Rational Use of Blood

and Blood Components

Best Transfusion is
“No Transfusion”
Why Avoid Blood Transfusion?
• Infection Risk
• HIV, Hepatitis
• Other Complications
• Febrile reactions
• Allergic, urticarial reactions
• Clerical Errors
• ABO mismatch
• Immunologic Issues
• TA-GvHD
• Immunosuppression
• Religious Reasons
Misconceptions and Myths
• Whole blood
• “Fresh” Blood
• Empirical Transfusion
• Nutritional Anemia
• Pre Surgical
• Wound Healing
• Enhancement of well being
Why whole blood not rational

 Maximize blood resource

Thalassemia
one unit of whole blood Bleeding
Aplastic anemia
Hemophilia
 Better patient management
 concentrated dose of required component
 avoid circulatory overload
 minimize reactions
 +2-60 C
Specific storage requirements of components
 Red Blood cells +220 C
 Platelets - 300 C
 Fresh frozen plasma
 Decrease cost of management
 except for the cost of bag, other expenses remain same
Whole Blood Vs Packed Red Cells
Parameter Whole blood Packed red cells
Volume 350 – 450 ml 200 – 240 ml
Increment in Hb 1 -1.5 gm/dl 1 -1.5 gm/dl
Red cell mass /ml Same as PRBC Same as WB
Viable platelets No No
Labile factors No No
Plasma citrate ++++ +
Allergic reactions ++++ +
FNHTR ++++ +
Risk of TTI ++++ +
Waste of components Yes No
“Fresh blood” – misconception.

 What is “fresh blood”?

• varying definition
• any unit kept at 4oC for 4 hours is no longer “fresh”

Increased disease transmission

• Intracellular pathogens (CMV, HTLV) survive in leukocyte in fresh blood
• Syphils transmission- tryponema can’t survive > 96 hours in stored
blood ( JAMA,95)
• Malaria transmission- malaria parasite cannot survive > 72 hours in
stored blood (Mollison)
“Fresh blood” – misconception.
 Immunological complication due to WBCs in fresh blood
• Transfusion Associated-Graft vs Host Disease – 90% fatality
• TA-immunomodulation
• Alloimmunization- Red cell / platelet
 Logistics
• no time for component preparation
• less time for infection screening
• storage lesions in different constituents due to storage temp
Rational Use of Blood

• Right product

• Right dose

• Right time

• Right reasons
Answer 4 Qs before transfusion
• Why to transfuse ?
 benefit > risk
 patients symptoms Vs lab levels
 prophylactic Vs therapeutic
• What to transfuse ?
 whole blood NO
 components / fractions
• How much to transfuse ?
 Single unit NO
• How to transfuse ?
 use of filter
 rate of transfusion
 warming
Packed Red Cells (PRBC)

Symptomatic deficiency of oxygen carrying

capacity or tissue hypoxia
Appropriate use of Packed red
cells
• Should be ABO and Rh compatible

• Clinical judgment- a vital role

• Co-existing conditions – age, general health, cause of anemia, its

severity and chronicity

• Not for conditions like Iron/ B12/ Folate deficiency

PRBC - Triggers
• Preoperative / peri-procedural : Hb< 6g/dl
Hb 6- 10 g/dl (bleeding,
cardio resp. disease)
• Symptomatic chronic anemia : Hb < 6 g/dl

• Acute blood loss : > 40% blood loss

> 30% continued
blood loss or on
respiratory support
Neonates
• Hemoglobin
• <12g/dl in first 24 hrs
• <12 g/dl with intensive support care
• <11 g/dl with chronic oxygen need
• < 7 g/dl in a stable infant

• Blood loss
• Stable infant > 10% loss of estimated volume
• Unstable infant > 5% loss of estimated blood volume
PRBC - Dosing
• One unit of compatible RBC –1 g/dl or Hct by 3%

• Neonates
Dose – 10- 15 ml/kg
Increase Hb - 2-3 g/dl
Issues in red cell transfusion

One unit of PRBC

• Vol 250 ml
• Hct 65%
• Raise Hb by 1 gm/dl
• 200 mg iron
• 70% post transfusion survival

Age of blood
• concerns regarding K level
• decreased post transfusion survival

Specific conditions
• intrauterine transfusion < 3 days old
• thalassemics < 5 days
• open heart surgery < 10 days
Cardinal principles in red cell transfusion in chronic anemia

• 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

• Determine if Signs / Symptoms of anemia are alleviated by

transfusion

• Determine that temporary relief of symptoms warrants continued transfusion

Platelets

•Stored at room temperature (20º-22ºC)

•Shelf life – 3-5 days
•Judicious use
•Group specific
Appropriate Transfusion of
Platelets
• Symptomatic platelet problems
 Number related – eg. Aplastic anemia
 Function related – eg. Glanzmann’s thrombasthenia

• Do not treat the number in isolation –

eg Chronic ITP with no bleeds
• Prophylactic in specific situations
 CNS, eye surgery, other major surgeries, acute leukemia, patients on
chemoradiotherapy

Dose: 1 RDP/10 Kg
Platelet- Triggers
Condition Platelet count
Prophylaxis against bleeding < 10,000/µl

Bedside invasive procedures < 50,000/µl

Neurosurgical procedures, < 100000/µl

Ophthalamic surgeries

Massive Transfusion < 50,000/µl

Neonates – Prophylactic Platelet
Triggers
Term Neonates
• Clinically stable - 20,000/µl
• Clinically sick - 30,000/µl
Preterm Neonates
• Clinically stable - 30,000/µl
• Clinically sick - 50,000/µl
Contraindications
• Thrombotic Thrombocytopenic purpura

• Heparin induced thrombocytopenia

• Immune Thrombocytopenic purpura

Fresh Frozen Plasma
Appropriate Transfusion of FFP
• Replacement of multiple factors: DIC, liver disease, warfarin reversal,
snake bite
• PT/ INR should be determined

• Dose: 10-15 ml/kg

• Not for volume expansion

• Not for nutritional support/ hypoproteinemia

Cryoprecipitate
• Out of group can be transfused but preferably ABO compatible

• RhD type need not be considered

• Thawed Cryoprecipitate transfused within 6 hours

• Indicated for bleeding associated with fibrinogen deficiency and

factor XIII deficiency
• Hemophilia A or von Willebrand disease when appropriate substitute
not available

• Bleeding with fibrinogen levels< 100mg/dl

• Dose - one unit/10 kg body weight

• Raises fibrinogen concentration by 50 mg/dl

Choice for ABO Blood Groups
Patient type Donor PRBC Donor FFP Donor PC

O Positive O O,B,A,AB O,B,A,AB

A Positive A,O A,AB A,AB,O,B

B Positive B,O B,AB B,AB,O,A

AB Positive AB,B,A,O AB AB,B,A,O

Choice for Rh Blood group
• Rh (D) negative patient transfused with Rh (D) positive components

PRBC Only as a life saving measure

and with consent from treating physician &
patient’s relative
FFP No anti-D immunoprophylaxis
required
PC Anti D immunoprophylaxis required
(300 µg anti-D gives protection for 7
plateletpheresis units or 30 Rh (D) positive
platelet concentrates for 6 weeks)
 Cross matching: Special Circumstances

Clinical urgency

Immediate Minutes Within an hour

Group O Rh neg ABO & Rh D type ABO & Rh D type

Packed RBCs

Group specific blood Immediate spin Complete crossmatch

(5-10 min) crossmatch
( 15-20) min)
If units are issued without X match – written consent of physician to be taken,
-complete X match protocols followed after issue
Take Home Messages
• 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

 Audit of transfusion practices

 CME on use of components
 Promote autologous use of blood
 Discourage single unit / fresh blood
Thank You