BLOOD COMPONENT THERAPY

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BLOOD COMPONENT THERAPY

• 2002
• EVAN G. PIVALIZZA, FFA
• Department of Anesthesiology
• University of Texas at Houston

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A. BLOOD PRODUCTS

• 22 x 106 components p.a.
• 50-70 peri-operatively
• 18-57 inappropriate (NIH reviews in 80s)

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Blood preservation and storage

• 75 RBCs in circulation _at_ 24 hrs
• Within 4 hrs, WB separated
• WB 63 ml preservative (HCT 36-40)
• CPD- A (citrate, phosphate, dextrose, adenine)
  shelf-life 35 days _at_ 1-60 C
• PRBC (HCT 60)
• CPD-A
• ADSOL (adenine, dextrose, saline, mannitol)
  shelf-life 42 days

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• Deglycerolized blood
• Frozen with glycerol for storage, washed before
  transfusion (years)
• Leucocyte depleted blood (see later)
• Washed (IgA deficiency)

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DO2 / VO2

• DO2 CO x (Hb x SaO2 x 1.34) PaO2 x 0.003
• Flow ? pressure, 1/R4, viscosity
• Balance hematocrit/ viscosity 30

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• 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

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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 gt 55, bleeding, cardiac surgery
• Determination transfusion based patient risks for
  complication of inadequate DO2
• 10 ml/kg ? Hct 10

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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 gt 1.5 normal

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• Massive BT with microvascular bleeding
• gt1 BV/ 24 hours
• gt 50 BV within 3 hrs
• gt 150 ml/min
• Plasmapheresis for TTP
• AT-III deficiency
• Succinylcholine apnea

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• 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

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Indications for cryoprecipitate transfusion

• 10 ml fibrinogen (150-250 mg), VIII (80-145 U),
  fibronectin, XIII
• 1U/ 10kg ? fibrinogen 50 mg/dL (usually a 6-
  pack)

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• Hypofibrinogenemia (congenital or acquired)
• Microvascular bleeding with massive BT
  (fibrinogen lt 80-100mg/dL)
• 2 BVs lt 100 mg/dL
• Bleeding patients with vWD (or unresponsive to
  DDAVP)

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Indications for platelet transfusion

• 7 million units p.a.
• 50 ml 0.5- 0.6 x 10 9 platelets (some RBCs and
  WBCs)
• Single donor apheresis OR
• Random donor (x 6)

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• Decreased production
• Prophylactic for surgical patient with platelets
  lt 50,000
• Microvascular bleeding in surgical patient with
  platelets lt 50,000
• Neuro/ ocular surgery gt 75,000

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• Massive transfusion with microvascular bleeding
  with platelets lt 100,000
• 2 BVs 50,000
• Qualitative dysfunction with microvascular
  bleeding (may be gt 100,000)
• Assessment of platelet function (TEG, Sonoclot)
  in O.R.

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B. TRANSFUSION REACTIONS

• RBCs
• Nonhemolytic
• 1-5 transfusions fever, chills, urticaria
• Slow transfusion, diphenhydramine
• Hemolytic
• Immediate ABO incompatibility (1/ 12-33,000)
  with fatality (1/ 500-800,000)
• Majority are group O patients receiving type A, B
  or AB blood

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• 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

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• 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)

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• 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 Abs against RBC membrane Ag
• Related to future delayed hemolytic reactions and
  difficulty crossmatching

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• WBCs
• 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

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• 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 (gt 4 pregnancies)

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• GVHD
• Rare immunocompromised patients
• Suggestion that more common with designated
  donors
• BMT, LBW neonates, Hodgkin's disease, exchange Tx
  in neonates

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• 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)

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• Immunomodulatory effects of transfusion
• Wound infection circumstantial evidence (?
  leukocyte filters for immunocompromised)
• Beneficial effects on renal graft survival (now lt
  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

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• 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

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• However, 2 recent prospective, randomized
  studies no effect on tumor related
  morbidity/mortality, but poorer outcomes
• Conservative trigger (lt 3 units)
• Clinical judgment to weigh risk-benefit ratio

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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

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• 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, 10-20
  develop cirrhosis

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• 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 lt 16 days

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• 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

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• 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

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• CJD (and variant CJD)
• BB implementing donor deferrals
• 1980-96
• gt 3 months UK
• TF in UK
• gt 5 years in France

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• II. Bacterial
• Contamination unlikely in products stored for gt
  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 (Chagas disease)

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D. METABOLIC COMPLICATIONS

• Citrate toxicity
• Citrate (3G/ unit WB) binds Ca2 / Mg
• Metabolized liver, mobilization bone stores
• Hypocalcemia ONLY if gt 1 unit/ 5 min or hepatic
  dysfunction
• Hypotension more likely due to ? cardiac output/
  perfusion than ? calcium (except neonates)
• Worse with hypothermia/ hepatic dysfunction

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• Hyperkalemia
• After 3 weeks, K is 25- 30 mmol/l
• Only 8- 15 mmol per unit PRBC/ WB
• Concern with gt 1 unit/5 min _at_ infants

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• 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 gt 7-10 mEq/l

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• 2, 3 DPG
• Depleted within 96 hours of storage
• O2 Hb DC to left
• Restored within 8- 24 hours of transfusion

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E. REFERENCES

• Practice Guidelines for Blood Component Therapy
  (ASA Task Force). Anesthesiology 1996 84
  732-47.
• Safety of the Blood Supply. JAMA 1995
  2741368--73.
• Infectious Disease Testing for Blood Transfusions
  (NIH Consensus Conference). JAMA 1995 274
  1374-9.

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• 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.

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• 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