BLOOD & BLOOD PRODUCTS

GOALS

1. To know variety of blood products2. To know right time and indications to start

blood or blood products transfusion3. To know the complications of massive

transfusion

PREGNANCY & BLOOD LOSS Pregnant women has an increased blood

volume of about 20-30% Blood volume estimation - about 100ml/kg 60kg = 6 litres of blood

As such 1.0L of blood loss in a pregnant woman is not the

same as 1.0L of blood loss in a non-pregnant woman 1.0L of blood loss in a 80kg woman is different from

a 40kg woman

CHANGES IN VITAL SIGNS WITH BLOOD LOSS

VITAL SIGNS When abnormal in the context of haemorrhage,

they are useful in assessing the severity of the hypovolemic shock

When normal however, they are not reliable in assessing the severity of the hypovolemic shock Remember that a drop in BP is a late sign of

hypovolaemia! Patient has lost at least 30% of her blood volume!!!

Should not rely on BP to assess volume loss!!!

LOSS OF CIRCULATING VOLUME

Replacement with crystalloids - every ml blood loss, 3ml crystalloids needed 3 to 1 ratio

Replacement with colloids – every ml blood loss, 1.5 ml colloids needed 3 to 2 ratio

VARIETY OF BLOOD COMPONENTS

Whole blood Red blood cells

Packed cells Platelet Fresh frozen plasma Cryoprecipitate

VARIOUS BLOOD PRODUCTS

Blood products

Volume (ml/unit

)

Contents Effects Compatibility

Packed red cells

280 +/- 50

RBC, WBC, plasma

Increase HCT by 3%, increase HB by 1gm/dL

ABO and RH

Platelets 50 +/- 10

PLT, RBC, WBC, plasma

Increase PLT between 5-10 x 109/L

ABO and RH

Fresh Frozen plasma (FFP)

200 – 250

One IU/ml of all coagulation factors; 400mg of fibrinogen per unit

Increase fibrinogen by 10mg/dL

ABO, no need RH compatibility

Cryoprecipitate

40 +/- 10

Fibrinogen, factorsVII, III, XIII, VonWillerbrand factorFibrinogen, factor VIII, XIII, Von Willebrand factor, fibronectin

Increase fibrinogen by 10mg/dL

ABO, no need RH compatibility

INDICATION FOR TRANSFUSION – WHOLE BLOOD

Whole blood vs Packed cells No data to suggest that the use of whole blood, even “fresh” is associated with better outcome in acute blood loss Usually used in exchange transfusion For acute blood loss

Give specific blood components as required: Packed cells Platelet concentrate FFP

Cryoprecipitate - Factor I, VIII, vWF (+ XIII, fibronectin) Cryosupernatant

INDICATION FOR TRANSFUSION – RED CELLS

Acute blood loss Based on haemoglobin concentration

Hb > 10 g/dl – not indicated Hb < 7 g/dl – indicated Hb 7 – 10 g/dl – less clear; depends on situation and

patient Based on risk of further blood loss

Based on estimation of blood lossCirculating volume lost

Signs Replacement

15% (750 mls)

Mild increase in PR -

15 – 30% (800 – 1500 mls)

Increase PRIncrease breathing

Use crystalloids or colloids to replace fluid loss

30 – 40%(1.5-2.0L)

Increase PRIncrease breathingFall in BP

Use crystalloids or colloids to replace fluid lossRed cells transfusion likely be required

>40%(Over 2 L)

Immediate life threatening

Blood transfusion is required immediatelyNeed rapid transfusion

Major problem!!!!!Underestimation of blood lost often

happens!!Therefore, clinical signs of shock are

important

Other indications Perioperative haemoglobin optimisation Chronic anaemia Anaemia in critical care

RAPID BLOOD TRANSFUSION IN LIFE THREATENING CONDITION

BP cuff (high-pressure infusion devices) No blood filters With warmers

O-ve or O +ve blood Unmatched blood

INDICATION FOR TRANSFUSION OF OTHER BLOOD PRODUCTS

Platelet In DIVC or at platelet transfusion trigger of 75,000/l

Fresh frozen plasma and cryoprecipitate In DIVC (evidenced clinically or from coagulation

screen) with evidence of bleeding There is no evidence for prophylactic

FFPntransfusion to prevent DIVC or to reduce transfusion

In massive transfusion FFP should be administered for every 6 units of red

cells transfusion; aim to maintain APTT < 1.5 Cryoprecipitate should be administered early in major

obstetric haemorrhage to keep fibrinogen > 1.5 g/l

DIVC IN OBSTETRICS Consumption coagulopathy (depletion of

platelets and coagulation factors) that leads to further haemorrhage

Can be due to: Massive bleeding (e.g. APH, PPH, abruption) Sepsis Amniotic fluid embolism Eclampsia IUD

Treat the underlying cause (sepsis, massive blood loss, severe vessel injury, toxins)

Transfuse platelet if bleeding associated with thrombocytopaenia. Aim for > 50 x 109 /L (C, IV) Platelets should not be allowed to fall <50 x 109 in

acutely bleeding patient

If bleeding continues after large volumes red cell and platelets have been transfused, FFP and cryoprecipitate may be given (depending on protocol e.g. after 10 units of RBCs, abnormal coagulation profile, etc)

Transfuse FFP and cryoprecipitate so that the PT and APTT ratios are within 1.5 and a fibrinogen level of > 1.0 g/ L

Adequate resuscitation from shock - most important in preventing coagulopathy

No evidence that prophylactic regimes prevents or reduce transfusion requirements

DIVC REGIMES?? Various regimes depends on hospital protocol Need to contact Transfusionist medicine specialist

for MTP (Massive blood transfusion protocol) Depends on patient’s body weight and also clinical

situation

NO LONGER 6U FFP, 4U Platelet, 2U cryopercipitate

THERAPEUTIC AIMS OF MANAGEMENT

FACTOR AIMS1. HB > 8 g/dL2. Platelet > 50K3. PT/ PTT ratio < 1.5 4. Fibrinogen level > 1.0 g/dL

Adapted from Malaysian CPG on blood transfussion

MASSIVE BLOOD LOSS Replacement of total blood volume (5 L) within 24

hours Loss of 50% blood volume in less than or equal to

3 hours 150ml/ min blood loss (Loss of half the blood

volume in 20 minutes) Transfusion of more than 20 units of erythrocytes

COMPLICATIONS OF MASSIVE TRANSFUSION

Hypothermia Acid-base disturbance – metabolic alkalosis >

acidosis Thrombocytopenia & reduced factor I,V,VIII Electrolyte imbalance

Hypokalemia > Hyperkalemia Hypocalcemia & citrate intoxication

QUESTIONS??