Blood and Blood Products

Sue Ranasinghe, M.D.

Content Outline:
Blood Components:
Red blood cells
Effects of Storage on RBCs
Compatibility Testing
Hemostatic Blood Components
Platelet Concentrates
Causes of Platelet Dysfunction
Fresh Frozen Plasma
Cryoprecipitate
Infectivity of Blood
Types of Transfusion Reactions
Autologous Transfusions
Red Cell Substitutes
Primary Hemostasis
Evaluation of Hemostasis
Anticoagulants

2006-2014 key words

Leuko reduction: Viral transmission
Effect of storage on RBCs/ Stored blood characteristics
Massive transfusion hypocalcemia
Calcium chelation : transfusion
Citrate intoxication : signs/ diagnosis/treatment
Calcium chelation : transfusion
Citrate intoxication/ Rx
Blood type compatibility
Blood bank type and screen
Positive type and screen management
Uncrossmatched blood transfusion
Antiplatelet drugs: mechanism of action
Aspirin: platelet effects
Platelet inhibitor drug: Tirofiban mechanism
FFP : indications
FFP : warfarin reversal
Cryoprecipitate : fibrinogen content
Hep C: lab sign of infection
Hep B: Needle stick Rx
Blood transfusion: mismatch
Transfusion reactions: types
Hemolytic transfusion reaction treatment
Direct antiglobulin: diagnosis of hemolytic reaction
Etiology of delayed transfusion reaction and treatment- 2014

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Febrile transfusion reaction mechanism/ causes- 2014
Transfusion reactions : allergic
Trsansfusion reactions : hemolytic
Hemolysis : bilirubin levels
Transfusion mortality : causes
TRALI : mechanism/ Rx
Transfusion : bacterial sepsis
Massive transfusion and coagulopathy
FVIII concentrate: indications
Coagulopathy in transfusion
Refusal of blood transfusion
Isovolemic hemodilution compensation
Blood loss physiologic response
Maximum ABL calculation
FVIII concentrate: indications
FFP : indications
FFP : warfarin reversal
Cryoprecipitate : fibrinogen content
Indication for cryoprecipitate treatment
Refusal of blood transfusion
Red cell substitutes, PFC problems
Von Willebrand disease : Rx 2012
Factor VLeiden:Treatment 2012
Factor VIII antibodies: Rx 2012
Coag factors in hepatic disease 2012
Child-Pugh score: Factors 2012
TRALI- findings on chest X-ray- 2012
IgA deficiency (IgAD) and transfusion 2012
Blood cross match 2014
Compensatory mechanism and anemia 2014
Dilutional coagulopathy- 2014
Transfusion- leukoreduction- 2014

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Red Blood Cell Components:

1. Whole Blood = RBC + Plasma

1 unit = 200 ml red cells + 250 ml plasma in 60 ml of anticoagulant – preservative
solution CPDA-1 (citrate, phosphate (buffer), dextrose (energy), and adenine allow
resynthesis of ATP)).
Hct = 35-45%
CPDA-1 allow storage up to 35 days in 1-6C
When stored >24 hours there is no functional platelets or leukocytes
On the other hand, most coagulation factors are relatively well maintained
With two exceptions, factors V and VIII. However the factor V and VIII level is still
adequate because only 5-20% of factor V and 30% of factor VIII are required for
hemostasis during surgery. Factor VIII is also an acute phase protein, rapidly released
in stress or injury.

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 2. Red Blood Cells (PRBC)
1 unit in CPDA-1 = 200 mls of RBC + 50 mls plasma
Hct = 70 – 80%
Adsol (AS-1), Optisol (AS-5):solution containing sodium chloride, dextrose, adenine
and mannitol; storage up to 42 days. (Hct = 50-60%)

1 unit of RBC or whole blood  Increase Hct by 2-3%

A common rule of thumb is that each unit of red cells should increase the hemoglobin by
approximately 1.0–1.5 g/dL.

Washed Red cells: Washed with normal saline to remove most of the plasma and white cells;
must be given within 24 hr since bag was opened to introduce saline.
Indications: For patients who has had repeated hypersensitivity reactions despite prophylaxis
with antihistamines.
Frozen, washed RBC has the same hepatitis risk as traditional storage.

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Practice Guidelines for Perioperative Blood Management
An Updated Report by the American Society of Anesthesiologists
Task Force on Perioperative Blood Management- 2015
Anesthesiology 2015;122:241-75.
The new guidelines include greater use of pharmacologic therapies to minimize
blood transfusions, such as:
1. erythropoietin for the anemic patient
2. prothrombin complex concentrates for urgent reversal of warfarin
3. intraoperative antifibrinolytic therapy during selected cardiac and noncardiac procedures
having a high risk for bleeding

Consequences of Transfusion of Stored RBCs

Blood stored for longer periods is shown to be less effective than fresher blood in critically ill
patients (left shift of the oxygen dissociation curve and also increased incidence of post operative
pneumonia in cardiac patients).

EFFECTS OF STORAGE ON RBCs:

As-3= Nutricel; As-5 = optisol

During storage, a series of biochemical reactions occur that alter the biochemical makeup of
blood and account for some of the complications of blood transfusion.
a) During storage, RBCs metabolize glucose to lactate, hydrogen ions accumulate, and plasma
pH decreases (Acidosis is also due to the accumulation of PCO2 inside the plastic container of
blood) .The pH of bank blood continues to decrease to about 6.9 after 21 days of storage.

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b) The storage temperature of 1 to 6oC stimulates the sodium potassium pump, and RBCs lose
potassium and gain sodium. Plasma potassium level may be up to 76 mEq/L in packed cells
stored for 35 days in CPDA-1! Plasma sodium is 122 mEq/L in 35 days CPDA-1 stored packed
RBCs.
However, Hyperkalemia rare; Potassium transfused typically is <4 mEq/ unit. Transfusion rates
> 100ml/unit may predispose to hyperkalemia.
Hypokalemia may be more common ( alkalemia as citrate converted to bicarbonate)

c) The osmotic fragility of RBCs increases during storage, and some cells undergo lysis. This
causes elevated plasma hemoglobin levels. (Plasma hemoglobin level = 246 mg/dL in packed
cells after 35 days of storage in CPDA-1).

d) Storage is also associated with progressive decrease in RBC concentration of ATP and 2,3-
DPG. (2,3-DPG < 1 μM/ml in packed cells after 35 days of storage in CPDA-1)).

e)The percent survival of packed cell RBCs stored in CPDA-1 or As-1 is 71%.

f)RBC that have long storage times (>21 days) are associated with loss of deformability and
this is not reversed during subsequent 3 days. (Some effect even in cellsaver blood)  reduce
ability to deliver O2 (A & A 2013 May)

Hypothermia: blood is stored at 1-6C.

At this temperature, platelet function decrease rapidly (10% activity after 24 h and 5% after 48h
storage).

Microaggregate formation: ARDS following large volume transfusions (>10-12 units in 24

hours). However, the need for micropore filters (40 micron) are unproven.

Citrate Intoxication:
This occurs due to hypocalcemia (not due to citrate per se). Citrate binds calcium and
magnesium. When large numbers of blood components are transfused over s short period of
time, the metabolism of citrate is overwhelmed and patient develops citrate toxicity
(hypocalcemia and hypomagnesemia) leading to adverse cardiac manifestations.

Hypocalcemia causes hypotension (loss of vascular tone), and narrow pulse pressure. Depression
of cardiac out put occurs at 0.7-0.8 mg/dl; coagulopathy only at 0.1-0.2mg/dl.

Decrease in ionized calcium may begin to occur only if citrated blood is given at a rate of more
than 150ml/70 kg/min (1unit/5min). Most normothermic, normovolemic adults with normal liver
function can tolerate up to 1 unit every 5 minutes without adverse clinical consequence (newer
preservatives have less citrate).
Rate of clearance of citrate is impeded by hypotension, hypothermia, alkalosis, hepatic or renal
ischemia, or in neonates, patients with significant liver disease or those undergoing liver
transplantation.

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Therefore, routine administration of calcium is not necessary. If calcium administration is
required, although irritating to veins, calcium chloride is preferred (3x calcium than gluconate).

Compatibility Testing

Compatibility tests = ABO-Rh type, cross match, and antibody screen.

The direct and indirect agglutination tests are the mainstay of laboratory compatibility
testing

IgM alloantibodies cross link via surface antigens leading to direct agglutination.

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Antibodies only cross link after addition of rabbit antihuman IgG, causing indirect
agglutination.

ABO-Rh typing alone results in a 99.8% (2: 1000 Rn) chance of a compatible transfusion, the
addition of an antibody screen increases the safety to 99.94% (6: 10,000 Rn), and a cross match
increases this to 99.95% (5:10,000 Rn)
.

1. ABO blood group type and Rh status for both recipient and donor blood –Blood type
depends on the antigen type present on the surface of RBC’s (type A have type A antigen on
surface of RBC).
Serum contains antibodies to whichever antigen lacking on the RBC’s. (Type O has anti-A&
anti-B)
Another antigen on surface of RBC is Rh (D) antigen; if present =Rh-positive.
(When not present, D antibody not automatically present in the serum. When exposed to Rh +ve
blood, begin to produce anti-D antibodies).
Therefore, patients with the least antigens on their cells ( =Type O –ve) have most antibodies in
their plasma. = Universal donors.
Type AB +ve, has no antibodies in serum = Universal recipients.

Antibody screen: 1 in 1000 demonstrate unexpected antibodies. For those who have been
exposed to transfusion of RBCs previously, antibody detection increases to 1:100.

Antibody screen is a trial transfusion between recipient’s serum and commercially supplied
RBCs and takes 45-60 min. (carried out in 3 phases and similar in length to cross match).

These RBCs contain optimal amount of RBC antigens capable of causing hemolytic transfusion
reaction.
The screen for unexpected antibodies is also done on donors serum immediately after
withdrawal.
There is a risk of becoming allommunized with each allogenic transfusion; but risk is low.
Presence of antibody increases the time necessary to find compatible blood. If the patient is
unstable, use emergency release O or type specific RBCs.

If emergency transfusion is required after type and screen (T& S), perform immediate phase
cross-match (takes 10 minutes) to eliminate human error. Complete cross match takes 30-45
minutes and also detects weakly reactive antibodies. However, these antibodies usually do not
cause serious hemolytic reactions.

Cross match: Transfusion ratio (C/T) should be 2.1 to 2.7. If this ratio is high, it causes large
blood inventory, staff time, high out-dated units (X-matched blood unavailable for others for
24-48h).

Cross match-
Donor RBC’s mixed with recipients serum = simulating actual transfusion
Requires 45 minutes (for incubation)

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Has 3 phases and detect
a. ABO, Rh incompatibility
b. Abs in MN, P and Lewis system
c. Abs in Rh, Kell, Kidd and Duffy
Increase compatibility to 99.95%

Cross match = trial transfusion in a test tube (donor RBC + recipient serum)

Three phases of cross-match of blood

Immediate phase, incubation phase and antiglobulin phase.
1. First phase (immediate phase): (check errors in ABO typing). This test combines
recipient’s serum and donor cells to test ABO group compatibility at room temperature. It
also identifies MN, P and Lewis incompatibilities. This phase takes approx. 5 min.
2. Second phase incubates (30-45 min) the products from the first in albumin at 37 oC,
enhancing incomplete antibodies. This phase primarily detects antibodies in the Rh
system.
3. Third phase: indirect antiglobulin test. Antiglobulin sera are added to the incubated test
tubes. This phase aids in the detection of incomplete antibodies in the blood group systems
including the Rh, Kell, Duffy and Kidd blood group systems.
First and second phases are the most important in preventing major serious hemolytic reactions.

If the patient was pregnant or received a transfusion, the cross-match sample should be <2 days
old to allow detection of newly developed antibodies.

Electronic Crossmatch
Starting in the 1980s, blood banks began selectively replacing conventional immediate spin
serologic crossmatching with computerized systems involving bar codes and laser wands to
identify and issue ABO-compatible units.

The blood bank’s computer has logic that recognizes when an incompatible unit has been
selected for transfusion and will not permit that unit to be issued.

To be eligible for erythrocyte issuing using the electronic crossmatch:

1. the recipient must have had their ABO and RhD group determined twice, a negative antibody
screen,
2. and no prior record of non-ABO antierythrocyte antibodies.

Anesthesiology. 2015;122(1):191-195

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As non-ABO antierythrocyte antibodies are found in only a small percentage of all recipients
(i.e., in approximately 5% of hospitalized surgical patients who do not have sickle-cell disease),
most patients qualify for this crossmatch system.
The main advantage of the electronic crossmatch is that erythrocytes can be issued in mere
minutes.

Emergency transfusion:
When nonidentical ABO groups are used, transfused blood should always be in the form of
RBCs rather than whole blood.
1st choice for emergency transfusion: Type specific partially x-matched (donor RBCs mixed with
recipient serum, centrifuged, and examined macroscopically. This takes 1-5 minutes and exclude
lab error in typing)
2nd choice- Type specific, non-x-matched
Last choice – O-ve packed RBCs.
-switch to patients own group as soon as possible (type specific un x-matched can be available in
5 minutes)

After transfusion of > 2 units of type O Rh negative uncrossmatched whole blood, can you
switch to patients own group?
‘The patient probably cannot be switched to his or her blood type. Switching could cause major
IV hemolysis by increasing anti A and anti B.
Continued use of O Rh negative whole blood results only in minor hemolysis of recipients
RBCs, with hyperbilirubinemia as the only complication.
The patient must not be transfused with his or her correct blood type until the blood bank
determines that the anti A and anti B has fallen to levels that permit safe transfusion of type
specific blood’.

The decision to switch type-specific blood made in conjunction with the blood bank. Continue
with Type O blood in the interim.
ASA 2011 article (see attached) states ‘recent case reports demonstrate potential for a hemolytic
transfusion reaction after as little as 2 units of type O RBCs; hence author likes to stay with type
O uncrossmatched blood if even only one unit has been given’.

Massive Transfusion: Patient’s own blood = banked blood (=10 units within 24h)
Or replacement of 50% of blood volume within 2h

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 th
Compatibility of blood with intravenous solutions (Miller 7 ed)

The osmolality of Plasmanate is only 180 mOsm/kg.

Hemostatic Blood Components:

PLATELET CONCENTRATES- Prepared from whole blood within 8h of collection.

One unit in a 50 ml (single-donor, provide about 70% of platelets in a unit of blood) raises
platelet count by 5-10,000/mm3 at 1 hour after transfusion in a 70 kg person. About 10 units are
required to increase the platelet count by 100,000 mm3. Recommended dose of platelets in adults
is 1 unit/10 kg of body weight within a 24-h period.
However, various factors may decrease the survival of transfused platelets.
Fresh blood (<6h and unrefrigerated) was shown to have a dramatic effect in patients with
extensive hemorrhage. One unit of fresh whole blood is = 8-10 platelet units.

Single donor platelet apheresis pack = 6 single units from a single donor (200-300 mls); serial
blood withdrawal followed by centrifugation and return of RBC to the donor. Most platelets
(75%) are collected by apheresis. The recovery rate of 5 day old platelet is roughly 50%, and it
may take up to 4h for platelets to become fully functional after administration.

Platelets are stored at room temperature (to prevent loss of activity) and under continuous
agitation for 7 days (stored 7 days minus 2 days for testing makes them available for 5 days).
Because of room temperature storage there is increased potential for growth of bacteria; the
estimated incidence of bacterial contamination of platelets was 1:2000 (one of the three leading
causes of death from transfusion). If fever occurs in < 6 h of transfusion, one should suspect
sepsis.
Shorter storage times are being enforced to reduce platelet- related sepsis. Therefore since 2004,
shelf life is 5 days and practical shelf-life is about 3 days.

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The transfused platelets has ABO and HLA (human leukocyte) antigens. However, ABO
compatibility preferred but not required. Because platelet concentrate can contain enough red
cells for Rh sensitization, Rh –ve patients should receive platelets from Rh –ve donors.
May be pooled into a single bag or given as single units.
Use 170 micron filers. Microaggregate filters (40 mic) should not be used (remove platelets).

Platelet Dysfunction
Renal failure, liver disease, DIC, and cardiopulmonary bypass can produce platelet dysfunction

Platelet dysfunction in patients who are uremic is an almost universal finding.

1. Accumulation of compounds- guanidine succinic acid and hydroxyphenolic acid is thought to

produce platelet dysfunction by interfering with the platelet’s ability to expose a phospholipid
surface, termed PF3 activity.
Both are dialyzable and dialysis frequently improves the hemostatic defect.

2. Another defect has been proposed that involves the interaction of vWF with platelet receptors.
DDAVP (intravenous, intramuscular, or intranasal), erythropoietin, estrogen compounds, and
cryoprecipitate (risk not justified) found to improve the bleeding disorder associated with
uremia.
However, when life-threatening bleeding occurs in the uremic patient, platelet concentrates
should be transfused.

Acute and chronic liver disease produces substantial platelet dysfunction.

Key word (2012) COAG FACTORS IN HEPATIC DISEASE

Liver function tests:

Many tests of liver biochemistry and excretory performance are called liver function tests.
However, rather than assessing liver function, several of these tests measure liver enzymes that
are released into the bloodstream (eg, release of aminotransferases from injured liver cells or of
alkaline phosphatase due to cholestasis). Only certain tests actually assess liver function by
evaluating hepatobiliary excretion (eg, bilirubin) or the liver's synthetic capability (eg, PT,
usually reported as the INR; albumin).

In advanced Liver failure, multifactorial coagulopathy:

1. Vitamin K deficiency- impaired storage or absorption

2. Impaired synthesis of coagulation factors (all except F VIII)
3. Splenic sequestration of platelets (if chronic alcoholic, there may be bone marrow
suppression)
4. Low grade DIC (liver clears FDPs; accumulated FDPs inhibit platelet aggregation and
normal cross linking of fibrin monomers)

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Cirrhosis reduces the ability of hepatocytes to synthesize functional hemostatic proteins- clotting
factors, the fibrinolytic factors, and their physiological inhibitors.
Treatment: Vitamin K.
If prolonged PT does not respond to vitamin K, the only treatment is transfusion of FFP.
If FFP has the risk of volume overload, may use cryoprecipitate for patients with
hypofibrinogenemia (but cryo precipitate has no Vitamin K dependent factors).

When faced with a patient with liver disease who is bleeding but has a normal platelet count,
platelet dysfunction should be presumed. DDAVP may be helpful, but transfusion of platelet
concentrates may become a necessity.

Key word (2012) Child-Pugh score: Factors

What liver function tests are most predictive of outcome following surgery in patients with
chronic liver disease?

Laboratory evaluation of liver function is complicated by the liver’s large functional reserve;
routine laboratory values may be normal in the presence of significant underlying disease. Those
that loosely reflect liver function include prothrombin time, albumin, bilirubin and serum
ammonia level.

Child’s scoring system is a predictive scoring index to stratify mortality risk in patients having
hepatobiliary surgery.

Group A B C
Serum bilirubin (mg/dl) <2 2 to 3 >3
Serum albumin (g/dl) > 3.5 3 to 3.5 <3
Ascites none easily controlled poorly controlled
Encephalopathy none minimal advanced
Nutrition excellent good poor

Using this method, mortality rate of 10%, 31% and 76% were identified in Child’s class A, B,
and C, respectively. The Pugh modification replaces nutrition with prothrombin time

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prolongation (A: 1-4 sec; B: 5-6 sec; C: > 6 sec). In patients with primary biliary cirrhosis, the
bilirubin limits are increased in each category.

The most common cause of acquired platelet dysfunction is due to drug administration.

DRUGS ALTERING PLATELET FUNCTION

Drugs can interfere with platelet membrane function, prostaglandin synthesis, or by inhibiting
phosphodiesterase activity or platelet receptors.

Interference with Platelet membrane Function: Amitryptiline, Imipramine, Cocaine,

Lidocaine, Procaine, Isoproterenol, Diphenhydramine, Nafcillin, Ticarcillin.

Cyclo-oxygenase Inhibitors: Aspirin (irreversible inhibitor), Indomethacin, Phenylbutazone,

Ibuprofen, Naproxen, Furosemide, verapamil.

Inhibition of Phosphodiesterase: (Cyclic AMP is an inhibitor of platelet aggregation),

Caffeine, Dipyridamole, Aminophyllin, Thephyllin.

Adenosine receptor antagonists: Ticlopidine, Clopidogrel. Used for stroke prophylaxis. The
effect is probably irreversible.

Glycoprotein IIb/IIIa receptor antagonists: These antagonize the sites to which fibrinogen and
vWF bind. Used for acute coronary syndrome and include abciximab, tirofiban, eptifibatide. The
effect is reversible. Glycoprotein IIb/IIa antagonists: abxicimab (ReoPro) d/c 24-48h before
neuraxial block (or surgery), eptifibatide (Integrilin) and tirofiban (Aggrastat) 4-8 h before
neuraxial block (or surgery).

Platelet dysfunction has been described after cardiac bypass surgery because of the traumatic
effects of cardiotomy suction, the bypass circuit, the membrane oxygenator, and hypothermia.
Platelets are transfused to correct deficiencies in platelet number or platelet function.

Suggested Criteria for Perioperative Transfusion of Non-RBC Blood Products

(Anesthesiology 2015;122:241-75).

Platelets
• Platelet transfusion may be indicated despite an apparently adequate platelet count or in the
absence of a platelet count if there is known or suspected platelet dysfunction (e.g., the presence
of potent antiplatelet agents, cardiopulmonary bypass, congenital platelet dysfunction and
bleeding)
• In surgical or obstetric patients, platelet transfusion is rarely indicated if the platelet count is
known to be greater than 100 × 109 /l and is usually indicated when the count is less than 50 ×
109 /l in the presence of excessive bleeding

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Platelet administration sets have filters with pore size of about 170µm. Filters with smaller pore
(microaggregate filters) should not be used, because they tend to remove a significant number of
platelets. (size of a platelet = 2-3 µm).
Use 19G or bigger IV needle to decrease the loss of platelets.

Fresh Frozen Plasma (FFP)- A single unit is from a single donor.

At –18oC has a one year shelf life (the plasma is frozen within 6 hours of collection).
Single unit contain about 2-4 mg /ml fibrinogen and normal amounts of all the coagulation
factors.
FFP unit must be ABO compatible. If ABO type is unknown, may use AB plasma (Rh need not
be considered because no RBCs).
1 unit = 225 ml, derived from 1 unit of whole blood
Requires a 20-30 min thaw time in the blood bank.
New regulations allow plasma to be thawed up to 5 days and labeled as ‘thawed plasma’.

Plasma products (e.g., FFP, PF24, or Thawed Plasma)

FFP is indicated: (Anesthesiology 2015;122:241-75).
º For correction of excessive microvascular bleeding (i.e., coagulopathy) in the presence of an
INR greater than 2.0, in the absence of heparin
º For correction of excessive microvascular bleeding secondary to coagulation factor deficiency
in patients transfused with more than one blood volume (approximately 70 ml/kg) and when PT
or INR and aPTT cannot be obtained in a timely fashion
º For urgent reversal of warfarin therapy when PCCs are not available
º For correction of known coagulation factor deficiencies for which specific concentrates are
unavailable

FFP is not indicated:

º If PT or INR and aPTT are normal
º Solely for augmentation of plasma volume or albumin concentration

Administer FFP in doses calculated to achieve a minimum of 30% of plasma factor

concentration. Four to five platelet concentrates, 1 unit single-donor apheresis platelets, or 1 unit
fresh whole blood provide a quantity of coagulation factors similar to that contained in one unit
FFP

Usually 30% of plasma factor concentrations achieved with 10-15 ml/kg of FFP. For warfarin
reversal 5-8 ml/kg suffice.
(1 ml/kg raise clotting factors by 1%; 1unit by 2.5%; 4 units by 10%)

(FFP contraindications 2013 keyword)

(Antithrombin III deficiency- key word 2013)

Precautions:
1. Fresh frozen plasma can cause anaphylactic reactions. Although rare, is seen in patients with a
history of previous many plasma or blood transfusions.

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2. Transfusion-transmitted infections-
3. TRALI

British Journal of Haematology, 2010;149, 834–843

TRALI is a common cause of transfusion related death.
The UK National Blood Service announced its decision not to supply FFP from female blood
donors in an effort to reduce the risk of TRALI in 2003. A recent summary of 10 years of
haemovigilance reports of TRALI in the UK suggested that this policy has been effective in
reducing the incidence of TRALI due to FFP (Chapman et al, 2008). However, the report also
found that, although low, the risk from cryoprecipitate seems to have increased. This could be
because there is now a greater proportion of female donor plasma being used to prepare
cryoprecipitate (Chapman et al, 2008).

In order to reduce the incidence of pathogen transmission:

(1) Solvent detergent treatment of pooled plasma (PLASMA+SD)
Plasma incubated with a mixture of organic solvent, which is a lipid destroying mixture of
solvent. This method is specific for viruses with a lipid envelope (HIV, HTLV 1&II and HBV,
HCV as well as HGV, CMV)
- Plasma is also filtered (leukoreduced and also reduce the largest vWF multimers, any
bacteria and parasites)
- These techniques cannot be used with cellular components. (RBC, platelets)
However, this method also has several disadvantages. It can be much more expensive than other
preparation. There is a risk of contamination of nonenveloped agents.

(2) DR plasma (donor retested): FFP kept frozen and not released until the donor returns for
another donation at least 3 months later- retested for HIV, HTLV(human T-cell
leukemia/lymphoma viruses), HBV, HCV- single donor

However, with the new tests of infectivity, the above approaches may not be necessary.

Treatment of Heparin resistance ASA refresher course 2014:

Heparin resistance is a complex, multifactorial disorder. It is complicated by the fact that
heparin’s anticoagulant effect is widely variable and the monitoring most commonly used, the
ACT, is not specific to heparin. Furthermore, the mechanism of decreased heparin
responsiveness is complex and not always dependent upon AT.

The first option is to administer additional heparin to account for the potential of excessive
heparin binding proteins. Monitoring heparin concentrations also has the benefit of avoiding
excessively high heparin concentrations, as there is a ceiling effect on heparin’s anticoagulant
effect. Furthermore, a high heparin
increases the risk of heparin rebound in the postoperative period and should be monitored for
when higher doses of heparin have been administered.

The second treatment option for heparin resistance is AT supplementation with fresh frozen
plasma. This

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has historically been the source of AT used to treat AT dependent heparin resistance. However,
evidence supporting this treatment option is lacking with only case reports and 1 small
retrospective study to support its use. The standard dose of FFP for heparin resistance is 2 units
(1 u AT is present in 1 mL FFP or ~ 500 units of AT in 2 units FFP), which is only expected to
increase the AT by 2-3% per unit. Although this does result in an increase in AT levels, such a
small increase is unlikely to have a clinical impact. This has been confirmed in the literature as
using 2 units of FFP failed to increase the ACT.

An alternative method of AT supplementation is with AT concentrates and because the AT

dose is more concentrated than FFP, results in a much greater increase in AT concentration.
Furthermore, studies have demonstrated a consistent increase in the ACT after its administration.
However, the literature is confusing in regards to the dose used to treat heparin resistance. The
traditional dose is ~500-1000 units, but many recent studies have used doses as high as 75
units/kg (7500 units for a 100 kg patient).

The last therapeutic option would be to accept the current ACT and commence
cardiopulmonary bypass. This option is often not chosen for fear of inadequate anticoagulation.
However, there is some evidence that clinicians could in fact chose this option in many situations
without negative sequalae for their patients. First, there is wide variability in the target ACTs
used in clinical practice with some institutions using target ACTs as low as 350 seconds with
good results. This suggests that many are using a target ACT that is higher than necessary to
safely conduct cardiopulmonary bypass and heparin resistance may be partially related to
choosing too high of a target ACT goal. Additionally, the evidence supporting the routine use of
ACT monitoring does not consistently support a benefit with its use.

A patient with hemophilia A is to have surgery.

How do you decide the dose of factor VIII needed preoperatively?
• Factor VIII has a half-life of 6-10 hours.
Twice-a-Day transfusions recommended following surgery.
• The minimal f VIII for hemostasis during major surgery is 30 to 40% of normal, but
many recommend >50% prior to surgery.
• The dose calculated on the assumption each unit of factor VIII infused /Kg raises plasma
VIII levels by 2%.

FFP contains 1 unit factor VIII activity per ml, (225ml/bag)

cryoprecipitate 5-10 units/ml (15 mls/donor, and pre-pooled 6 units)
factor VIII concentrates 40units/ml.
• In the patient with no factor VIII activity, 20 units/kg should be the initial dose, followed
by 1.5units/kg/hr.
Additional factor VIII is given on the basis of factor levels for 6 to 10 days postoperatively.
• DDAVP may be a good adjuvant.

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Cryo fibrinogen content- 2013 keyword
.
Cryoprecipitate: This is available in pre-pooled concentrates of 6 units. Each unit of
Cryoprecipitate is prepared from a single unit of volunteer donor plasma.
Stored at –20oC up to 1 year.
Each unit (from 1 donor unit) is contained in less than 15 ml of plasma:
1. Factor VIII:C (the small subcomponent, absent in hemophelia A, procoagulant activity)
2. Factor VIII: vWF
(von Willebrand factor –important for platelet adhesion to vascular endothelial cells. Factor VIII
is bound to vWF while inactive in circulation; Factor VIII degrades rapidly when not bound to
vWF. Factor VIII is released from vWF by the action of thrombin. A deficiency of vWF can
result in decreased factor VIII levels. In von Willebrand’s disease bleeding time is prolonged and
factor VIII level may be decreased causing bleeding similar to hemophilia. vWF is synthesized
by endothelial cells and megakaryocytes).
3. 150-250 mg of fibrinogen /unit =<15ml = 15g/L (FFP Single unit =225ml, contain about
2-4 mg /ml fibrinogen= 2.5g/L)
4. Factor XIII
5. Fibronectin- glycoprotein that play a role in reticuloendothelial clearance of foreign particles.

Because of minimal amount of plasma, ABO compatibility generally not required. Rh

sensitization possible due to presence of red cell fragments.

Indications for cryoprecipitate (Anesthesiology 2015;122:241-75):

Cryoprecipitate is indicated:
º When a test of fibrinogen activity indicates a fibrinolysis
º When the fibrinogen concentration is less than 80–100 mg/dl in the presence of excessive
bleeding.
º As an adjunct in massively transfused patients when fibrinogen concentrations cannot be
measured in a timely fashion
º For patients with congenital fibrinogen deficiencies
º Whenever possible, decisions regarding patients with congenital fibrinogen deficiencies should
be made in consultation with the patient’s hematologist

• Transfusion of cryoprecipitate is rarely indicated if fibrinogen concentration is greater than 150

mg/dl in nonpregnant patients.
• Treat bleeding patients with von Willebrand disease types 1 and 2A with desmopressin and
subsequently with specific VWF/FVIII concentrate, if available. Cryoprecipate should be
administered if there is no response to or availability of desmopressin or VWF/FVIII concentrate
• Treat bleeding patients with von Willebrand disease types 2B, 2M, 2N, and 3 with specific
VWF/FVIII concentrate, if available. If VWF/FVIII concentrate is not available, cryoprecipitate
is indicated
Cryoprecipitate 6 bags in a 70 Kg patient, raises fibrinogen level by 45 mg/dl.
350 mg x 6 = 2100 mg; recovery from transfusion 75% = 1560mg.
70 kg x .05 = plasma volume, 35 dl or 3.5 L.
1560 mg / 35 = 45 mg/ dl.

18
Current sources of fibrinogen:
British Journal of Haematology, 2010;149, 834–843

FFP, cryoprecipitate and fibrinogen concentrate.

FFP is the most widely available but has several drawbacks- time to thaw and get ready,
transfusion related complications, require blood group matching and high volumes needed to
raise fibrinogen levels.

Cryoprecipitate has higher fibrinogen levels but has the risk of pathogen transmission.

Fibrinogen concentrate is produced from pooled human plasma. The product is stored
as a lyophilised powder at room temperature

Cryo vs Fibrinogen concentrate

Blood Transfus. 2012 January; 10(1): 23–27.
Cryoprecipitate
 No viral inactivation, potential risk of
 pathogen transmission
 Variable fibrinogen levels
 Accurate dosing not possible
 Infusion volume lower than FFP but higher than fibrinogen concentrate
 Must be thawed before infusion,
 ABO compatibility is required

Fibrinogen concentrate
 Rapidity of reconstitution, no cross-matching required
 Low infusion volume
 Viral inactivation,
 minimal risk of pathogen transmission
 Standardised fibrinogen content, accurate and consistent dosing

19
 New guidelines (2015) favor use of fibrinogen concentrate in patients with excessive
bleeding when treating hypofibrinogenemia.

Advantages of fibrinogen in haemostasis

British Journal of Haematology, 2010;149, 834–843

Substitution of fibrinogen may act at more than one level in clot formation, compensating for
low thrombin generation and decreased platelet function.
High fibrinogen levels may compensate for a low concentration of thrombin because it only
takes a single thrombin molecule to cleave up to 1680 molecules of fibrinogen (Elodi &
Varadi, 1979).
Similarly, the number of platelets present may not be the limiting factor in clot formation if
fibrinogen levels are high, as there are 40 000–80 000 copies of GPIIb/IIIa receptors on a
single activated platelet (Kestin et al, 1993). This is supported by the observation that the
effect of platelet- blocking substrates, such as clopidogrel, can be antagonized by increasing
the concentration of fibrinogen (Li et al, 2001). In patients undergoing thoracoabdominal
aortic aneurysm surgery, fibrinogen supplementation with concentrate was more effective
than transfusion of FFP and platelet concentrate in achieving effective haemostasis and
reducing postoperative bleeding (Rahe-Meyer et al, 2009a)

Prothrombin Complex Concentrates (PCC)-

Prothrombin Complex Concentrates (PCC)- from pooled plasma solvent

detergent treated.
Different processing techniques involving ion exchangers enable the production of either three-
factor (i.e., factors II, IX and X) or four-factor (i.e., factors II, VII, IX and X) concentrates with a
final overall clotting factor concentration approximately 25 times higher than in normal plasma.
To prevent activation of these factors, most PCC contain heparin. PCC may also contain the
natural coagulation inhibitors protein C and protein S. The PCC are standardised according to

20
their factor IX content. All PCC undergo at least one step of viral reduction or elimination
(solvent detergent treatment, nanofiltration, etc.)

PCC Is used to hasten INR correction instead of FFP.

FDA has approved its use in hemophelia B (IX def).
Now approved for warfarin reversal in the US (2013)

Comparison with other methods of reversing INR:

INR will normalize in 4 days if warfarin is D/C’d..
With vit K normalize in 24h with oral and 6-12h with IV administration.
PCC needs to be reconstituted (minutes) IV PCC over 5-10 min correct INR within 60 min. Dose
10-40IU/kg over 5-15 min
FFP takes > 60 min to get (ABO blood typing, thawing, transport) . Take 2h to complete 10-
20ml/kg for a 70 kg patient .
However, the effect of Vit K lasts beyond the short half-lives of FFP and PCCs.

Cost: FVIIc> PCC ($1000)>FFP ($600)

Infectivity of Blood
Infection with cytomegalovirus (CMV), a member of the herpes virus family, is very common.
Between 50% and 80% of people in the United States have had a CMV infection by the time
they are 40 years old, according to the CDC. Once a person has had a CMV infection, the virus
usually lies dormant (or inactive) in the body, but it can be reactivated. The virus is more likely
to be reactivated — and cause serious illness — in people who have weakened immune systems
due to illness.

21
The symptoms of a CMV infection vary depending upon the age and health of the person who is
infected, and how the infection occurred. Transfusion-transmitted cytomegalovirus infection
(TT-CMV) is associated with considerable morbidity and mortality in at-risk populations, which
include CMV-seronegative neonates, patients with AIDS, and stem cell transplant (SCT)
recipients.
“CMV-reduced-risk” such as CMV seronegative or leukocyte reduced cellular blood products
decrease risk of transfusion transmitted symptomatic CMV infection in recipients that are CMV
naïve and profoundly immunocompromised.

Hepatitis D (originally called delta agent) requires hepatitis B virus (HBV) to act as a helper for
assembly of envelope proteins. Screening for HBV prevents transmission of hepatitis D.
Hepatitis G, share similarities with Hepatitis C, but it has no association with liver disease.

No reported transfusion transmitted Lyme disease.

Percentage Risk of Transfusion-Transmitted Infection with a Unit of Screened

Blood in the United States (Miller 7th ed)

In 2010:
HIV 1 in 2.3 million
Hp C 1 in 1.8 million
Hep B 1 in 350,000
Infectious risks of blood transfusion are now rare.
The availability of NAT test for HIV and Hepatitis C since 1999 has reduced the transmission.

22
HBV is the greatest risk currently, will have NAT test available shortly.
Human error, TRALI, and sepsis are the dominant concerns of blood transfusion currently.

TRALI is now the leading cause of transfusion –associated fatalities.

Transfusion-Related Fatalities in the United States, 2008 through 2012

(Miller 7th ed)

Post-transfusion syphilis is unlikely - infective agent cannot survive storage at 1°C to 6°C
(transmission through platelet likely).

23
Bacterial contamination -Yersinia enterocolitica most commonly RBC
contaminants-
The symptoms are mostly mild gastrointestinal problems; however, sepsis, DIC and death can
occur.
Storage of blood at 4°C in phosphate buffer enhances its growth.
The donor screening process is important (whether GI problems occurred within 4 weeks of
donation).
Bacterial contamination commoner with platelets than RBC:
1. Stored at room temp
2. Commonly pools of 6-10 units
Staph. aureus, diptheroid and streptococcus are the most frequent infections with platelet
transfusion..
There has been a significant decrease in fatalities associated with bacterial contamination since
2001, as process to detect bacterial contamination have been put into place..

Post exposure prophylaxis:

• HCW (Health Care Worker) exposed to HBV, and not known to be immune should be
tested for HBsAg
• If previously vaccinated but not tested for anti-HBsAg (Ab) in the past 24 months should
be tested for immunity- duration of protection unknown. (10% or more will not have
protective titers).
If inadequate (<10mIU/ml)- HB immunoglobin x1 and vaccine booster should be given.
• If clearly susceptible to HBV (and occupational exposure), HBV hyper Ig and
recombinant HBV vaccine should be given.
• HCV- No effective post exposure prophylaxis or therapy, Ig not recommended. Follow
up testing for HCV and LFT.
50% progress to chronic liver disease and significant number may develop cirrhosis and hepato-
cellular cancer.

Hepatitis B

• Acute hepatitis B infection resolves without significant hepatic damage in about 85% of
cases.
• Less than 1% of acutely infected patients will have fulminant hepatitis.
• About 1% develop hepatocellular carcinoma
• About 9% develop chronic persistent hepatitis
• 10% of infected people become chronic carriers of HBV (i.e., serologic evidence
demonstrated for more than 6 months).

24
 • Within 2 years, half of the chronic carriers resolve their infection without significant
hepatic impairment.
Chronic active hepatitis, which may progress to cirrhosis, is found most commonly in those
individuals with chronic viral infection for more than 2 years.

The diagnosis and classification of the stage of HBV infection can be made on the basis of
serologic testing (see Table below).
• Hepatitis B surface antigen (HBsAg) is detectable in the serum within 3–4 weeks after
infection with HBV. At this time, the patient is asymptomatic but is capable of infecting
others.
• Within 8–12 weeks after infection, symptoms of hepatitis and jaundice occur, and liver
function test findings are elevated.
• With resolution of acute hepatitis B, HBsAg disappears from the serum and is followed
by the appearance of antibody to the surface antigen (anti-HBs). Anti-HBs is the
antibody that confers lasting immunity against subsequent HBV infections.
• During the “window” period in which HBsAg has declined to undetectable levels and
anti-HBs is not measurable, antibody to the core antigen (anti-HBc) is detectable.
• With resolution of the infection, anti-HBc and anti-HBs persist, but after many years one
of these antibodies may no longer be detectable in the serum.
Chronic HBV carriers are likely to have HBsAg and anti-HBc present in the serum samples.

PATTERNS OF SEROLOGIC MARKERS OF HEPATITIS B VIRUS INFECTION

Stage of Infection HBsAg Anti-HBc Anti-HBs

Early acute hepatitis B or + - -

chronic carrier state

Acute* or chronic hepatitis B + + -

Recovery from acute* or chronic - + +

hepatitis B

Distant hepatitis B virus infection,

early recovery stage of hepatitis B*, - + -
or chronic carrier state

Distant hepatitis B virus infection or

after immunization with
hepatitis B vaccine - - +

*Antibody to the core antigen (anti-HBc) of IgM type should be present.

Percutaneous exposure (usually an accidental needle stick) to blood carrying HBV may result in
infection in up to 30% of occurrences.

25
HBV can be found in saliva, but transmission appears unlikely after permucosal contact with
infected oral secretions.
HBV is a hardy virus that may be infectious for at least 1 week when there is contact with dried
blood on environmental surfaces.
Hepatitis B Vaccines (recombinant technology) is the primary strategy to prevent disease, anti-
HBs develops in more than 90% of vaccinees. Serologic testing of vaccinees for anti-HBs should
be performed within 6 months. Non-responders may develop immunity with additional vaccine
doses. Booster doses are given in 7 years. Vaccine-induced antibodies decline over time, with
maximum titers after vaccination correlating directly with duration of antibody persistence.
Nonvaccinated anesthesia personnel with exposure to a contaminated needle or to blood from an
HBsAg-positive patient, should receive postexposure prophylaxis with HBV hyperimmune
globulin, and initiation of HBV vaccine series recommended. HBV hyperimmune globulin is
prepared from human plasma that contains a high anti-HBs titer and provides temporary, passive
immunity.
The following table summarizes the various hepatitis B tests and their uses:
While the tests described below are specific for HBV, other liver tests such as AST, ALT,
and gamma-glutamyl transferase (GGT) may be used to monitor the progress of the
disease. In some cases, a liver biopsy may be performed for confirmation.

Test Description Use

Often used to screen for and detect HBV
Hepatitis B Protein that is present on the infections; earliest indicator of acute hepatitis B
surface surface of the virus; will be and frequently identifies infected people before
antigen present in the blood with acute symptoms appear; undetectable in the blood
(HBsAG) and chronic HBV infections during the recovery period; it is the primary way
of identifying those with chronic infections.
Used to detect previous exposure to HBV; can
Hepatitis B Antibody produced in response also be acquired from successful vaccination. This
surface to HBV surface antigen; levels test is done to determine the need for vaccination
antibody in the blood rise during the (if anti-HBs is absent) or to determine if a person
(anti-HBs) recovery phase. has recovered from an infections and is immune
(cannot get the infection again).
IgM antibody to the hepatitis B
Anti-hepatitis core antigen (The hepatitis B
First antibody produced after infection with HBV;
B core (anti- core antigen is present only in
used to detect acute infection
HBc), IgM infected liver cells; it cannot be
detected in the blood.)

Hepatitis C
Serologic assays for detection of IgG antibodies to HCV (anti-HCV) have been developed.

26
Anti-HCV can be detected in most patients with hepatitis C, but its presence does not correlate
with resolution of the infection or progression of the hepatitis.
Immunity against HCV infection is not conferred by anti-HCV.

For the diagnosis of acute or chronic HCV infection, hepatitis C RNA by polymerase chain
reaction (HCV RNA by PCR) is available. However, now NAT test is available.
These are markers of acute or chronic HCV infection, and can be used to identify individuals
with potential to transmit infection.
With exposure by needle stick to HCV, the current recommendation:
• Monitor the healthcare worker for seroconversion to HCV antibody positive status at 3
and 6 months.
• If seroconversion occurs, interferon at conventional dosage (3 million units three times a
week) should be commenced.
• A more aggressive approach is to detect infection by HCV RNA by PCR at 3 and 6
months in addition to HCV antibody. If conversion occurs, interferon 5 to 10 million
units daily has been recommended for a minimum of 6 months.

People infected with HCV have a high rate of chronic hepatitis despite mild initial presentation.
80% progress chronic state with significant mortality and morbidity.
20% of chronic carriers develop cirrhosis.
1-5% may develop hepatocellular Carcinoma.
Interferon-alphaIIb has been an effective treatment for chronic hepatitis C, but unfortunately
most patients relapse on discontinuation of the therapy.
Hepatitis C virus is transmitted through blood and sexual contact, like HBV.

The risk of hepatitis C after a HCV-infected needle stick exposure appears to be about 2–4%. -
significantly less than for HBV, possibly because there is a lower viral titer in the blood of
carriers.

Hepatitis C new drugs- approved by FDA 2013

Sovaldi and newer drugs work by inhibiting enzymes produced by the hepatitis C virus.
Cure rates with Sovaldi, a polymerase inhibitor, are over 80 percent, though success and
treatment duration depend in part on which strain, or genotype, of the virus is involved.
For genotypes 2 and 3, which together account for about 20 to 25 percent of cases in the United
States, Sovaldi’s label recommends the drug be used with ribavirin (combination to reduce
resistance developing). This will constitute the first all-oral, interferon-free treatment for
hepatitis C. Genotype 2 will require 12 weeks of treatment and genotype 3 will need 24 weeks.
For genotype 1, which accounts for more than 70 percent of American cases, Sovaldi is supposed
to be used with injected interferon and ribavirin. But the treatment is for only 12 weeks instead
of 24 or 48, and the cure rate is about 90 percent for newly treated patients.
Ribavirin may cause birth defects and/or death of the exposed fetus and therefore contraindicated
in pregnancy.

27
HIV/ Health Care Worker (Landovitz RJ, et al. N Engl J Med 2009;361:1768-75)

Universal Precautions
(Consider infectious nature of CSF in HIV patients)
A needle stick injury - 0.3% risk of seroconversion.
0.09% risk in mucous membrane exposure.
Exposure site washed.
Risk of seroconversion assessed- experts contacted for advice.
The following situations are considered serious exposure:
• Exposure to a large amount of blood.
• Blood came in contact with cuts or open sores on the skin.
• Blood was visible on a needle that stuck someone.
• Exposure to blood from someone who has a high viral load.

PEP (post exposure prophylaxis) within one hour

•  reduce seroconversion rate by 80%
Or taken within 36 hours.
• Treatment with 2 or 3 ARVs: AZT, 3TC, Viread should continue for 4 weeks, if
tolerated.
• For less serious exposure- two drugs: AZT and 3TC?
Adherence to PEP 70-80%.
PEP 80% effective in averting seroconversion.

HIV-antibody testing by enzyme immunoassay:

Baseline testing  follow-up testing at 6 wks, 12 wks, and 6 m

Testing the source patient:

Unknown HIV status
• Rapid ELISA (results in 5 -30min)
• If +ve confirm with Western Blot
• Testing for HBsAg
• ELISA for antibodies against HCV
If the source patient is at risk for recent HIV (sero-conversion 2-12 wks):
NAT should be considered.

28
Types of Transfusion Reactions:

FDA reported death rates due to hemolytic transfusion reactions alone are more than twice
that due to all infectious hazards combined. Anesthesiology 2009:108;759-69 (march 2009).

(1) Acute hemolytic Transfusion Reaction

This is the most severe form of transfusion reaction and occurs due to attack on transfused donor
cells by recipient antibody and compliment. Usually this is caused by errors involving ABO
incompatibility. Intravascular hemolysis occurs (as little as 10 ml of blood is enough) and
prevention of renal failure and DIC is crucial.

Signs and symptoms of a hemolytic transfusion reaction

Awake patient:
The symptoms include fever, chills, nausea, and vomiting, diarrhea, and rigors. The patient
becomes hypotensive, tachycardic, restless, flushed and dyspneic.
Chest, flank and back pain result from diffuse intravascular occlusion by agglutinated RBCs.
Between 20% and 60% of patients with severe symptomatic hemolytic reactions may die.
During general anesthesia:
The above signs are masked. The only signs may be hypotension, hemoglobinuria and diffuse
bleeding. Oliguria may develop due to renal failure.

Hemolytic Transfusion Reaction: Treatment

If a reaction is suspected:
1. STOP the transfusion, recheck patient’s identity and blood label.
2. Management has three main objectives:
a. Maintenance of systemic blood pressure- volume, pressors, inotropes
b. Preservation of renal function - Maintain urine output at a minimum of 75-100 ml with
generous IV fluids (CVP 10-15 cm H2O), mannitol 12.5-50 g, furosemide, and alkalinize
the urine to prevent acid hematin from hemoglobin precipitating in distal tubule (this is of
questionable value).
c. Prevention of DIC by preventing hypotension and hypoperfusion

29
 3. Blood samples collected in EDTA tube for:
a. repeat cross match
b. direct antiglobulin test confirms hemolytic transfusion reaction (Coombs test)-
This test shows if there is antibody attached to transfused donor RBCs.
Other tests such as serum haptoglobin level, plasma and urine hemoglobin, bilirubin assays
are only an evidence of hemolysis, not of an immune reaction. Hemoglobinuria or hemolysis
should be assumed to be due to hemolytic transfusion reaction until proved otherwise.
When plasma hemoglobin level is 100 mg/dL plasma is red. At levels exceeding 150 mg/dL
hemoglobinuria occurs (exceed the binding capacity of haptoglobin).

4. Determine platelet count, PT, aPTT, TT, fibrinogen level, FDPs- DIC commonly occurs
(30-50% incidence).

5. Return unused blood to blood bank for re-crossmatch.

6. Send patient’s blood and urine sample to blood bank

Schematic representation of what happens to hemolyzed erythrocytes (RBC) as a result of

the administration of incompatible blood.

Frequency and signs and symptoms of hemolytic transfusion reactions in 40

patients
Sign or Symptom No. of Patients
Fever 19
Fever and chills 16
Chest pain 6
Hypotension 6
Nausea 2
Flushing 2

30
 Dyspnea 2
Hemoglobinuria 1

(2) Delayed hemolytic – (DHTRs)

This occurs in patients who have been previously sensitized by transfusion or pregnancy.
Usually, in the first or second week present with low grade fever, increased bilirubin, anemia
The level of antibody has diminished to undetectable levels at the time of transfusion. Therefore,
seemingly compatible units transfused.
In several days increased antibody production in response to the secondary stimulus cause RBC
destruction extravascularly, which is less fatal and self limiting.
Resultant anemia may be misdiagnosed as posttransfusion bleeding (antibody-coated RBCs have
shorter half-life).
When tested they show positive direct Coombs test.
Rh and Kidd system rather than ABO system is commonly involved with DHTRs.

(3) Nonimmune Hemolytic Transfusion Reactions

In these reactions there are symptoms of hemolysis with negative antibody detection tests.
Causes are excessive heating or accidental freezing of donor units, contact with incompatible IV
solutions, bacterial contaminations, etc.

(4) Febrile Nonhemolytic Transfusion Reactions

These are the most common transfusion reactions and has no long term effects
The symptoms (usually noted within 30 minutes) are fever, headache, myalgia, nausea, and non
productive cough occurring shortly after blood transfusion. Usually this is seen in multi-
transfused or multiparous patients with antibody against donor leukocytes or platelets. This
reaction has been attributed to the presence, in the recipient's plasma, of antibodies
reactive against antigens on donor leukocytes or platelets or to cytokines
Treatment: antipyretics; if second reaction occurs request leukocyte-reduced blood, or use
leukodepletion filters.

(5) Allergic reactions

Simple allergic reactions are the second most common type of transfusion complications and
presents with hives, itching, and rarely laryngeal edema.
Management: Observe carefully, benadryl 10-50mg, and may continue blood transfusion if only
skin rash and respond to treatment.

(6) Anaphylactic/ anaphylactoid reactions – Both reactions present with similar clinical
symptoms, but anaphylactoid reactions are not mediated by IgE.
The patient presents with sudden flushing, hypotension, laryngeal edema, chest pain and shock
usually after transfusion of only a few milliliters of blood or plasma.
Management: Stop the transfusion, subcutaneous epinephrine, and IV volume replacement.
Usually the reaction is due to transfusion of IgA to patients who are IgA deficient or have
formed IgA-antibody (anti-IgA). They can be transfused with washed red cells.

31
If a patient experiences a fever with or without chills during blood
transfusion, what is the differential diagnosis?

Fever occurs in 0.1 to 1% of transfusions and must be considered ominous until proven
otherwise.
1. Febrile nonhemolytic reactions due to leukocyte antibodies - treated with acetaminophen.
Typically the temperature increase > 1oC occurs within 4 hours of a blood transfusion and for
most patients is unpleasant but temporary.
2. Bacterial contamination of blood products (especially platelets)
3. Acute hemolytic transfusion reaction
4. Administration of thrombocytes as a result of antibodies against thrombocytes or cytokines in
the product.

If a transfusion reaction is suspected

1. Stop transfusion, Recheck ID of patient and blood label
2. Clinical management – 3 goals:
a) Maintain BP-volume, pressors, inotropes
b) Preserve renal function – urine OP (75-100 ml), mannitol, furosemide
c) Prevention of DIC by preventing hypotension and hypoperfusion
4. Send new blood sample from patient (in EDTA tube) to lab for:
Tests- Repeat x-match
• Direct antiglobulin test confirm HTR (Coombs test)-reflecting the presence of complement
(C3d) on circulating red cells, as well as the recipient's anti-A, anti-B, or anti-A,B (antibody)
• Other lab tests for evidence of hemolysis:
Serum haptoglobin level
Plasma and urine Hb and bilirubin (centrifuge blood - pink color> 2 mg/dl Hb)
• Lab tests to establish baseline coag status: PT,PTT, TT, Fibrinogen level, FDPs
Return unused blood (for re X-match), pt’s bld and urine sample to blood bank

White cell- related transfusion reactions

1. Febrile reactions

2. Transfusion associated graft-versus-host disease (GVHD)

Donor lymphocytes from transfused blood products engraft in the recipient and initiate an
immune reaction against the host tissue. Severely immuno-compromised patients have a high
risk. The symptoms are generalized rash, leucopenia, thrombocytopenia (pancytopenia); sepsis
and death can result..
Leukoreduction may reduce incidence, and irradiation of blood can prevent the reaction.

3. Transfusion-Related Acute Lung Injury (TRALI) –The exact mechanism of TRALI is not
fully understood and thought to be an antigen/antibody reaction involving human leukocyte
antigen and granulocyte antigens.
TRALI is fatal in 5% to 10% of cases. TRALI is one of the top 3 causes of transfusion-related
mortality, and manifests as non-cardiogenic pulmonary edema. Chest x-rays will show bilateral

32
alveolar infiltration giving a classic "white-out" picture (TRALI- findings on chest X-ray- key
word 2012)
The symptoms/signs (fever, hypoxemia, acute respiratory distress, increased peak airway
pressure) occur within 6h after transfusion. During anesthesia, a persistent decrease in SaO2 can
be the presenting sign.
All blood components, especially FFP, are causative factors.
There is no specific therapy; stop transfusion, provide supportive measures.
Most recover in 96 hours.
Diagnosis of TACO (transfusion associated circulatory overload) vs TRALI: In TRALI there is
no evidence of circulatory overload (JVD or S3 gallop, CVP and PCWP normal)
TACO suggested by absolute B natriuretic peptide level in plasma of more than 100 pg/dl and a
post transfusion to pre transfusion ratio > 1.5.

4. Transfusion-related Immunomodulation
Homologous blood exerts a nonspecific immunosuppressive action on the recipient and may be
the reason for recurrence of resected cancer, postoperative infections, virus activation, and
increased progression of HIV/AIDS after transfusion.
There is also a decreased rate of transplant rejection after blood transfusion.

Leukoreduction of RBC transfusions: anticipated benefits include decreased transmission of

vCJD, CMV, leukocyte-induced immunomodulation, and even decreased postoperative
mortality. Universal leukoreduction is the direction in which transfusion medicine is going
(prestorage depletion to prevent mediator release from white cells during storage).

Key word (2012) IgA deficiency (IgAD) and transfusion

Many IgAD patients are asymptomatic (ie, "normal" blood donors) and are identified by finding
a laboratory abnormality, without any apparent associated clinical disease.
IgA deficiency is the most common human immunodeficiency. From a transfusion medicine
perspective, the presence of anti-IgA in an IgA deficient recipient is a possible cause of
anaphylactic transfusion reactions. Approximately 20% of anaphylactic transfusion reactions in a
Caucasian population may be associated with anti-IgA in IgA deficient recipients. Therefore,
IgA-poor blood or washed red cells are preferred for those patients.

IgA-deficient patients with immunoglobulin E (IgE)–class anti-IgA antibodies are at risk for
anaphylaxis if they receive blood or intravenous immunoglobulin, but this situation is extremely

33
rare. Individuals with such an unusual profile should receive only low IgA intravenous
immunoglobulin preparations. However, caution must be used when administering IGIV to
patients with IgAD if their anti-IgA status is unknown.

Coagulopathy following massive transfusion:

Caused by combination of factors- most important are
1. volume of blood given
2. duration of hypotension or hypoperfusion ( more likely to lead to DIC)
If both present, probably has coagulopathy from DIC and dilution of factors.

Correlation between units of blood administered and percent of patients who had a
hemorrhagic diathesis. The numbers in parentheses represent the number of patients at
each data point.

Differential Diagnosis of bleeding after blood transfusion include:

1. Dilutional thrombocytopenia (acutely developed thrombocytopenia, eg after massive
transfusion, develop h’agic diathesis at a much higher platelet count than do patients with
chronic thrombocytopenia. Also patients undergoing surgery or after trauma require
higher platelet count)
2. Low F V and VIII (only 5-20% of FV and 30% of F VIII needed for adequate hemostasis
during surgery. Also F VIII increase during surgical stress).
3. Disseminated Intravascular Coagulation (DIC): fibrinogen level is decreased.
4. Hemolytic transfusion reaction

There has been considerable discussion of whether, in the face of massive transfusion of blood
products, patients will first manifest deficiencies of platelet or clotting factors.
The initial conclusion was that thrombocytopenia would develop first (wider use of whole blood
previously). In spite of the lability of F V and VIII, sufficient concentrations of these probably
remain in banked whole blood even in the face of very large transfusions.

34
This is not true when packed RBCs with small residual plasma is transfused.
Investigations of patients receiving large-volume isovolemic transfusions suggest that clinically
significant dilution of fibrinogen; F II,V,VIII; and platelet will occur after volume exchange of
approx. 140%, 200-230%, and 230% (1.4, 2, 2.3 blood volumes), respectively.
Resuscitation from hypovolemia will result in reaching these thresholds at smaller percentage
volume exchanges.
FFP transfusion should be considered after 12 or more PRBCs (or cell saver blood) and
platelet transfusion after 20 or more PRBC units.

Still though decision to administer blood products depend on clinical and lab evidence of
coagulopathy.

Coagulopathy following major blood Transfusion following trauma (Acta

Anaesthesiol Scand 2010;54:1039-1049).

Causes:

1. Dilution:
• Crystalloids
• Colloids may cause reduced F VIII and vWF, inhibition of PLT function
2. Hypocalcemia < 0.6-0.7 mmol/L
3. Hypothermia:
• PLT dysfunction
• Reduced coagulation factor activity
Each 1oC decline in body Temp  10% reduction in coag activity. Significant below 33oC.
Reversible with normalization of body temperature.
4. Acidosis: Can occur due to hypoperfusion and excess NaCL
• At pH < 7.4, PLT change their structure and shape
• Activity of coagulation factor complexes on cell surfaces reduced
Acidosis  increase degradation of fibrinogen
5. Trauma
• Induces immediate activation of coagulation system (upregulation of tissue factor)
Enhanced fibrinolysis  DIC

Treatment with blood products after massive trauma (According to more

recent articles)
RBC:
Lowered Hct itself contributes to coagulopathy.
• Erythrocytes induces marginalization of PLT
• Erythrocytes modulates biochemical and functional responsiveness of activated
PLT
RBC activate PLT by liberating ADP
Optimal Hct for PLT / vessel wall interaction not known.

FFP:

35
FFP: RBC ratio of 1:4 leads to increased mortality compared with FFP: RBC ratio of 1:1.
Recent outcome studies in (non-obstetric) massive hemorrhage suggest M & M reduced (by
approx 60%) when:
• Transfusion is initiated early
• Received the most coagulation factors (plasma)
However, optimal ratio of FFP to RBC s remains to be established.
(Transfusion 2010;50:1370-83)

Platelets
Highest survival in patients who received:
both high PLT: RBC and a high FFP: RBC ratio
Patients treated aggressively with plasma and platelets demonstrated reduced mortality (Curr
Opin Anesthesiol 2009;22:267-74).
.

ASA Practice Guidelines for blood component therapy:

RBCs indicated rarely when Hb>10g/dl)
FFP usually indicated when PT/PTT > 1.5 x control
Platelets usually indicated when Platelet count <50,000 (rarely when >100,000)
Cryoprecipitate usually indicated if bleeding and fibrinogen <80 mg/dl and bleeding in von
Willebrand disease unresponsive to DDAVP.

Ultimate hematocrit or hemoglobin values at which blood should be given:

This is a clinical judgment based on many factors
cardiovascular status
age
anticipated additional blood loss
arterial oxygenation
mixed venous oxygen tension
cardiac output
blood volume.
Oxygen Extraction Ratio (OER 50%) has been recommended as an indicator for
transfusions. However, this requires invasive monitoring (pulmonary artery catheter for mixed
venous O2 measurement).
Even so, results by this indicator were not dramatic between groups who were or were not
transfused.

Erythropoietin and iron to can be used to restore red cell mass.

EPO is a protein hormone produced by the kidney. Erythropoietin is produced to a lesser extent
by the liver (10%). After being released into the blood stream it binds with receptors in the bone
marrow, where it stimulates the production of red blood cells.
Recombinant DNA technology is used to prepare epoetin alfa (Epogen, Procrit). It can be given
as an injection intravenously or subcutaneously.

36
Erythropoietin requires:
48-72h for a significant reticulocyte response
10-14 days to increase hemoglobin level
Belfort M, et al. Am J perinatol 2011;28:207-10

Autologous Transfusions
Potential complications of allogenic transfusion that can be eliminated or minimized using
autologous blood:
1. Acute or delayed hemolytic reactions
2. Alloimmunization
3. Allergic and febrile reactions
4. Transfusion transmitted infections

Patient selection:
1. Donor’s hemoglobin not less than 11 g/dL or the hematocrit lass than 33% before donation.
2. There are no age or weight limits.
3. Patients may donate 10.5 ml/kg
4. Patients may donate 1/week, but last not less than 72h before surgery.
5. Common practice to exclude patients with hepatitis B surface antigen and HIV positivity.

Three types of autologous donations:

1. Preoperative autologous donation (PAD)
2. Acute normovolemic hemodilution (ANH): Blood should be collected in standard bags with
citrate anticoagulant in an aseptic manner. Units properly labeled and stored in room temperature
to be used within 8 hours. If more time elapses it should be stored in a monitored refrigerator.
The units are reinfused in the reverse order. (This is currently the only source of fresh whole
blood). ANH minimizes clerical error.
3. Intra/ postoperative blood recovery (blood salvage/ cell saver):
Blood is collected, washed, and concentrated and usually result in 225 ml units of saline
suspended RBCs with a hematocrit of 50-60%. Microaggregate filters (40u) are most often used
to filter debris, blood clots, bone, etc. In massive bleeding may collect up to 12 units/h.
The oxygen transport and survival of recovered RBCs, are at least compatible to allogenic RBC.
Intra-opertive blood collection is contraindicated when certain procoagulant materials (topical
collagen) used at the surgical field.
Cell saver blood may be stored at room temperature up to 4 hours or at 1-6oC fro up to 24 hours.

Potential complications associated with use of the cell processing devices include:
1. Air and fat emboilism
2. Pulmonary dysfunction secondary to infusion of debris in recovered blood
3. Coagulopathy- Processed blood is depleted of coagulation proteins and functional platelets.
Disseminated intravascular coagulation also has been reported.
4. Renal dysfunction
5. Sepsis (clinical infection is rare).
6. Dissemination of malignant cells.

37
7. Lysis of red blood cells can occur as a result of high vacuum suction levels or aspiration
techniques that cause turbulence during blood collection. This may lead to hemoglobinuria. Cell
rupture can result from excessive suction (>150 mmHg), hypotonic irrigation, povidone iodine,
hydrogen peroxide, alcohol, bone cement. Cell damage promotes coagulopathy. High
concentration of free hemoglobin may be nephrotoxic to patients with renal impairment.
Excessive free hemoglobin may indicate inadequate washing.
8. During cesarean section can result in the administration of a substantial additional load of fetal
erythrocytes which may cause Rh iso-immunisation

Practical Considerations for Intraoperative Cell Recovery, Storage and Cell

Reinfusion

Autologous blood: is not without risk.

One of every 16,000 autologous blood donations results in a reaction severe enough to require
hospitalization.
Include misidentification, bacterial contamination, volume overload.

Advantages and disadvantages of autologous blood donation

Advantages Disadvantages
Prevents transfusion-transmitted disease Does not affect risk of bacterial contamination
Prevents red cell alloimmunization Does not affect risk of ABO incompatibility error

38
 Supplements the blood supply
Provides compatible blood for patients
with alloantibodies
Prevents some adverse transfusion
reactions
Provides reassurance to patients
concerned about blood risks
Is more costly than allogeneic blood
Results in wastage of blood not transfused
Increased incidence of adverse reactions to
autologous donation
Subjects patient to perioperative anemia and
increased likelihood of transfusion

Wastage of PAD units = 50%.

. Complications associated with autologous blood transfusions include the following:

1. Anemia
2. Preoperative myocardial ischemia from anemia
3. Administration of the wrong unit (1:100,000)
4. Need for more frequent blood transfusions
5. Febrile and allergic reactions7

Hyperbilirubinemia- conjugated vs unconjugated

Diseases that reduce the rate of secretion of conjugated bilirubin into the bile or the flow of bile
into the intestine (hepatobiliary disease- viral infection, drugs, alcohol, sepsis, cirrhosis, biliary
tract stones/tumors) produce a mixed or predominantly conjugated hyperbilirubinemia due to the
reflux of conjugates back into the plasma.
The morbidity and mortality associated with conjugated hyperbilirubinemia result from the
causative disease rather than from the hyperbilirubinemia itself.

Hemolysis, hematoma resorption, or bilirubin overload from blood transfusion produce increased
unconjugated hyperbilirubunemia

(Normal total bilirubin is 0.3- 1.9 mg/dl)

ISO-VOLEMIC HEMODILUTION
When anemia develops but blood volume is maintained (iso-volemic hemodilution)
four compensatory mechanisms serve to maintain oxygen delivery:
1. Increase in CO
2. Redistribution of blood flow to organs with greater oxygen requirements
3. Increases in the extraction ratios of some vascular beds
4. Alteration of oxygen- Hb binding to allow the Hb to deliver oxygen at lower oxygen
tension
Because the heart has the greatest ER, it is the organ at greatest risk under conditions of
normovolemic anemia

39
What is acute normovolemic hemodilution?

This is a point of care method of autologous blood procurement.

The term acute normovolemic hemodilution (ANH) refers to the removal of blood from a
surgical patient immediately before or just after induction of anesthesia (1 to 1.5 liters, to a
hematocrit of 27 to 33%) , and replacement with asanguinous fluid to maintain normovolemia .
The removed blood is stored in a CPD bag at room temperature up to 6 hours to preserve platelet
function and later reinfused. ANH is employed to reduce the need for allogenic blood and to
avoid potential transfusion associated complications. An additional potential advantage of ANH
is improvement in tissue perfusion as a result of decreased viscosity.
The presence of malignancy or wound infection may contraindicate blood recovery during
surgery (cell saver), but not ANH.

With iso-volemic hemodilution, CO increases primarily because of an increase in stroke

volume brought about by the reduction in systemic vascular resistance (SVR).
There are two principal determinants of SVR:
1. Vascular tone
2. Viscosity of blood (decreases with decrease in Hct)
Decrease in SVR increases stroke volume and
consequently CO and blood flow to the tissues.
Some increase in venous return is thought to occur as a result of the reduction in viscosity and a
passive increase in blood flow in the post capillary venules.

Redistribution of CO:

40
Is the principal means by which healthy heart compensates for anemia.

Increased O2 extraction:
Thought to play an important role when normovolemic Hct drops < 25%
One investigation demonstrated: when Hct decreases to 15%, whole body O2 ER increases from
38% to 60% and the SvO2 decreases from 70% to 50% or less.
Some organs (brain and heart) already have high ER under basal conditions, and have a limited
capacity to increase O2 delivery by this mechanism.

Changes in O2-Hb affinity:

P50 of normal adult Hb at 37oC and pH of 7.4 is 27 mm Hg.
When anemia develops slowly, the affinity for O2 may be decreased as a result of the
accumulation in RBCs of 2,3-DPG.
Synthesis of supranormal levels of 2,3-DPG begins at a Hb of 9 g/dl. At Hb of 6.5, the curve is
shifted more prominently.
Increased levels of 2,3-DPG requires 12h to develop.

Hemodilution
If normovolemia is maintained, whole body ER increases linearly as Hct deceases until a
critical point is reached
At Hct 10%:
• Whole body ER about 50% (Under basal conditions = 24-28%)
• No further increases in (O2 consumption) VO2 occurs.
• Tissue converts to anaerobic metabolism, leading to metabolic acidosis and
hemodynamic instability.
• Death is due to high output cardiac failure with severe tissue hypoxia. (survival seen at
even lower Hct).

Hemodilution/ Transfusion Trigger:

CO, arterial and mixed venous O2, whole body ER should provide objective criteria for these
judgments.
Mixed venous PO2 < 25 mm Hg,
Whole body O2 ER > 50%
Reduction of total O2 consumption to < 50% of baseline
= indicates significantly impaired O2 delivery.

How can you estimate the volume of blood to be removed preoperatively when you are
using the normovolemic-hemodilution/ autotransfusion technique to reduce the loss of red
cells intraoperatively?
The volume can be calculated according to the following formula:
V=EBV ({HCToriginal – Hctfinal}/Hctaverage), where V= volume to be removed and EBV=
estimated blood volume (65 ml/kg multiplied by weight (kg)).

What is the normal blood volume in adults, children, infants and neonates?
Adults 70 (men 75 and women 65); children 75; infants 80; full-term neonates 85 (ml/kg).

41
Criteria for Selection of Patients for Acute Normovolemic Hemodilution

Erythropoietin and iron to restore red cell mass:

Erythropoietin requires:
48-72h for a significant reticulocyte response
10-14 days to increase hemoglobin level
Belfort M, et al. Am J perinatol 2011;28:207-10

RED CELL SUBSTITUTES

(1) Perfluorochemical (PFC) emulsions, Fluosol-DA:

Perfluorochemicals (PFC) are completely immiscible with water and intravenous injection is
immediately lethal because the injection forms a liquid bolus. Therefore PFCs must be prepared
as an emulsion. The principal limitation of Fluosol-DA 20% was the difficulty in producing a
stable emulsion.

Because of the inert nature of PFC, they are not metabolized but are cleared from the vascular
space by the reticuloendothelial system (RES) and have a half-life of 8-24 hours. Because they
are cleared by the RES, it is possible that there may be a maximum dose or rate at which they
may be administered. Eventually, the PFC slowly leaves the body as vapor in the respiratory gas.
Primary toxicity concern of these compounds is their effect on the RES as they are cleared. An
influenza-like syndrome and sequestration of circulating platelets are commonly seen with PFC.

Because PFCs transport oxygen by simple solubility, the amount of oxygen they carry is directly
proportional to the percentage of PFC in the blood stream and to the PaO2. Because PFC carries
oxygen by direct solubility, it also releases it in direct proportion to the pO2. Thus PFCs have a
linear oxygen dissociation curve unlike the sigmoid curve for hemoglobin.
The two inherent limitations- short endovascular half-life and the requirement of high FiO2-
limit the usefulness of PFC to acute settings in which supplemental oxygen is readily available.

42
Because of combination of difficulties (high cost, low oxygen carrying capacity, requirement for
high FiO2), and limited use it was eventually pulled from the US market.
A newer PFC compound, perfluorooctyl bromide, carries 3-4 times more O2 and has a longer
half-life than Fluosol-DA.

(2) Hemoglobin-based O2 carriers (HBOCs)

These are made by modifying the hemoglobin molecules from humans, animals or
recombinant technology.
Appealing:
1. Hemoglobin has no “blood type” – universal donor
2. Can be stored for a long time

Problems:
1.When hemoglobin is removed, it breaks down into 2 alpha+ beta, and diuresed.
2. 2,3 DPG dissociates from hemoglobin, and the p50 decreases to 12 mmHg (high affinity)
Therefore HBOCs = red mannitol
Cross linking and polymerization has been tried to form a larger molecule that is not readily
diuresed.
3. Still identified as foreign protein in vascular space and rapidly cleared by RES, has a
Plasma half life of 12-20h.
Clinical application is only for acute resuscitation.
4. Hemodynamic response: pulmonary and systemic hypertension
Free hemoglobin is a nitric oxide (NO) scavenger.

Hemopure: Ultrapurified bovine RBCs that are modified to have a higher P50.
(P50.= 43)!
Complications include slight increase in mean arterial pressure and decrease in cardiac index,
may be from nitric oxide.

However, recent meta-analysis regarding HBOCs is not encouraging. They showed that there
was a significant increased risk of myocardial infarction and death when HBOCs are given.

Hemostasis – 2006-2014 key words

43
Antiplatelet drugs: mechanism of action
Enoxaparin: assessment of effects
Antithrombotic drugs: duration
LMW heparin: cont vs discont
Hepain-nduced thrombocytopenia: Rx
Desmopressin for Von Willebrand
Elevated INR: factor treatment
Cholestasis: coagulopathy Rx
Factor VII: hemostatic in liver disease
Refractory hemophilia
Rx: antithrombin III deficiency
TEG- Decreased MA Dx/ Rx- 2014
LMWH- Assessment- 2014
Herbal medications: Anticoag effects- 2014

Primary Hemostasis- Confirmational and surface changes by platelets- receptors appear

44
Platelets contain both dense granules and alpha granules. In the process of platelet activation, the
contents of these are released.

Thromboxane-Prostacycline balance-
Primary hemostasis is, in part, controlled by the balance between the actions of 2 PGs.

45
The classic extrinsic and extrinsic pathway replaced by the concept that integrates all of the
factors into a single coagulation pathway. In his model coagulation is triggered by the exposure
of blood to “tissue factor” that is extrinsic to blood. “tissue factor pathway of coagulation”

46
Antiplatelet Agents

Evaluation of Hemostasis:
1. PTT – measure intrinsic pathway; aPTT much faster than PTT normal 25-35 s
2. ACT – also measure intrinsic pathway-widely used to monitor heparin therapy in OR
(mix whole blood with an activating substance –kaolin)
Easy to use and reliable for high heparin concentration; 180-300 = adequate effect of
heparin
Normal 90-120 s (ACT far less sensitive than aPTT for factor deficiencies and is
influenced by hypothermia).
3. PT – measure extrinsic pathway; INR (International Normalized Ratio) can be
compared from one lab to another, PT test use many different thromboplastin
reagents)
4. TT – measure ability of thrombin to convert fibrinogen to fibrin (F I and II) normal 9
– 11 s. Bypass all other preceding reactions. (increased TT when fibrinogen level
<100 mg/dl
5. Normal plasma fibrinogen –200-400 mg/dl; If <100  increased risk of bleeding
6. FDP and D-dimer –increased in DIC

Since Heparin affects chiefly the intrinsic pathway – in low doses prolongs PTT only; In high
doses prolongs PT.

In contrast, warfarin primarily affects vitamin K-dependent factors (II, VII, IX, X). So, PT
prolonged at usual doses; PTT prolonged at high doses.

47
Bleeding may occur if the level of any clotting factor is decreased to 20% to 40% baseline. The
PT is most sensitive to the activities of F VII and X and relatively insensitive to F II. An INR of
> 1.4 (i.e. on warfarin) is typically associated with F VII activity < 40% (and the potential for
inadequate clotting)

TEG:
Viscoelastic test of whole blood clotting (coagulation factors, plt, Ca)
Provide information about:
a. Clotting cascade
b. PLT function
c. Clot lysis

48
Reaction times (r) are related to the PTT and normally range from 6-8 min.
> 15 min can be treated with FFP.
MA- related to platelet function and is normally 50-70 mm.
MA < 40 mm is treated with platelet concentrate.
Clot formation rate (alpha) is related to fibrinogen function and is normally > 50 degree.
<45 degree can be treated with cryoprecipitate.

What prevents coagulation of blood in normal tissues?

1. Normal blood flow clears activated coagulation factors
2. Multiple inhibitors of coagulation in plasma-
a. Anti thrombin III – heparin augments this
b. Proteins C (specifically inhibit F V and VIII)
c. Protein S – augments protein C
-deficiency of these  hypercoagulability

49
Nonthrombogenic property of endothelial lining
Protein C circulates in plasma as an inactive precursor until it is activated by thrombin.
Thrombin binding to thrombomodulin (TM-protein located in vascular endothelium) enhances
Protein C activation greatly. When bound to TM thrombin cannot catalyze conversion of
fibrinogen to fibrin or activate clotting F V and VIII (indirectly inhibits its own synthesis).

Protein S, like protein C is vitamin K-dependent. It acts as a cofactor in the protein C- catalyzed
inactivation of F Va and VIIIa.

Antithrombin III – Binds to thrombin to inactivate this master coagualtion enzyme. ATIII can
also bind and inactivate each of the activated clotting factors of the classic intrinsic coagulation
cascade.

ATIII deficiency (40-50% normal) leads to dangerous thrombotic events.

Acquired deficiency in – liver disease, nephrotic syndrome, DIC, sepsis, PIH, Fatty liver of
pregnancy, post -surgery, oral contraceptive use.

Naturally occurring heparan sulfate on the endothelial surface

Much like heparin, has the ability to accelerate binding of ATIII to thrombin and other clotting
factors of intrinsic system.

50
Fibrinolysis

Primarily by plasmin- formed from plasminogen, and rapidly degraded by antiplasmin

(antiplasmin concentration 10 X plasmin).
Once plaminogen is bound to fibrin surface t-PA converts it to plasmin (only the bound). Once
bound to fibrin antiplasmin cannot attack it.
t-PA found on the endothelial surface is important for “nonthrombogeneic” surface by
dissolution of clot.
t-PA release stimulated by:
Activated protein C, or in response to venous occlusion, physical activity, stress, vasoactive
drugs (epinephrine, vasopressin, DDAVP)

t-PA inhibitors – Slows fibrinolytic process. If increased levels, leads to thrombotic disorders.
t-PA inhibitors found in placental tissue (hypercoagulable state of pregnancy?)

Other Plasminogen activators:

Urokinase in urine only

51
Physiological activation of fibrinolytic system- vigorous exercise, anoxia, stress.

Exogenous plasminogen activators- streptokinase, urokinase, recombinant t-PA.

Streptokinase and urokinase will also activate circulating plasminogen.
These are used in unstable angina, acute peripheral arterial occlusion, DVT, PE.

Key word (2012)

Factor VLeiden:Treatment
Factor VIII antibodies: Rx

Factor VLeiden -Prothrombotic state

Abnormal Factor V that is resistant to normal cleavage and inactivation by activated protein C.
Prolonged action of Factor VLeiden leads to increased thrombin generation. If homozygous, risk
of DVT is increased up to 80 fold. If heterozygous, 5-7 fold increased risk of DVT.
Durgs for DVT: heparin, warfarin, hirudin (direct thrombin inhibitors) and F Xa inhibitors
(fondaparinux).
Heparin confers 60-70% risk reduction
Graded compression stockings have a 40-45% risk reduction
Intermittent pneumatic compression stockings = heparin
With regional anesthesia (even with early ambulation and intraop antiembolism stockings) risk is
still unacceptably high.

Factor VIII antibodies: Rx

About 30-40% of patients with severe F VIII deficiency develop circulating antibodies to F VIII.
They are usually middle aged or older with no previous history of abnormal bleeding but
suddenly develop severe, spontaneous hemorrhage.
Diagnosis is by mixing patient’s plasma with normal plasma 1:1 ratio. In classic hemophilia,
with no circulating inhibitors, PTT shortens within 4 sec. with the mixing. No correction occurs
with inhibitors.
Inhibitors are measured in Bethesda units. High responders (> 10 Bethesda units/ml) cannot be
neutralized by replacement therapy. Life threatening bleeding is treated with F VIIa (by pass
products).
Low responders can usually be managed with F VIII concentrates.
(Anesthesia and co-existing disease)

Some Clinical Conditions Associated with Bleeding Disorder

Prostatic Surgery:
Patients undergoing prostatic surgery have a much higher incidence of fibrinolysis. Prostatic
tissue release urokinase, which activates the transformation of plasminogen to plasmin, which in
turn lyses fibrin. EACA, epsilon -aminocaproic acid is a synthetic antifibrinolytic agent used to
decrease bleeding in these patients.

Antifibrinolytics

52
Used when exaggerated fibrinolysis is suspected, such as in cardiopulmonary bypass, hepatic
transplant, prostatic surgery.
These include: Epsilon aminocapric acid (EACA), tranexamic acid (TXA), aprotinin.
EACA and TXA, binds to both plasminogen and plasmin.
These drugs have a dual action
a. reduced clot lysis
b. reduced formation of FDPs

Aprotinin- is an inhibitor of numerous serine protease enzymes, plasmin and kallikrein. It has a
dual action like above. There is a small incidence of allergic reactions with aprotinin, therefore,
use a test dose.

FDPs
These are inhibitors of both primary hemostasis and coagulation. FDPs impair platelet function,
inhibit thrombin and prevent crosslinking of fibrin.

BILIARY DISEASE AND COAGULATION

Biliary obstruction leads to deficiency of coagulation factors

Activation some factors (factors II, VII, IX, and X), depends on the presence of vitamin K.
Absorption of vitamin K depends on the excretion of bile into the gastro-intestinal tract.
Usually the coagulation disorders are moderate, and parenteral vitamin K corrects the problem.
If this treatment is not fully effective suspect that the disease is not purely cholestatic, and that
hepatic parenchymal disease exists because long-lasting biliary obstruction leads to liver injury.
Should such patients need urgent surgery, fresh frozen plasma will be required to correct the
coagulopathy.

53
Other Causes of Coagulopathy

What is the most common inherited bleeding disorder?

von Willebrand disease. (1:800-1000)

What are the two key functions of von Willebrand factor (factor VIII:vWF)?
von Willebrand factor is necessary for platelet adhesion to collagen in the subendothelial layer of
injured blood vessels and formation of the hemostatic plug through regulation and release of
factor VIII antigen.

What is the molecular abnormality in von Willebrand’s disease?

Defective vWF, or low levels of a normal vWF resulting in an inability of platelets to bind to
collagen.
Factor VIII is bound to vWF while inactive in circulation; Factor VIII degrades rapidly when not
bound to vWF. Factor VIII is released from vWF by the action of thrombin. A deficiency of
vWF can result in decreased factor VIII levels. In von Willebrand’s disease bleeding time is
prolonged and factor VIII level may be decreased causing bleeding similar to hemophilia.
In summary: vWF – Help to link platelets
Serves as a carrier for F VIII
Defect  prolonged BT, normal platelet count, decreased vWF concentration, decreased FVIII
level/activity, variable PTT.
Screening coagulation tests may be normal in many patients.

How does von Willebrand’s disease manifest itself?

Most patients have a history of bleeding excessively with surgery, tooth extractions, trauma or
following ingestion of aspirin or NSAIDs. Nosebleeds or menorrhagia are the most frequent
clinical problems. Typical laboratory findings: prolonged PTT and bleeding time, with
qualitative platelet dysfunction.

What are the different types of von Willebrand’s disease (vWD)?

Type 1 and 3 vWD – quantitative defects in the protein (type 1 = partial, type 3 = severe).
(normal vWF level 5-10 mg/l)
Type 1- accounts for 70% of all cases.
Type 2: qualitative abnormality (20% of all vWD)
Unique subtype, (type3?) type 2B (20% of the patients in type 2 vWD belongs to the type 2B):
In this type there is an increased affinity of vWF for platelet glycoprotein 1b. This leads to
spontaneous binding and clearance of both.

Von Willebrand disease : Rx key word

What is the treatment for Von Willebrand’s disease?
Depends on the type, severity of the disorder, and type of surgery. The aim of treatment is to
correct the dual defect of hemostasis; the abnormal intrinsic coagulation pathway caused by low
factor VIII levels and the prolonged bleeding time resulting from abnormal platelet adhesion.
Desmopressin (DDAVP) is the treatment of choice for type 1 VWD because it corrects the
FVIII/VWF levels and the prolonged bleeding time in the majority of cases. In type 3 and in

54
severe forms of type 1 and 2 VWD, DDAVP is not effective and plasma virally-inactivated
concentrates containing FVIII and VWF (von Willebrand factor) are the mainstay of treatment.

A patient with Type I von Willebrand’s disease is to have a breast reduction. What should
be the first line of therapy?
DDAVP 0.3 µg/kg, 30 minutes before surgery, to increase vWF levels. DDAVP (desmopressin
acetate) is an analogue of vasopressin without vasopressor activity. Infusion of DDAVP
increases the release of von Willebrand’s factor and factor VIII from the endothelium;
intravenous peak effect in 15 to 30 minutes, with an increase in vWF seen over 3 hours and an
increase in factor VIII over 4 to 24 hours. Desmopressin usually increase plasma von
Willebrand factor and factor VIII concentrations two- to fivefold. Cryoprecipitate or factor VIII
concentrates are administered to non-responders.
Does not involve platelet transfusion (not defective platelets)

Avoid anti-PLT drugs in vWD

Hemophilia A: Reduced or defective F VIIIc, normal vWF

Hemophilia A is the most common type of hemophilia. It is also known as factor VIII
deficiency or classic hemophilia.
It is largely an inherited disorder. In about 30% of cases, there is no family history of the
disorder and the condition is the result of a spontaneous gene mutation.
F VIII has 2 components: coagulant factor VIII (VIII:C) and vWF)
X-linked  males
Symptoms when <5% of normal F VIII activity
Prolonged PTT but normal PT and BT
Normal plasma levels of FVIII range from 50% to 150%.
People with mild hemophilia have 6% up to 49% of the normal clotting factor in their
blood. Women with mild hemophilia often experience menorrhagia, heavy menstrual periods,
and can hemorrhage after childbirth.
• People with moderate hemophilia about, 15% of the hemophilia
population, have 1% up to 5% of the normal clotting factor in their blood. They tend to
have spontaneous bleeding episodes.
People with severe hemophilia about 60% of the hemophilia population, have <1% of the normal
clotting factor in their blood. bleeding episodes, often into their joints and muscles.

No increased bleeding intra-op if F VIII level >30% (better >50%)

• DDAVP can increase FVIII in some patients. 0.3 mcg/kg of body weight in the inpatient
setting. Peak effect is observed in 30-60 minutes
Avoid aspirin and other PLT inhibiting drugs.

The following types of FVIII concentrates are available:

(1) Plasma-based products: Undergo purification to inactivate viruses

55
(2) First-generation recombinant products: Produced in mammalian cell lines and have a small
amount of human serum albumin added for stability

(3) Second-generation recombinant products: Manufactured without human albumin

(4) Third-generation products: Have no exposure to animal proteins

The development of alloantibodies in persons with hemophilia is a serious complication

that leads to increased bleeding and a lack of response to the usual therapy, which can be
fatal

DOSING FOR FACTOR VIII PRODUCTS

1 unit of factor VIII/kg will increase circulating factor VIII level by 2%
Pt weight in Kg x 50 units/kg = 100% correction.
Example: a 30-kg patient requiring 100% of factor VIII
30 kg x 50 units/kg = 1500 units of factor VIII to be infused to reach 100%

Hemophilia B – X-linked
F IX deficiency

Recombinant Factor VIIa (rfVIIa)

rfVIIa initiate thrombin generation via 2 pathways.
1) Active complex with TF (tissue factor) via extrinsic pathway
2) Acts directly on F IX / X on membrane of activated platelets.
At pharmacological doses results in a ‘thrombin burst’
The clot that forms is morphologically different: greater fibrin cross-linking, and more resistant
to fibrinolysis.
rfVIIa should have enough co-factors to enable it to work. Therefore, within 30 minutes of
administration, transfuse with:
• 6 units of platelets
• 4 FFP
• 2 pooled packs of cryoprecipitate

Dose range of rfVIIa: Different responses (complete, partial, or no response) occurs and found
to be not different at <70 to >90 ug/kg.
However, the use of significantly fewer blood products after rfVIIa therapy has been shown.

At the moment:
Decision on when and where to use FVIIa for uncontrolled bleeding must be made by individual
physician with blood bank and hematology help.

Thrombotic events:
Thrombotic complications have been reported. (myocardial infarction, cerebrovascular accidents
are possible in older patients)

56
Therefore, caution in patients with known hypercoagulability (history or antiphospholipid) or
excessive bleeding in DIC setting.

rfVIIa in postpartum hemorrhage (PPH)

• “Off-label or “out-of-license” use. (rfVIIa was originally developed to treat hemophilia
and bleeding in factor VII deficiency).
Editorial comment (Br J Anaesth 2005;94:553-55)
“When conventional surgical, interventional and blood product support measures have failed, a
trial of rFVIIa is certainly worth a try in PPH”.

Anticoagulants
Heparin Therapy:
Poorly lipid soluble, high molecular weight anticoagulant administered IV or SC.
Dose and response is not linear; anticoagulation response increases disproportionately in
intensity and duration as the dose increases. (el t ½ for 100u/kg IV is 56 minutes, for 400u/kg 
152 min.
Decrease in body temperature greatly prolongs the elimination half life.
Heparin by it self has no anticoagulant activity. In the presence of heparin, AT III binding is
accelerated 100-1000 times. Heparin – AT III complex has a greater affinity for factor Xa than
for thrombin (factor II), the basis for differential dosing in therapeutic versus prophylactic uses.
Mini-dose (DVT prophylaxis) blocks Xa while the standard therapy (to treat thromboembolism)
blocks thrombin.
Heparin's action is terminated by uptake and metabolism by the reticuloendothelial system and
liver and by renal excretion of the unchanged drug. The amount excreted by kidlney increases as
dose increases. Renal insufficiency decreases rate of heparin clearance.

Heparin induced thrombocytopenia (HITT):

HITT may occur with standard heparin therapy (or low molecular weight heparin), after IV or
SC and the occurrence is not dose dependent.
There are two syndromes –
1. Mild; 30-40% patients; platelet count drops to 100,000 and is seen 3-5 days after initiation of
therapy.
2. More severe – 0.5-6% patients; platelet count drops below 50,000 and often seen with
resistance to the heparin effect. One of the serious complications is venous and arterial occlusion,
even if platelet counts are low (HITT syndrome).

When HIT is diagnosed heparin discontinued and fast acting non heparin anticoag initiated
promptly ( lepirudin, bivalirudin). Warfarin avoided – slow acting and cause early reduction in
protein C and S- and may promote thrombosis.
Give for 1 month or more (3-6 m) if thrombosis present.

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Enoxaparin (LMWH):

Derived from chemical depolymerization of standard heparin and has 1/3rd the size of heparin
molecule.
The Antiactivated factor X to antiactivated factor II activity is about 4: 1 to 2: 1.
Enoxaparin binds much less avidly to proteins, has superior bioavailability at low doses, and
more predictable. HIT is relatively uncommon.

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It has a longer elimination half life and 1/day dosing is adequate.

Fondaparinux- (given SQ).

A synthetic five saccharide molecule that is functionally and structurally like heparin.
Inhibit F Xa. In contrast to heparin, fondaparinux does not inhibit thrombin. Unlike direct F Xa
inhibitors (see below), it mediates its effect indirectly through AT III, but unlike heparin it is
selective for F Xa. One potential advantage of fondaparinux over LMWH or unfractionated
heparin is that the risk for HIT is substantially lower

Danaproid:
Danaproid is derived from porcine intestinal mucosa.
It has a substantially greater inhibitory effect on factor Xa activity than either standard
unfractionated heparin or LMWH.
Following SC administration, there is 100% bioavailability. The maximum factor Xa activity
occurs within 2-5 h with linear kinetics. Elimination is predominantly through the kidney (the
dose should be reduced in significant renal insufficiency).
Antithrombotic effects should be monitored using an anti-factor Xa method because aPTT and
TT are minimally affected. As with LMWH, no agents for reversal are available.

Hirudin (and Bivalirudin):

This is indicated for patients with HITT
It is a direct acting thrombin inhibitor derived from the leech. It does not depend on AT III for
anticoagulant activity. Hirudin has also been found to stimulate PGI2 production; therefore is
antithrombotic, reduce platelet aggregation, and cause vasodilatation).
The administered is by IV infusion. It is excreted mainly unchanged in urine.
The activity is monitored with PT and modified ACT during cardiac surgery.

What are the new oral anticoagulants, which received approval by the FDA recently?

Dabigatran: This is a thrombin inhibitor. Dabigatran received the FDA approval to be used for
the prevention of stroke in patients with AF in Oct 2010.
Argatroban- is also a direct thrombin inhibitor. Argatroban is metabolized in the liver and
has a half life of about 50 minutes. It is monitored by PTT. Because of its hepatic metabolism, it
may be used in patients with renal dysfunction. (This is in contrast to lepirudin a direct thrombin
inhibitor that is primarily renally cleared).

Rivaroxaban and apixaban: These are potent direct F Xa inhibitors. This is approved by the
FDA for the prevention of venous thromboembolism after hip and knee arthroplasty in July
2011.Rivaroxaban is also effective for the treatment of symptomatic venous thromboembolism
and for preventing strokes in patients with nonvavular AF. It is also being evaluated for
secondary prevention after acute coronary syndromes.

Both groups of drugs are administered orally at fixed doses and no monitoring is necessary. The
drawback is these drugs lack an effective antidote or reversal agent. rVIIa and PCC do not seem
to reverse rivaroxaban induced bleeding.

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One of the advantages of new anticoagulants:
They all have a considerably shorter half-life than warfarin (7-17h vs 38-42h)

These new medications are eliminated by the kidneys to varying degrees, and in the presence of
renal impairment half lives will be prolonged.

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Regional anesthesia management:
Dabigatran-
Given the irreversibility and uncertainty of patient’s renal function dabigatran should be
discontinued 7 days before neuraxial blocks. If a shorter time interval is desired, assess TT and
ECT before the block. Epidural catheter should be removed at least 6h before initiation of
dabigatran.

Rivaroxaban- According to European guidelines, 22-26h should elapse after discontinuation to

receive neuraxial block in patients with normal renal function.

Kaatz s, et al. Guidance on the emergent reversal of oral thrombin and factor Xa
inhibitors. Am J Hematol 2012. Mar 14. [Epub ahead of print]

T. T. Horlocker. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet

therapy. British Journal of Anaesthesia 107 (S1): i96–i106 (2011)

Vorapaxar
Aspirin irreversibly  decreased platelet activation and aggregation
(impedes the formation of TXA2-)
Clopidogrel irreversibly inhibits the P2Y12 ADP receptor decreased platelet activation and
aggregation.3
The concurrent blockade of multiple platelet-aggregating pathways  reduce ischemic CV
events compared with aspirin alone.
However, there is an increase in bleeding with dual antiplatelet therapy.

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Vorapaxar- reduce platelet-mediated thrombosis without increasing bleeding liability.
Thrombin is a potent platelet activator through proteolytic activation of cell-surface protease-
activated receptors (PARs). Four PARs (1-4). Theoretically, block platelet activation during clot
formation while preserving essential vascular repair and protective hemostatic function.
A synthetic analog of the natural product himbacine, orally active,, highly selective, competitive
PAR-1 inhibitor. Vorapaxar is a thrombin receptor antagonist (TRA) that exhibits reversible
inhibition and inhibits platelet aggregation in a dose-dependent manner.

Herbal medications: Anticoag effects:

Keyword 2014
Ref: Open anesth.org

Garlic: discontinuation of garlic at least 7 days before surgery, especially if

intraoperative or postoperative bleeding is a concern or other platelet inhibitors are
used.

ginkgo should be discontinued at least 36 hours before surgery.

Ginseng: Ginsenosides inhibit platelet aggregation in vitro and prolong the PT and
PTT in animal studies.
- discontinue ginseng use at least 24 hours before surgery, but discontinuation at
least 7 days before surgery is preferred because of the potential for irreversible
platelet inhibition.

Herbal medicines that increase the risk of bleeding:

 Black Cohosh: Contains small amounts of anti-inflammatory compounds,

including salicylic acid. Theoretically could have intrinsic/additive antiplatelet
activity.

 Chamomile: Increases risk of bleeding because it contains phytocoumarins,

which have additive effects with warfarin.

 Feverfew: Increases the risk of bleeding because it individually inhibits

platelet aggregation, has additive effects with other antiplatelet drugs. Also
additive effects with warfarin.

 Fish Oil: Dose dependent bleeding risk increases with dose >3g/day.

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  Garlic, Ginger, Ginko, Ginseng: Increases bleeding risk by interacting with
antiplatelet drugs to inhibit platelet aggregation and inhibit fibrinolysis. Also
augments warfarin.

Herbal medicines that increase clotting risk:

 Coenzyme Q10: Decreases response to warfarin.

 Goldenseal: Increases risk of thromboembolism by opposing effects of

warfarin and heparin.

 St. John’s Wort: Increases thromboembolism risk by reducing blood levels of

warfarin.

References:
1. Barash PH, Cullen BF, Stoelting RK, Cahalan MK, Stock MC. Clinical Anesthesia 6th ed.
Philadelphia. Lippincott Williams & Wilkins, 2009:465-497.
2. Miller RD. Miller’s Anesthesia 8th ed. 2014.
3. Perioperative transfusion Medicine, 2nd edition, 2006
4. Longnecker DE. Anesthesiology. McGraw-Hill, 2008:869-896.
5. Practice Guidelines for Perioperative Blood Management
6. An Updated Report by the American Society of Anesthesiologists
Task Force on Perioperative Blood Management. Anesthesiology 2015; 122:241-75
7. Therapeutic Plasmapheresis Anesthesiology 2013 March;118:722-8
8. ASA refresher course 2014 Transfusion Therapy: Optimal Use of Blood Products
9. ASA refresher course 2014 Perioperative Coagulation and Coagulopathy
10. ASA 2014 Update on Strategies for Blood Conservation and Hemostasis in Cardiac
Surgery

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