1. Encountered when blood is administered too Encountered when blood is administered too rapidly or in large volumesrapidly or in large volumes

2.2. Pulmonary edema is commonPulmonary edema is common

3.3. Must be differentiated from ARDSMust be differentiated from ARDS

4.4. Diuretics may be used – Furosemide administered Diuretics may be used – Furosemide administered at incremental dosage of 20-40 mg depending on at incremental dosage of 20-40 mg depending on response 6-8 hrly until desired diuresis occurs. response 6-8 hrly until desired diuresis occurs.

Transfusion haemosiderosisTransfusion haemosiderosis– Iron overload in monocyte-macrophage systemIron overload in monocyte-macrophage system– Especially a problem in childhood anemias (e.g. Especially a problem in childhood anemias (e.g.

thalassemia) and in patients with chronic refractory thalassemia) and in patients with chronic refractory anemiaanemia

– Iron chelation therapy with desferrioxamineIron chelation therapy with desferrioxamine

Graft-versus-host diseaseGraft-versus-host disease– Rare, but fatal complicationRare, but fatal complication– Occurs mainly in immunodeficient patientsOccurs mainly in immunodeficient patients– Caused by the T-lymphocytes from donor blood Caused by the T-lymphocytes from donor blood

get engrafted into the immunodeficient host’s get engrafted into the immunodeficient host’s marrow and launch an immune response against marrow and launch an immune response against the host.the host.

– Starts 3-30 days after the transfusionStarts 3-30 days after the transfusion– Patient develops high fever, diffuse erythematous Patient develops high fever, diffuse erythematous

skin rash, desquamation, GI symptoms, severe skin rash, desquamation, GI symptoms, severe hepatic dysfunction and pancytopeniahepatic dysfunction and pancytopenia

– Prevented by administering gamma-irradiated Prevented by administering gamma-irradiated cellular componentscellular components

Delayed Hemolytic Transfusion ReactionsDelayed Hemolytic Transfusion Reactions

1.1. Result of Anamnestic Response to Donor RBC antigen to Result of Anamnestic Response to Donor RBC antigen to which a recipient has been previously exposed.which a recipient has been previously exposed.

2.2. Commonly involve antibodies against Kell, Kidd and Commonly involve antibodies against Kell, Kidd and Rhesus antigens.Rhesus antigens.

3.3. Occur within first or second week following transfusionOccur within first or second week following transfusion4.4. Symptoms include low grade fever, increased indirect Symptoms include low grade fever, increased indirect

bilirubin or unexpected reduction in Hb concentrations.bilirubin or unexpected reduction in Hb concentrations.5.5. It is typically mild and self limiting.It is typically mild and self limiting.6.6. Treatment is supportive including Hb monitoring, hydration Treatment is supportive including Hb monitoring, hydration

and provision of compatible blood if necessary.and provision of compatible blood if necessary.

Transfusion Related ImmunomodulationTransfusion Related Immunomodulation

1.1. There are changes in immunity related processes There are changes in immunity related processes such as T-lymphocyte Helper/Suppressor ratio, such as T-lymphocyte Helper/Suppressor ratio, function of T Killer cells, Lymphocyte function of T Killer cells, Lymphocyte responsiveness and Delayed Hypersensitivity. responsiveness and Delayed Hypersensitivity.

2.2. Adverse effects on immunocompetence such as Adverse effects on immunocompetence such as accelerated reccurences of malignancy, increased accelerated reccurences of malignancy, increased rates of infection and more rapid progression of rates of infection and more rapid progression of HIV/AIDS.HIV/AIDS.

3.3. Cause Unknown.Cause Unknown.

Infective risksInfective risks

1.1. Hepatitis B, C and GHepatitis B, C and G

2.2. HIV 1 and 2HIV 1 and 2

3.3. HTLV 1 and 2HTLV 1 and 2

4.4. CytomegalovirusCytomegalovirus

5.5. Parasitic diseases – Malaria, Filariasis and Chaga’s Parasitic diseases – Malaria, Filariasis and Chaga’s disease.disease.

6.6. Prion related Diseases ( CJD)Prion related Diseases ( CJD)

7.7. Bacterial Contamination:Bacterial Contamination:

More common with platelet transfusions. More common with platelet transfusions. Risk is less in single donor apheresis derived units.Risk is less in single donor apheresis derived units. Gram negative Yersinia enterocolitica is the most common Gram negative Yersinia enterocolitica is the most common

cause of fatal sepsis. cause of fatal sepsis. Symptoms – Fever, Chills, Tachycardia, Dyspnea, Shock, Symptoms – Fever, Chills, Tachycardia, Dyspnea, Shock,

DIC and Acute Renal Failure. DIC and Acute Renal Failure. Needs to be distinguished from other common transfusion Needs to be distinguished from other common transfusion

reactions.reactions. Treatment:Treatment:1.1. Transfusion stopped immediatelyTransfusion stopped immediately2.2. Blood cultures obtainedBlood cultures obtained3.3. Broad spectrum AntibioticsBroad spectrum Antibiotics4.4. Supportive care as required.Supportive care as required.5.5. Notification of blood bank.Notification of blood bank.

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