"No Transfusion"
Why Avoid Blood Transfusion?
? Infection Risk
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? HIV, Hepatitis
? Other Complications
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? Febrile reactions? Allergic, urticarial reactions
? Clerical Errors
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? ABO mismatch
? Immunologic Issues
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? TA-GvHD? Immunosuppression
? Religious Reasons
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Misconceptions and Myths? Whole blood
? "Fresh" Blood
? Empirical Transfusion
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? Nutritional Anemia
? Pre Surgical
? Wound Healing
? Enhancement of well being
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Why whole blood not rational
? Maximize blood resource
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Thalassemia
one unit of whole blood
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BleedingAplastic anemia
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Hemophilia
? Better patient management
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? concentrated dose of required component? avoid circulatory overload
? minimize reactions
? Specific storage requirements of components
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? Red Blood cel s
+2-60 C
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? Platelets+220 C
? Fresh frozen plasma
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- 300 C
? Decrease cost of management
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? except for the cost of bag, other expenses remain sameWhole Blood Vs Packed Red Cel s
Parameter
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Whole bloodPacked red cells
Volume
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350 ? 450 ml
200 ? 240 ml
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Increment in Hb1 -1.5 gm/dl
1 -1.5 gm/dl
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Red cell mass /ml
Same as PRBC
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Same as WBViable platelets
No
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No
Labile factors
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NoNo
Plasma citrate
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++++
+
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Allergic reactions++++
+
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FNHTR
++++
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+Risk of TTI
++++
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+
Waste of components
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YesNo
"Fresh blood" ? misconception.
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v What is "fresh blood"?
? varying definition
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? any unit kept at 4oC for 4 hours is no longer "fresh"vIncreased disease transmission
? Intracel ular pathogens (CMV, HTLV) survive in leukocyte in fresh
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blood
? Syphils transmission- tryponema can't survive > 96 hours in stored
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blood ( JAMA,95)? Malaria transmission- malaria parasite cannot survive > 72 hours in
stored blood (Mol ison)
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"Fresh blood" ? misconception.
v Immunological complication due to WBCs in fresh blood
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? Transfusion Associated-Graft vs Host Disease ? 90% fatality
? TA-immunomodulation
? Al oimmunization- Red cel / platelet
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v Logistics? no time for component preparation
? less time for infection screening
? storage lesions in different constituents due to storage temp
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Rational Use of Blood
? Right product
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? Right dose? Right time
? Right reasons
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Answer 4 Qs before transfusion
? Why to transfuse ?
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benefit > riskpatients symptoms Vs lab levels
prophylactic Vs therapeutic
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? What to transfuse ?
whole blood
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NOcomponents / fractions
? How much to transfuse ?
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Single unit
NO
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? How to transfuse ?use of filter
rate of transfusion
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warming
Packed Red Cel s (PRBC)
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Symptomatic deficiency of oxygen carryingcapacity or tissue hypoxia
Appropriate use of Packed red cel s
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? Should be ABO and Rh compatible? Clinical judgment- a vital role
? Co-existing conditions ? age, general health, cause of anemia, its
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severity and chronicity
? Not for conditions like Iron/ B12/ Folate deficiency
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PRBC - Triggers? Preoperative / peri-procedural : Hb< 6g/dl
Hb 6- 10 g/dl
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(bleeding, cardio resp. disease)
? Symptomatic chronic anemia : Hb < 6 g/dl
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? Acute blood loss : > 40% blood loss> 30% continued
blood loss or on
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respiratory supportNeonates
? Hemoglobin
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? <12g/dl in first 24 hrs
? <12 g/dl with intensive support care
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? <11 g/dl with chronic oxygen need? < 7 g/dl in a stable infant
? Blood loss
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? Stable infant > 10% loss of estimated volume
? Unstable infant > 5% loss of estimated blood volume
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PRBC - Dosing? One unit of compatible RBC ?1 g/dl or Hct by 3%
? Neonates
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Dose ? 10- 15 ml/kg
Increase Hb - 2-3 g/dl
Issues in red cel transfusion
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One unit of PRBC
? Vol 250 ml
? Hct 65%
? Raise Hb by 1 gm/dl
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? 200 mg iron? 70% post transfusion survival
Age of blood
? concerns regarding K level
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? decreased post transfusion survivalSpecific conditions
? intrauterine transfusion
< 3 days old
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? thalassemics
< 5 days
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? open heart surgery< 10 days
Cardinal principles in red cel transfusion in
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chronic
anemia
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? Evaluate etiology of anemia - AIHA, IDA? Do not transfuse just on the basis of given Hb level
? Try to establish whether Signs / Symptoms are due to anemia
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? Determine if Signs / Symptoms of anemia are al eviated by
transfusion
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? Determine that temporary relief of symptoms warrants continuedtransfusion
Platelets
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?Stored at room temperature (20?-22?C)?Shelf life ? 3-5 days
?Judicious use
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?Group specific
Appropriate Transfusion of Platelets
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? Symptomatic platelet problems? Number related ? eg. Aplastic anemia
? Function related ? eg. Glanzmann's thrombasthenia
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? Do not treat the number in isolation ?eg Chronic ITP with no bleeds
? Prophylactic in specific situations
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? CNS, eye surgery, other major surgeries, acute leukemia, patients on
chemoradiotherapy
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Dose: 1 RDP/10 KgPlatelet- Triggers
Condition
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Platelet countProphylaxis against bleeding
< 10,000/?l
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Bedside invasive procedures
< 50,000/?l
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Neurosurgical procedures,< 100000/?l
Ophthalamic surgeries
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Massive Transfusion
< 50,000/?l
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Neonates ? Prophylactic Platelet TriggersTerm Neonates
? Clinical y stable - 20,000/?l
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? Clinical y sick - 30,000/?lPreterm Neonates
? Clinical y stable - 30,000/?l
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? Clinical y sick - 50,000/?lContraindications
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? Thrombotic Thrombocytopenic purpura? Heparin induced thrombocytopenia
? Immune Thrombocytopenic purpura
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Fresh Frozen Plasma
Appropriate Transfusion of FFP
? Replacement of multiple factors: DIC, liver disease, warfarin reversal,
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snake bite
? PT/ INR should be determined
? Dose: 10-15 ml/kg
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? Not for volume expansion? Not for nutritional support/ hypoproteinemia
Cryoprecipitate
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? Out of group can be transfused but preferably ABO compatible? RhD type need not be considered
? Thawed Cryoprecipitate transfused within 6 hours
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? Indicated for bleeding associated with fibrinogen deficiency and
factor XI I deficiency
? Hemophilia A or von Willebrand disease when appropriate substitute
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not available
? Bleeding with fibrinogen levels< 100mg/dl
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? Dose - one unit/10 kg body weight? Raises fibrinogen concentration by 50 mg/dl
Choice for ABO Blood Groups
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Patient type
Donor PRBC
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Donor FFPDonor PC
O Positive
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O
O,B,A,AB
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O,B,A,ABA Positive
A,O
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A,AB
A,AB,O,B
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B PositiveB,O
B,AB
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B,AB,O,A
AB Positive
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AB,B,A,OAB
AB,B,A,O
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Choice for Rh Blood group
? Rh (D) negative patient transfused with Rh (D) positive components
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PRBC
Only as a life saving measure and with consent
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from treating physician & patient's relativeFFP
No anti-D immunoprophylaxis required
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PC
Anti D immunoprophylaxis required
(300 ?g anti-D gives protection for 7
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plateletpheresis units or 30 Rh (D) positive
platelet concentrates for 6 weeks)
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Cross matching: Special CircumstancesClinical urgency
Immediate
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Minutes
Within an hour
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Group O Rh negABO & Rh D type
ABO & Rh D type
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Packed RBCs
Group specific blood
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Complete crossmatchImmediate spin
(5-10 min)
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crossmatch
( 15-20) min)
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If units are issued without X match ? written consent of physician to be taken,-complete X match protocols followed after issue
Take Home Messages
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? No place for Whole Blood in clinical medicine? Component preparation and use is the demand of time
? Best Transfusion is "No Transfusion"
? Promotion of judicious use of blood / components
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4 Audit of transfusion practices4 CME on use of components
4 Promote autologous use of blood
4 Discourage single unit / fresh blood
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Thank You