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Part 1 – Ruba Al-Sheyab
IV Fluid & Blood Component
Therapy
Distribution of Body Water
• Total Body Water (TBW) equals to 60% of total
body weight in adult males
• In females, the percentage is around 55%,
while in infants is around 75%
• Obese individuals have less TBW per weight
than non-obese individuals
• Using a 70 Kg male as an example, TBW is 42
Litres

Fluid Compartments are divided by water-permeable
membranes.

Intracellular space is separated from the extracellular
space by the cell membrane.

The capillary membrane separates the components of
the extracellular space.
Transcelullar fluid : Transcellular fluid is the portion
of TBW contained within epithelial lined spaces. It is the
smallest component of extracellular fluid , e.g :cerebrospinal
fluid , and ocular fluid, joint fluid.[1]
• You should know the electrolyte values (including the units)
• The main extracellular electrolyte is Na and the main intracellular electrolyte is K
Intravenous solutions
• During anesthesia, fluids are given IV to replace losses due to surgery, and to
provide the patient’s normal daily requirements
• Three types are used:
1. Crystalloids
2. Colloids
3. Blood and its components
We give IV fluid in adult according to the blood loss :
- If there is < 15 % blood loss we use crystlloids because they are safer
- >15 % blood loss start with colloids >> more effective
- >20 % start to give blood ( some sources said that after 30 % we give blood
but actually anesthetist think of blood after the 20 % blood loss in
hemodynimically stable pt.s >> if CVS is not ok we can give blood at 10 % in
adult so it depends )
-
**** in children we start to give blood if there is > 10 % blood loss
Crystalloids
• Solutions of crystalline solids in water
• Once they are given, they are redistributed amongst various body
fluid compartments, with the extent depending on their
composition
• The solutions can be considered into three groups:
A.
Those that contain electrolytes in a similar composition to plasma,
have an osmolality similar to plasma, and referred to as being isotonic
(eg, 0.9% normal saline and Ringer’s lactate)
B.
Those that contain less or no electrolytes (hypotonic) but contain
glucose to ensure that they have an osmolality similar to plasma (eg,
5% dextrose, 0.25% NS, 0.45% NS, and 4% glucose + 0.18% NS)
C. Hypertonic solutions used recently, consisting of
between 1.8 and 7.5% sodium chloride solutions.
Crystalloids
Na+
mmol/L
K+
mmol/L
Ca++
mmol/L
Clmmol/L
HCO3mmol/L
pH
Osmolality
(mosmol/L)
Hartmann’s
(Ringer’s
lactate)
131
5
4
112
29*
6.5
281
0.9% sodium
chloride
(Normal
saline)
154
0
0
154
0
5.5
300
4% glucose +
0.18 NaCl
31
0
0
31
0
4.5
284
5% Glucose
(5% dextrose
in water;
D5W)
0
0
0
0
0
4.1
278
0.9% Normal Saline
• 0.9% NS is distributed throughout the intravascular and
interstitial volumes ( ECF compartment) in proportion to
their size.
• After 15-30 min, only 25-30% of the volume administered
remains intravascular, i.e. limited intra-vascular half-life.
• Therefore, if such a fluid is used to restore the circulating
volume, three to four times the deficit will need to be
given.
• 0.9% NS is used in the perioperative period and as the first
line emergency fluid resuscitation.
0.9% Normal Saline
• Commonly used for electrolyte replacement
• The preferred fluid for hypovolaeminc
resuscitation in many countries
• Useful for replacing electrolyte-rich GI losses
Contains high sodium and chloride
concentrations and may be responsible for
hyperchloraemic metabolic acidosis
Hartmann’s Solution (Ringer’s lactate)
• Physiological solutions
• Osmolality is similar to ECF and thus useful for restoring
extracellular volume
• First-line replacement therapy in the perioperative period and
for emergency fluid resuscitation
• May reduce iatrogenic hyperchlorarmic metabolic acidosis,
associated with use of higher chloride-containing solutions
• The addition of K+ and Ca++ limit usefulness in hyperkalemia
or with citrated blood transfusions
5% Dextrose (D5W)
• For this hypotonic solution, once the glucose is metabolized
the remaining fluid is distributed throughout the entire body
water (i.e. ECF and ICF), and so it provides a convenient way of
giving free water.
• But less than 10% will remain intravascular, and thus, they
have no role as plasma expanders
• Glucose-containing solutions are a
dehydration as a result of water losses.
way
of
treating
• They are not routinely used perioperatively, as excessive use
lead to hyponatraemia
• Sugar-containing solutions provide 4kcal/g glucose (glucose
5% contains 5g/100ml), a considerable energy source, but
their potential deleterious osmotic effects limit use
Effect of large volume crystalloid infusion
1- extravascular accumilation in skin,
connective tissue, kidney.
2-inhibition of GI motility
3-delay healing of anastomosis
4-large volume ,Rapid infusion cause
hypercoagulability
Colloids
• Suspensions of high molecular weight particles
• Mainly two types: Natural (albumen) & Synthetic
(the others)
• Most commonly used are derived from gelatin
(Haemaccel, Gelofusine), protein (albumin), or
starch
• Primarily, they expand the intravascular volume and
can initially be given in a volume similar to the
estimated deficit to maintain the circulating volume
• However, they have a finite life in the plasma
and will eventually be either metabolized or
excreted, and therefore, need replacing.
o Definition from Oxford Handbook of Anaesthesia
Colloids
are
homogenous,
non-crystalline
substances consisting of large molecules or
ultramicroscopic particles, which persist in the
vascular compartment to expand the functional
plasma volume (lasting several hours to several
days)
1. Human Albumin Solution (HAS)
• Molecular weight (MW) 69000
• Available as 4.5% solution for the treatment of
hypovolaemia, and as a salt-poor 20% solution
for the treatment of hypoalbuminemia
• It is manufactured from whole blood
fractionation
2. Gelatins
• Succinylated gelatins (MW 30000), e.g.
Gelofusine 4% presented in NaCl solution
• Manufactured from bovine collagen from BSEfree herds
• Rarely lead to histamine release causing
bronchospasm, urticarial rash, hypotension,
and tachycardia
• No limit on total volume that may be
administered
3. Hydroxyethyl starches (HES)
• The best colloid
• MW 70000-450000
• Manufactured from hydrolysed amylase-resistant maize or
sorghum
• S/E:
Anaphylactoid reactions: hypersensitivity, mild influenza-like
symptoms, tachycardia, bronchospasm and non-cardiogenic
pulmonary edema , renal impairment
Also Decrease in hematocrit , disturbances in coagulation and
bleeding
4. Dextrans
• Branched polysaccharides derived from bacterial action on sucrose
Dextran 70 “ MW 70000”: (Better volume expander).
Dextran 40: “MW 40000” (Improves blood flow through
microcirculation).
*Associated with anticoagulation.
*Use for vascular surgery – prevent thrombosis.
*Can cause mild-moderate anaphylactoid and anaphylactic reactions
*Infusions exceeding 20 ml/kg/d can interfere with blood typing, renal
failure, prolong Beeding Time (Dextran 40).
• Initially 20ml/kg for the 1st 24 hours and 10ml/kg thereafter for 5
days only!
Side effects and precautions(Important)
• Anaphylaxis with the gelatins
• coagulopathy and bleeding with starched, in
addition to itching after their use
• There is no limit on the volume of gelatins
that can be given (provided that haemoglobin
concentration is maintained!) whereas
starches are limited to 30-50ml/kg
Differences between colloids and
crystiloids :
colloids Expensive relatively to crystiloids
Colloids have high molecular weight
Half life for crystilloids 15-20 mins while colloids
for 2-3 hrs
Colloids effects as plasma expanders
Maram AlAnbar- Part 2
Intraoperative fluid
requirements
 Optimal perioperative fluid therapy requires an
understanding of the changes that occur in the
volume and composition of the body fluid
compartments ..
 Intravenous fluids are used to replenish fluid losses
while maintaning :
** intravascular volume ( which is essential for adequate
perfusion of vital organs )
** cardiac preload
** oxygen-carrying capacity
** coagulation status
** acid-base balance
** electrolyte balance
The total fluid requirement is composed of :
• compensatory intravascular volume expansion (CVE) ..
• maintenance fluids ..
• preoperative deficits ( NPO ,, GI losses ,, blood loss )
..
• ongoing surgical Losses ( evaporation ,, blood loss ,,
3de space loss )..
<1> compensatory intravascular volume expansion (CVE)
• Intravascular volume must usually be supplemented to
compensate for the venodilation and cardiac depression
caused by anesthesia ..
• Increasing cardiac preload by infusing fluid
intravascularly to return stroke volume to an acceptable
range ..
• 5 mL/kg of balanced salt solution (Ringer's lactate) should
be introduced before or simultaneous with the onset of
anesthesia ..
• Postoperatively ; venodilation and cardiac depression
rapidly subside when administration of the anesthetic is
stopped ..
• ** Note : Patients with impaired cardiac or renal
responses may then become acutely hypervolemic !!
<2> Maintenance fluids
• Maintenance fluid requirements for any body weight can be calculated
using the :
"4-2-1" rule for hourly fluid requirements
or the "100-50-20" rule for daily fluid requirements
For example, a 75 kg adult will require:
Per hour:
10 kg x 4 ml/hr = 40 ml/hr
10 kg x 2 ml/hr = 20 ml/hr
55 x 1 ml/hr = 55 ml/hr
Total : 75 kg 115 ml/hr
Per day:
10 kg x 100 ml/day = 1000 ml/day
10 kg x 50 ml/day = 500 ml/day
55 x 20 ml/day = 1100 ml/day
Total : 75 kg 2600 ml/day
<3> Preoperative deficits
1. as a result of a period of fasting ( NPO deficit ) :
• In the absence of oral intake ; fluid and electrolyte deficits can
rapidly develop as a result of continued urine formation,
gastrointestinal secretions , and insensible losses ( from the skin
and lungs ) ..
can be calculated by multiplying the patient's hourly maintenance
requirements by the number of hours fasted --->
Maintenance requirements / hour x number of hours fasted
$ 75 kg 115 ml/hr $
= 115 × 8
= 920 ml
** in surgery that takes 4 hrs for ex. we give half deficit in 1st
hour ( 920/2 = 460) & other half divided by 3hrs ( 460/3 ) per
hr **
2. preoperative losses from the gastrointestinal tract ( eg.
vomitting or diarrhea ) ,,
best replaced with a crystalloid of similar composition (0.9% NS or
Ringer’s lactate )
<3> Preoperative deficits
3. Blood loss
** < 15% blood loss we use crystlloids ;
If 1000 ml of NS is infused intravenously ;
only 1/3 (approx. 300 ml) will remain in the intravascular
compartment ,, the remaining 2/3 ( 700 ml) will move into the
interstitial and intracellular compartments
3 times the volume of blood lost must be infused when crystalloids
(NS or RL) are used to maintain the intravascular volume ( 3:1
volume basis ) ..
** 15-30% blood loss use colloids ;
given in a volume similar to the estimated deficit to maintain the
circulating volume (1:1 volume basis) ..
** > 30% start to transfuse blood (unit-for-unit) esp in young
patients..
• in children we start blood transfusion at 10% blood loss ..
• in elderly & preexisting medical condition as in IHD start
blood transusion at 20% blood loss ..
Blood loss
• we prefer to start with crystalloids in replacement of blood loss
bcz they're safer ..
• we don't prefer to use colloids bcz of the side effects ( eg.
coagulopathy ,, anaphylaxis .. ) ..
• we don't prefer to transfuse blood bcz of the complications
until the danger of anemia outweighs the risks of transfusion (
transfusion point )then we should transfuse blood ( red blood
cells to maintain hemoglobin concentration or hematocrit at
certian level )..
• usually we start the procedure when Hb >10g/dl esp in elderly
and sicker patients with cardiac or pulmonary disease
but could be acceptalble >7-8 g/dl in younger & medically
free patient
Blood loss
The transfusion point can be determined preoperatively from
the hematocrit and by estimating blood volume ..
• hematocrit : volume percentage (%) of red blood cells in blood
in (Men= 42-52% ,, Women= 37-47%)
•
• blood volume : can be either calculated in formula ( plasma
volume/ 1-hematocrit ) or generally estimated as in table below :
Age group
Average blood volume (ml/kg)
Premature neonates
95
Full-term neonates
85
Infants
80
Adult male
75
Adult female
65
•
** the amount of blood loss necessary for the hematocrit to
fall to 30% can be calculated as follows :
1. Estimate blood volume from .
2. Estimate the red blood cell volume (RBCV) at the preoperative
hematocrit (RBCV preop ).
3. Estimate RBCV at a hematocrit of 30% (RBCV 30% ), assuming
normal blood volume is maintained.
4. Calculate the RBCV lost when the hematocrit
is 30%; RBCV lost = RBCV preop – RBCV 30% .
5. Allowable blood loss = RBCV lost × 3
example : An 85-kg woman has a preoperative hematocrit of
35% How much blood loss will decrease her hematocrit
to 30%?
•
•
•
•
•
Estimated blood volume = 65 mL/kg × 85 kg = 5525 mL.
RBCV 35% = 5525 × 35% = 1934 mL.
RBCV 30% = 5525 × 30% = 1658 mL.
Red cell loss at 30% = 1934 − 1658 = 276 mL.
Allowable blood loss = 3 × 276 mL = 828 mL.
<4> ongoing surgical Losses
1. Evaporation :
This can occur during body cavity surgery or when large
areas of tissues are exposed ,, and here evaporation from
exposed viscera is entirely water, but the electrolyte is
left behind, leading to a need for free water ..
2. Blood loss :
Depends upon the type and site of surgery ..
3. Third space loss : -->
third space
• first ( intravascular ) and second ( interstitial ) spaces are the
constituents of the ECF which are normal physiological
compartments ..
• "third space" is a space in the body where fluid does not
normally collect in larger amounts ,, it's related to and formed
from the ECF ,, examples :
** peritoneal cavity ( eg. ascites ) ..
** pleural cavity ( eg. pleural effusion ) ..
** lumen of the gastrointestinal tract ( as in a patient with
ileus ) ..
** swelling of the tissues after surgical trauma or burns ..
Replacing third space fluid losses is a ( 4-6-8 ml/kg/hr ) rule ;
4 for minor trauma ( eg. hernia, tonsilictomy ),
6 for moderate trauma ( eg. hysterectomy),
8 for major trauma ( eg. AAA repair)
Liberal versus Restrictive Fluid Management
• routine intraoperative fluid management strategy has been
criticized ,,
• ex. in lung surgery ; the risk of postpneumonectomy pulmonary
edema is clearly associated with the amount of administered
fluid ,,
** As a result ; “fluid-conservative” or “dry” fluid strategies are
now commonly employed for patients undergoing lung surgery ..
• another ex. gastrointestinal surgery Excessive perioperative
fluid administration may also lead to edema of the
gastrointestinal tract contributing to ileus ,,
** perioperative fluid restriction can lead to improved outcomes
after major elective gastrointestinal surgery ..
Restrictive Fluid Management
There are several approaches to fluid restriction :
** Replacement of blood loss on a “mL per mL” basis with
colloid ..
** No replacement of third space loss during surgery ..
** No fluid loading prior to general anesthesia ..
** Postoperative restriction of fluids with administration
of diuretics ..
Monitoring Adequacy of Fluid Replacement
** Vital Signs : BP and HR
if patient get hypotensive during surgery most likely cause is
hypovolemia and 1st sign is tachycardia ,, but ,, Anesthetic drugs
can cause hypotension and mask traditional signs of hypovolemia
such as tachycardia ..
** Urine output :
Nl --> 1.0 ml/kg/hr
Decreased intraoperative urine output does not necessarily indicate
hypovolemia but could be of help ..
** periodic monitoring of hemoglobin and hematocrit ..
** Invasive monitoring :
- central venous pressure (It is a good approximation of right
atrial pressure ,, used as a surrogate for preload ,, changes in
CVP in response to infusions of intravenous fluid have been used
to predict volume-responsiveness )
- transesophageal echocardiography
Ahmad H. Hdaib
Group A1 – HOPE 2014/2015
Blood Transfusion
Blood Groups
 Human red cell membranes are estimated to contain at
least 300 different antigenic determinants, and at least 20
separate blood group antigen systems are known.
 Fortunately, only the ABO and the Rh systems are
important in the majority of blood transfusions.
 Individuals often produce antibodies (alloantibodies) to
the alleles they lack within each system.
 Such antibodies are responsible for the most serious
reactions to transfusions.
 Antibodies may occur “naturally” or in response to
sensitization from a previous transfusion or pregnancy.
Blood Groups
The ABO System
The Rh System
Other Red Blood Cell Antigen Systems
Blood Groups – The ABO System
 ABO blood group typing is determined by the presence or
absence of A or B red blood cell (RBC) surface antigens:
– Type A blood has A RBC antigen
– Type B blood has B RBC antigen
– Type AB blood has both A and B RBC antigens
– Type O blood has neither A nor B RBC antigen present
 Almost all individuals not having A or B antigen “naturally”
produce antibodies, mainly immunoglobulin (Ig) M, against
those missing antigens within the first year of life.
Blood Groups – The Rh System
 There are approximately 46 Rhesus group red cell surface
antigens, and patients with the D Rhesus antigen are
considered Rh-positive.
 Approximately 85% of the white population and 92% of
the black population has the D antigen, and individuals
lacking this antigen are called Rh-negative.
 In contrast to the ABO groups, Rh-negative patients usually
develop antibodies against the D antigen only after an Rhpositive transfusion or with pregnancy, in the situation of
an Rh-negative mother delivering an Rh-positive baby.
 AB+ is the universal recipient
 O- is the universal donor
Blood Groups – Other Red Blood Cell Antigen Systems
 Other red cell antigen systems include Lewis, P, Ii,
MNS, Kidd, Kell, Duffy, Lutheran, Xg, Sid, Cartright, YK,
and Chido Rodgers.
 Fortunately, with some exceptions (Kell, Kidd, Duffy,
and Ss), alloantibodies against these antigens rarely
cause serious hemolytic reactions.
Compatibility Testing
 The purpose of compatibility testing is to
predict and to prevent antigen–antibody
reactions as a result of red cell transfusions.
Compatibility Testing
ABO-Rh Testing
Antibody Screen
Crossmatch
Type & Crossmatch versus Type & Screen
Compatibility Testing – ABO–Rh Testing
 The most severe transfusion reactions are due to ABO
incompatibility; naturally acquired antibodies can react
against the transfused (foreign) antigens, activate
complement, and result in intravascular hemolysis.
 The patient’s red cells are tested with serum known to have
antibodies against A and against B to determine blood type.
Because of the almost universal prevalence of natural ABO
antibodies, confirmation of blood type is then made by
testing the patient’s serum against red cells with a known
antigen type.
Compatibility Testing – ABO–Rh Testing
 The patient’s red cells are also tested with anti-D antibodies
to determine Rh status.
 If the subject is Rh-negative, the presence of anti-D antibody
is checked by mixing the patient’s serum against Rh positive
red cells. The probability of developing anti-D antibodies
after a single exposure to the Rh antigen is 50–70%.
Compatibility Testing – Antibody Screen
 The purpose of this test is to detect in the serum the
presence of the antibodies that are most commonly
associated with non-ABO hemolytic reactions.
 The test (also known as the indirect Coombs test) requires
45 min and involves mixing the patient’s serum with red
cells of known antigenic composition; if specific antibodies
are present, they will coat the red cell membrane, and
subsequent addition of an antiglobulin antibody results in
red cell agglutination.
 Antibody screens are routinely done on all donor blood and
are frequently done for a potential recipient instead of a
crossmatch.
Compatibility Testing – Crossmatch
 A crossmatch mimics the transfusion: donor red cells are
mixed with recipient serum. Crossmatching serves three
functions:
1. Confirms ABO and Rh typing
2. Detects antibodies to the other blood group systems
3. Detects antibodies in low titers or those that do not
agglutinate easily.
Compatibility Testing – Type & Crossmatch versus
Type & Screen
 In the situation of negative antibody screen without
crossmatch, the incidence of serious hemolytic reaction with
ABO- and Rh-compatible transfusion is less than 1:10,000.
 Crossmatching, however, assures optimal safety and detects
the presence of less common antibodies not usually tested
for in a screen.
 Because of the expense and time involved (45 min),
crossmatches are often now performed before the need to
transfuse only;
– when the patient’s antibody screen is positive
– when the probability of transfusion is high
– when the patient is considered at risk for
alloimmunization.
Emergency Transfusions
 When a patient is exsanguinating, the urgent need to
transfuse may arise prior to completion of a crossmatch,
screen, or even blood typing.
 If the patient’s blood type is known, an abbreviated
crossmatch, requiring less than 5 min, will confirm ABO
compatibility.
 If the recipient’s blood type and Rh status is not known with
certainty and transfusion must be started before
determination, type O Rh-negative (universal donor) red
cells may be used.
Blood Bank Practices
 Blood donors are screened to exclude medical conditions
that might adversely affect the donor or the recipient.
 Once the blood is collected, it is typed, screened for
antibodies, and tested for hepatitis B, hepatitis C, syphilis,
and human immunodeficiency virus (HIV).
 A preservative–anticoagulant solution is added. The most
commonly used solution is CPDA-1, which contains citrate as
an anticoagulant (by binding calcium), phosphate as a buffer,
dextrose as a red cell energy source, and adenosine as a
precursor for adenosine triphosphate (ATP) synthesis.
 CPDA-1-preserved blood can be stored for 35 days, after
which the viability of the red cells rapidly decreases.
Alternatively, use of either AS-1 (Adsol) or AS-3 (Nutrice)
extends the shelf-life to 6 weeks.
Blood Bank Practices
 Nearly all units collected are separated into their component
parts (ie, red cells, platelets, and plasma).
 In other words, whole blood units are rarely available for
transfusion in civilian practice.
 When centrifuged, one unit of whole blood yields
approximately 250 mL of packed red blood cells (PRBCs)
with a hematocrit of 70%; following the addition of saline
preservative, the volume of a unit of PRBCs often reaches
350 mL.
 Red cells are normally stored at 1–6°C, but may be frozen in
a hypertonic glycerol solution for up to 10 years. The latter
technique is usually reserved for storage of blood with rare
phenotypes.
Blood Bank Practices
• The supernatant is centrifuged to yield platelets and
plasma. The unit of platelets obtained generally contains 50–
70 mL of plasma and can be stored at 20–24°C for 5 days.
• The remaining plasma supernatant is further processed and
frozen to yield fresh frozen plasma; rapid freezing helps
prevent inactivation of labile coagulation factors (V and VIII).
• Slow thawing of fresh frozen plasma yields a gelatinous
precipitate (cryoprecipitate) that contains high
concentrations of factor VIII and fibrinogen.
• Once separated, this cryoprecipitate can be refrozen for
storage. One unit of blood yields about 200 mL of plasma,
which is frozen for storage; once thawed, it must be
transfused within 24 h.
Blood Bank Practices
 Most platelets are now obtained from donors by apheresis,
and a single platelet apheresis unit is equivalent to the
amount of platelets derived from 6–8 units of whole blood.
 The use of leukocyte-reduced ( leukoreduction ) blood
products has been rapidly adopted by many countries,
including the United States, in order to decrease the risk of
transfusion-related febrile reactions, infections, and
immunosuppression.
Intraoperative Transfusion Practices
Packed Red Blood Cells
Fresh Frozen Plasma
Platelets
Granulocyte Transfusions
Indications for Procoagulant Transfusions
Packed Red Blood Cells
 Blood transfusions should be given as PRBCs, which allows
optimal utilization of blood bank resources.
 Surgical patients require volume as well as red cells, and
crystalloid or colloid can be infused simultaneously through
a second intravenous line for volume replacement.
 Prior to transfusion, each unit should be carefully checked
against the blood bank slip and the recipient’s identity
bracelet.
 The transfusion tubing should contain a 170-μm filter to
trap any clots or debris.
Packed Red Blood Cells
 Blood for intraoperative transfusion should be warmed to
37°C during infusion, particularly when more than 2–3 units
will be transfused; failure to do so can result in profound
hypothermia.
 The additive effects of hypothermia and the typically low
levels of 2,3-diphosphoglycerate (2,3-DPG) in stored blood
can cause a marked left ward shift of the hemoglobin–
oxygen dissociation curve and, at least theoretically,
promote tissue hypoxia.
Fresh Frozen Plasma
 Fresh frozen plasma (FFP) contains all plasma proteins,
including most clotting factors.
 Transfusions of FFP are indicated in the treatment of isolated
factor deficiencies, the reversal of warfarin therapy, and the
correction of coagulopathy associated with liver disease.
 Each unit of FFP generally increases the level of each
clotting factor by 2–3% in adults.
 The initial therapeutic dose is usually 10–15 mL/kg. The goal
is to achieve 30% of the normal coagulation factor
concentration.
Fresh Frozen Plasma
 FFP may also be used in patients who have received massive
blood transfusions and continue to bleed following platelet
transfusions. Patients with antithrombin III deficiency or
thrombotic thrombocytopenic purpura also benefit from
FFP transfusions.
 Each unit of FFP carries the same infectious risk as a unit of
whole blood. In addition, occasional patients may become
sensitized to plasma proteins. ABO-compatible units should
generally be given but are not mandatory.
 As with red cells, FFP should generally be warmed to 37°C
prior to transfusion.
Platelets
 Platelet transfusions should be given to patients with
thrombocytopenia or dysfunctional platelets in the
presence of bleeding.
 Prophylactic platelet transfusions are also indicated in
patients with platelet counts below 10,000–20,000 × 10^9 /L
because of an increased risk of spontaneous hemorrhage.
 Platelet counts less than 50,000 × 10^9 /L are associated
with increased blood loss during surgery.
 Thrombocytopenic patients often receive prophylactic
platelet transfusions prior to surgery or invasive procedures.
Platelets
 Vaginal delivery and minor surgical procedures may be
performed in patients with normal platelet function and
counts greater than 50,000 × 10 9 /L.
 Administration of a single unit of platelets may be expected
to increase the platelet count by 5000–10,000 × 10 9 /L, and
with administration of a platelet apheresis unit, by 30,000–
60,000 × 10 9 /L. ABO-compatible platelet transfusions are
desirable but not necessary.
 Transfused platelets generally survive only 1–7 days
following transfusion.
Platelets
 ABO compatibility may increase platelet survival. Rh
sensitization can occur in Rh-negative recipients due to
the presence of a few red cells in Rh-positive platelet
units.
 Moreover, anti-A or anti-B antibodies in the 70 mL of
plasma in each platelet unit can cause a hemolytic
reaction against the recipient’s red cells when a large
number of ABO-incompatible platelet units is given.
 Administration of Rh immunoglobulin to Rh-negative
individuals can protect against Rh sensitization following
Rh-positive platelet transfusions.
Granulocyte Transfusions
 Granulocyte transfusions, prepared by leukapheresis, may
be indicated in neutropenic patients with bacterial
infections not responding to antibiotics.
 Transfused granulocytes have a very short circulatory life
span, so that daily transfusions of 10^10 granulocytes are
usually required.
 Irradiation of these units decreases the incidence of graft –
versus host reactions, pulmonary endothelial damage, and
other problems associated with transfusion of leukocytes,
but may adversely affect granulocyte function.
 The availability of granulocyte colony- stimulating factor (GCSF) and granulocyte macrophage colony- stimulating factor
(GM-CSF) has greatly reduced the use of granulocyte
transfusions.
Indications for Procoagulant Transfusions
 Blood products can be misused in surgical settings. Use of a
transfusion algorithm, particularly for components such as
plasma, platelets, and cryoprecipitate, and particularly when
the algorithm is guided by appropriate laboratory testing,
will reduce unnecessary transfusion of these precious (but
dangerous) resources.
 Derived from military experience, there is a trend in major
trauma care towards transfusing blood products in equal
ratios early in resuscitation in order to preempt or correct
trauma-induced coagulopathy.
 This balanced approach to transfusion of blood products,
1:1:1 (one unit of FFP and one unit of platelets with each
unit of PRBCs) is termed damage control resuscitation.
Old Blood Units
 Changes that happen to old blood units:
1. Increased 2,3 DPG that reduce the affinity of
hemoglobin to oxygen (right shift of O2-Hb dissociation
curve)
2. Hyperkalemia  metabolic acidosis
3. Decreased or no platelets at all due their short half life
(which is about 7 days)
4. Deficient coagulation factors
 E.g. if we gave a patient 4 units of blood, but we observed
more loss of blood, explain? because the blood is more than
7 days old, so the coagulation factors (fibrinogen) and
platelets are non functional and therefore the patient will
bleed out
Complications of blood transfusion
Allergic Reaction
Symptoms can include:
1-Anxiety
2-Chest and/or back pain
3-Troubled breathing
4-Fever, chills, flushing, and clammy skin
5-Tachycardia or low blood pressure
7-Nausea
Viruses and Infectious Diseases:
1-HIV.
2-Hepatitis B and C.
Fever:
a normal response to white blood cells in the donated
blood. treat the fever by antipyretics.
IronOverload
Getting many blood transfusions can cause (iron overload).
People who have a blood disorder like thalassemia, which
requires multiple transfusions, are at risk for iron overload.
Iron overload can damage your liver, heart, and other parts
of your body.
iron chelation therapy.
Acute immune hemolytic reaction:
is very serious, but also very rare.
It occurs if the blood type during a transfusion doesn't match
or work with your blood type. Body attacks the new red blood
cells, which then produce substances that harm kidneys.
The symptoms include chills, fever, nausea, pain in the chest
or back, and dark urine.
Stop the transfusion at the first sign of this reaction.
Delayed Hemolytic Reaction
This is a much slower version of acute immune hemolytic
reaction.
Both acute and delayed hemolytic reactions are most
common in patients who have had a previous transfusion
Massive blood transfusion
Replacement by transfusion of one blood volume (or >10
units) within 24 hours or of more than 50% of a patient's
blood volume (or >5 units) in 2-4 hours in adults
Complication of massive blood transfusion
1- coagulopathy like DIC
2- acidosis
3-hypothermia
4-hypocalecmia
5-hyperkalemia
6-impaired O2 diffusion .