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BLOOD TRANSFUSION THERAPY Dr. Capulong

Surgery 2011

Need for transfusion

• Late 19th century
• ABO grouping
• Rh grouping (D antigen) – most Filipinos are Rh (+)

ABO grouping

Blood Group A Antigen B Antigen Anti-A Anti-B

A Yes No No Yes
B No Yes Yes No
O No No Yes Yes
AB Yes Yes No No

Principles of Replacement Therapy

• Blood typing and cross matching
• Transfuse type-specific blood
o Type A blood for type A patient
o Rh (-) blood for Rh (-) patient
• Extreme situations, type O (-) blood may be given
o Administration of > 4 U of Type O blood will ↑ hemolysis
• Cross matching should be done before administration of Dextran
(plasma expanders – sugar based)
o Autologous transfusion
- ‘same blood’
- now becoming more popular
- done prior to elective surgery
- to minimize reaction of blood transfusion
- parameters:
1. Hgb >11g/dl
2. Time frame of bleeding (extraction) ≤ 40 days
3. Can only bleed 4-5 U of blood
4. Last 1 U must be extracted 3-4 days prior to surgery

Blood components Span Advantage Disadvantage

1. Banked Whole Blood 6 wks Good source of Long standing blood
clotting factors with ↑ in lactate, K,
ex. V and VII ammonia

↓ O2 carrying
capacity for
prolonged banking
2. Fresh Whole Blood 24 hrs Very good Limited source
coagulation activity
3. Fresh Frozen Plasma Immediatel Only source for Can also transmit
y drawn Factor V infection
from FWB replacement
4. Packed RBC & Frozen 6 wks ↓ reaction by Not readily available

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RBC components in emergency cases
-like FWB minus the plasma
5. Leukocyte reduced or Prevents most Only available in
Washed RBC febrile, non- Western nations
hemolytic reactions
6. Platelet Concentrate 120 hrs Given for Can transmit
- component of choice for thrombocytopenia infections, diseases
dengue and platelet and allergic reactions
disorders

Indications
1. ↓ O2 or carrying capacity
2. anemia
3. volume replacement – most common surgical indication

Hemorrhage
- normal individual: 5-6 L of blood

Class Blood Loss Blood Loss S/Sx

(%)
I ≤ 15 ≤ 750 ml With normal Hgb, asymptomatic
II 15-30 750 – 1.5 L With s/sx of acute blood loss
(cardio)
• tachycardia (1st sx)
• ↓ BP
III 30-40 1.5 – 2 L (respi) tachypnea!
IV ≥ 40 ≥2L Life threatening

Damage Control Resuscitation

-most important advancement in trauma care for hospitalized civilian & military
casualties from war
-usually done in government hospitals

Lethal triad
• Acidosis – base deficit ≥ 6
• Coagulopathy – INR > 1.5
• ↓ BP – systolic BP < 90
Acidosis Death Hypothermia • Hgb <11
• Temp < 96.5F
• Pattern recognition
o Weak radial pulse
Coagulopathy o Abnormal mental
status
o Severe traumatic
injury

Standard Resuscitation Paradigm

*provided that you’re done with A-B-C

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Crystalloid 3:1 ratio

Transient / no response
Blood (Usually start with 6-10 U PRBC)

FFP

Crystalloid (bolus = circulatory overload)

New Concept:
A. Initial Transfusion of RBC
B. Adult Massive Transfusion Guideline
• 1:1:1 ratio of components

Markers if transfusion is already enough: Hct and Hgb count

Timing: 6-8 hrs

Complication of transfusion
A. Non-Hemolytic
Febrile non-hemolytic transfusion reaction (FNHTR)
very common 1%
B. Hemolytic
Immediate or Delayed – 2-10 days
Coomb’s Test – Direct or Indirect
↑ body temp (progressive) after 1-2 hours after transfusion
C. Allergic Reactions
Common 1%
Rashes, urticaria, fever
D. Respiratory Complication
Circulatory overload due to massive, rapid transfusion
TRALI (transfusion related acute lung injury)
- non cardiogenic pulmonary edema
- 1-2 hrs from transfusion
- studies: TRALI often follow transfusion of female blood donors
E. Infectious Disease Transmission
• Chills and seizure Hepa C
Malaria (P. malariae) HIV
Syphilis *positivity is affected by incubation
period

Lab Tests (STUDY NORMAL VALUES)

CBC
Bleeding Time
N: under 7 mins; evaluate platelet and vascular dysfunction
Platelet Count
N: 150 – 400
<100,000/ul – major OR
<50,000/ul – minor OR
<20,000/ul spontaneous bleeding

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PT
Prothrombin time
Detects coagulation caused by Vit K deficiency and warfarin therapy
Measures function of Factors I, II, V, VII, X
Reported together with INR (1-1.3)
aPTT
measures function of Factors I, II & V and Factors VIII, IX, XII of intrinsic
Heparin therapy is monitored by regular aPTT readings

Evaluation of Hemostasis Risk in Surgical Patient

Pre-operative
GOOD Hx and PE
- essential
- Hx (family), tx, meds (aspirin)
Anemia (sickle cell, immune hemolytic type)
Oral anticoagulation therapy
Liver and renal diseases
- liver produces clotting factors
- kidney replenishes RBC thru erythropoietin
Intra and Post-operative
Excessive bleeding
Amount of BT
Co-morbid medical conditions (HPN, diabetes, pulmonary, renal which will contribute to
outcome)
DIC

*in general, the more blood you transfuse, the higher the morbidity and mortality rate.

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