Transcript BLOOD COMPONENT THERAPY

BLOOD COMPONENT
THERAPY
2002
EVAN G. PIVALIZZA, FFA
Department of Anesthesiology
University of Texas at Houston
A. BLOOD PRODUCTS

22 x 106 components p.a.

50-70 % peri-operatively

18-57% inappropriate (NIH reviews in 80’s)
Blood preservation and
storage
75 % RBC’s in circulation @ 24 hrs
 Within 4 hrs, WB separated
 WB: 63 ml preservative (HCT 36-40%)

– CPD- A (citrate, phosphate, dextrose, adenine)
shelf-life 35 days @ 1-60 C

PRBC: (HCT 60%)
– CPD-A
– ADSOL (adenine, dextrose, saline, mannitol)
shelf-life 42 days

Deglycerolized blood
– Frozen with glycerol for storage, washed before
transfusion (years)

Leucocyte depleted blood (see later)

Washed (IgA deficiency)
DO2 / VO2

DO2 = CO x [(Hb x SaO2 x 1.34) + PaO2 x
0.003]

Flow  pressure, 1/R4, viscosity

Balance hematocrit/ viscosity + 30%

Compensations chronic anemia
–  viscosity =  flow, venous return, SV
–  O2 extraction except cardiac and cerebral
circulation
– O2 DC shifted to right
– DO2 adequate to Hct 18-25%
Indications for PRBC
transfusion



ONLY: Increase O2 carrying capacity
Use of single ‘trigger’ transfusion inappropriate
TRICC: ? more conservative trigger in ICU (7-9
vs 10-12)
– NOT apply to > 55, bleeding, cardiac surgery


Determination transfusion based patient risks for
complication of inadequate DO2
10 ml/kg  Hct 10 %
Indications for FFP transfusion





2 million units p.a.
200-260 ml: procoagulants (1U/ml) and fibrinogen
(3-4 mg/ml)
Urgent reversal of coumadin therapy (5-8 ml/ kg)
Correction of known coagulation factor
deficiencies (no concentrates available) to + 30%
(10-15 ml/ kg)
Microvascular bleeding with PT/ PTT > 1.5
normal

Massive BT with microvascular bleeding
– >1 BV/ 24 hours
– > 50 % BV within 3 hrs
– > 150 ml/min

Plasmapheresis for TTP

AT-III deficiency

Succinylcholine apnea
– S.D plasma
– Pooled plasma, Rx solvent and detergent
– Virus inactivated,  bacteria, WBCs
– Consistent coagulation factors (1 U  2-3%)
BUT:
– Cost
– ? Transmission unknown particles
Indications for cryoprecipitate
transfusion

10 ml: fibrinogen (150-250 mg), VIII (80145 U), fibronectin, XIII

1U/ 10kg  fibrinogen 50 mg/dL (usually a
6- pack)

Hypofibrinogenemia (congenital or
acquired)

Microvascular bleeding with massive BT
(fibrinogen < 80-100mg/dL)
– 2 BVs = < 100 mg/dL

Bleeding patients with vWD (or
unresponsive to DDAVP)
Indications for platelet
transfusion
7 million units p.a.
 50 ml: 0.5- 0.6 x 10 9 platelets (some RBC’s
and WBC’s)

Single donor apheresis OR
 Random donor (x 6)


Decreased production
Prophylactic for surgical patient with
platelets < 50,000
 Microvascular bleeding in surgical patient
with platelets < 50,000
 Neuro/ ocular surgery > 75,000


Massive transfusion with microvascular
bleeding with platelets < 100,000
– 2 BVs = 50,000

Qualitative dysfunction with microvascular
bleeding (may be > 100,000)

Assessment of platelet function (TEG,
Sonoclot) in O.R.
B. TRANSFUSION
REACTIONS
RBC’s
 Nonhemolytic
– 1-5 % transfusions: fever, chills, urticaria
– Slow transfusion, diphenhydramine
 Hemolytic
– Immediate: ABO incompatibility (1/ 1233,000) with fatality (1/ 500-800,000)
– Majority are group O patients receiving
type A, B or AB blood


Anesthesiologist major trauma hospital:
Transmit HIV once / 1,000 years
 Hep C 200
 Hep B 100
 Administer incorrect blood 30

– UK: 1996-99 – 97 life-threatening
ABO incompatible transfusions
 Complement
activation, RBC lysis, free
Hb (+ direct Coombs Ab test)
– Anesthesia: hypotension, urticaria,
abnormal bleeding
– Stop infusion, blood and urine to blood
bank, coagulation screen (urine/plasma Hb,
haptoglobin)
– Fluid therapy and osmotic diuresis
– Alkalinization of urine (increase solubility
of Hb degradation products)
– Delayed: (extravascular immune)
– 1/ 5-10,000
– Hemolysis 1-2 weeks after transfusion
(reappearance of Ab against donor Ag from
previous exposure)
– Fever, anemia, jaundice
– Alloimmunization
– Recipient produces Ab’s against RBC
membrane Ag
– Related to future delayed hemolytic reactions
and difficulty crossmatching

WBC’s
Europe: All products leukodepleted
USA: Initial FDA recommendation now reversed
pending objective data (NOT  length of stay for
 expense)

Febrile reactions


– Recipient Ab reacts with donor Ag, stimulates pyrogens
(1-2 % transfusions)
– 20 - 30% of platelet transfusions
– Slow transfusion, antipyretic, meperidine for shivering

TRALI (Transfusion related acute lung
injury)
– Donor Ab reacts with recipient Ag (1/ 10,000
but causes 15 % of mortality due to BT)
– Noncardiogenic pulmonary edema
– Supportive therapy
– ? relation to multiparous donors (> 4
pregnancies)

GVHD
– Rare: immunocompromised patients
– Suggestion that more common with designated
donors
– BMT, LBW neonates, Hodgkin's disease,
exchange Tx in neonates
Platelets
Alloimmunization

– 50 % of repeated platelet transfusions
– Ab-dependent elimination of platelets with lack
of response
– Use single donor apheresis

Post-transfusion purpura
– Recipient Ab leads to sudden destruction of
platelets 1-2 weeks after transfusion (sudden
onset)
Immunomodulatory effects of transfusion
 Wound infection: circumstantial evidence (?
leukocyte filters for immunocompromised)
 Beneficial effects on renal graft survival
(now < NB with CyA)

– 97: 9% graft survival advantage after 5 years

Nonspecific overload of RES
–  lymphocytes, APCs
– Modification T helper/suppressor ratio
– Allogeneic lymphocytes may circulate for years
after transfusion

Cancer recurrence (mostly retrospective)
– Colon: 90 % studies suggest increased
recurrence
– Breast: 70 % studies
– Head and neck: 75 % studies
“Allogeneic blood products increase cancer
recurrence after potentially curative surgical
resection” - Landers
 Evidence circumstantial NOT causal


However, 2 recent prospective, randomized
studies: no effect on tumor related
morbidity/mortality, but poorer outcomes
Conservative trigger (< 3 units)
 Clinical judgment to weigh risk-benefit
ratio

C. INFECTIOUS
COMPLICATIONS
I. Viral (Hepatitis 88% of per unit viral risk)
Hepatitis B
 Risk 1/ 200,000 due to HBsAg, antiHBc
screening (7-17 % of PTH)
 Per unit risk 1/63-66,000
 0.002% residual HBV remains in ‘negative’
donors (window 2-16 weeks)
 Anti-HBc testing retained as surrogate
marker for HIV

NANB and Hepatitis C
Risk now 1/ 103,000 (NEJM 96) with 2nd/
1/ 125,000 with 3rd generation HCV Ab/
HVC RNA tests
 Window 4 weeks
 70 % patients become chronic carriers, 1020 % develop cirrhosis

HIV
29 cases -transfusion recipients  93
 7,800 by 12/ 95
 Current risk 1/ 450- 660,000 (95)
 With current screening (Abs to HIV I, II and
p24 Ag), window 6-8 weeks (third
generation ELISA tests in Europe)
  sero -ve window to < 16 days

HTLV I, II
Only in cellular components (not FFP, cryo)
 Risk 1/ 641,000 (window period unknown)
 Screening for antibody I may not pick up II

CMV
Cellular components only
 Problem in immunocompromised, although
80 % adults have serum Ab
 WBC filtration decreases risk of
transmission
 CMV -ve blood:
– CMV -ve pregnant patients, LBW
neonates, CMV -ve transplant recipient,
– CMV-ve/ HIV +ve

CJD (and variant CJD)

BB implementing donor deferrals
– 1980-96:
 > 3 months UK
 TF in UK
 > 5 years in France
II. Bacterial
 Contamination unlikely in products stored
for > 72 hours at 1-6 0 C (10 cases Yersinia)
 Platelets stored at room temperature for 5
days, with infection rate of 0.25%

III. Protozoal
 Trypanosoma cruzi (Chaga’s disease)

D. METABOLIC
COMPLICATIONS
Citrate toxicity
 Citrate (3G/ unit WB) binds Ca2+ / Mg+
 Metabolized liver, mobilization bone stores
 Hypocalcemia ONLY if > 1 unit/ 5 min or
hepatic dysfunction
 Hypotension more likely due to  cardiac
output/ perfusion than  calcium (except
neonates)
 Worse with hypothermia/ hepatic
dysfunction


Hyperkalemia
After 3 weeks, K+ is 25- 30 mmol/l
 Only 8- 15 mmol per unit PRBC/ WB
 Concern with > 1 unit/5 min @ infants


Acidosis
Acid load after after 3 weeks 30-40 mmol/l
(pH 6.6 - 6.9)
 Metabolic acidosis more likely due to
decreased perfusion, hepatic impairment,
hypothermia
 NaHCO3 or THAM if base deficit > 7-10
mEq/l


2, 3 DPG
Depleted within 96 hours of storage
 O2 Hb DC to left
 Restored within 8- 24 hours of transfusion

E. REFERENCES
Practice Guidelines for Blood Component
Therapy (ASA Task Force). Anesthesiology
1996; 84: 732-47.
 Safety of the Blood Supply. JAMA 1995;
274:1368--73.
 Infectious Disease Testing for Blood
Transfusions (NIH Consensus Conference).
JAMA 1995; 274: 1374-9.

Blood Transfusion- Induced
Immunomodulation. Anesth Analg 1996;
82: 187-204
 ASA Questions and Answers about
Transfusion Practices (3rd ed., 1997)
 Immunomodulatory aspects of transfusion.
Anesthesiology 1999; 91: 861-5.


“Blood is still the best possible thing to
have in our veins” - Woody Allen

“Blood transfusion is a lot like marriage. It
should not be entered upon lightly,
unadvisedly or wantonly, or more often than
is absolutely necessary” - Beal