BLOOD TRANSFUSION AND

CONSERVATION

BY :
DR. T.C. KRIPLANI
PROF. DEPT. OF
ANAESTHESIOLOGY
NSCB MEDICAL COLLEGE
JABALPUR (M.P.)
“Pope Innocent VIII (Giovanni Battista
Cibo) was on death bed dying of old age
in 1492 in Rome. The physician
proposed to rejuvenate him with the
blood of three young healthy boys. The
result was unquestionably disastrous.
The boys died. The pope died (on 25th of
July) and physician had to runaway from
the country”.
 BLOOD
GROUPS
ABO 1901
Rh ‘D’ 1940

Dr. Karl Landsteiner

14-6-1868 – 26-6-1943
(Nobel Prize – 1930)

th
In India :
About 1124 Licensed Blood Banks
564 Govt.
125 Voluntary
226 Private Hospitals
209 Private Commercial
1124 Total
About 4 million (40,00000) units are collected
per year
Appropriate Transfusion :
Defined As :
“The transfusion of safe blood or blood products to treat a condition
leading to significant morbidity and mortality that can not be prevented
or managed effectively by other means.

Appropriate use of blood requires :

1. Maintain National standards of blood
2. Development and correct use of standard operating procedures
3. Training of all staff of transfusion service
4. Audit to check whether correct procedures are being observed or not
5. An effective system of independent inspection and accreditation
Avoid or Minimise Blood Transfusion :
1. Early diagnosis and treatment of anaemia
2. Do not unnecessary raise Hb
3. In acute blood loss at times other replacement fluids
would be safer and equally effective
4. Good anaesthetic and surgical management can
minimize the blood requirement
5. When blood is given when not needed patient receives
no benefit but is exposed to unnecessary risk
6. Blood is expensive, scarce resource inappropriate use
may cause shortage for the patients in real need
Transfusion can be minimized by following means :
1. Prevention and early diagnosis and treatment of anaemia and
conditions that cause anaemia
2. Correction of anaemia and replacement of iron stores before
surgery
3. Use of crystalloids and colloids in acute blood loss
4. Good anaesthetic and surgical management
• Using best anaesthetic and surgical techniques to minimize
blood loss during surgery
• Minimizing taking blood for pathological investigations
• Salvaging and reinfusing surgical blood losses
• Using alternative approaches such as
• Desmopressin
• Aprotinin
• Erythropoetin
Getting the Right Blood to Right Patient at Right Time
Take Blood sample correctly :
•Label the sample tube clearly and accurately
•Patient’s name and surname
•Patient’s date birth
•Patient’s hospital reference number
•Ward / bed
•Date
•Signature of the person taking sample
DO NOT LABEL THE TUBE BEFORE OBTAINING THE
SPECIMEN
Clinical Transfusion Procedures :
•Follow National Guidelines
•Ideally Hospital transfusion committee should be made
•Take informed consent from the patient or relatives
•Blood bank should only issue blood when request in a
prescribed from is made which is correctly filled and correct
labelled blood sample is sent
•Every hospital should have standard operating procedure for
collection of blood from blood bank
•Proper transport and proper storage in clinical area
•Identity check : Patient and blood very important
•Each patient should be labelled using an identity wrist
band or some other firmly attached marker. Hospital
reference number should always be used.
Clinical Transfusion Procedure (Contd.) :-
•Final check : Should be undertaken by two
people for identity
•Check the blood pack
•Before it is issued from Blood Bank
•On arrival in OT
•See signs of haemolysis/ contamination
•Any clot
•Signs of leakage broken seal
 DO NOT USE BLOOD UNIT
If
•Unit is out of refrigerator for longer than 30
mts
•Any signs of leak
•Plasma is pink
•RBC – Look purple or dark
•Date has expired
Time Limits for Infusion
Once removed from storage condition
Start Complete
Whole blood Within 4 hrs
30 mts (or less if ambient temp is
higher)
Platelet Immediately 20 mts
FFP Within 30 mts 20 mts

Blood and plasma should be given through filter 120-200 micron size
(some prefer 80 micron) (170 micron commonly used).
In cardiopulmonary bypass 40 micron size
WARMING BLOOD FOR TRANSFUSION
•When infusion is slow warming is not required
•Cold blood can cause spasm of vein hence local warming of vein
can be done
•Warming of blood is required :
•When rate is > 100 ml/mt
•50 ml/Kg/ hour (Adults)
•15 ml/Kg/ hour (Children)
•Hypothermia can cause cardiac arrest
•Blood should be warmed in blood warmer
•Warmer should have visible thermometer and an audible alarm
•Blood warming coil, countercurrent aluminium heat exchanger are
available
Transfusion Reactions :
•Monitor the transfused pt.
•First 15 mts very important
•May occur in 1-2% of patients
•Acute haemolytic transfusion reaction 1: 30,000 (fatal 1:5
lac)
•Commonest cause is failure to adhere to correct
procedure
•Acute complications (During or within 24 hrs of
transfusion)
•Delayed complications – after 24 hrs
Acute Complications of Blood Transfusion
•MILD (Allergic, urticarial reactions)
•Moderately severe (severe urticarial reaction)
Febrile – non haemolytic reaction
•Antibodies to WBC or platelets
•Bacterial contamination
•Pyrogens
•Severe
(Life threatening)
-Acute intra vascular haemolysis
-Bacterial contamination (septic shock)
-Fluid over load
-Anaphylactic reaction
-Transfusion associated lung injury
Delayed Complications of Blood Transfusion
•Infection (HIV, HTLV, Viral Hepatitis B & C;
Syphilis, chagas disease, malaria, cytomegalovirus
human parvovirus, hepatitis A)
•Delayed Haemolytic Reaction
•Post transfusion purpura
•Graft Vs Host disease
•Iron overload (after repeated transfusion)
Management (and investigations) of
Transfusion Reactions
•Except allergic urticarial and febrile non haemolytic
reactions REST ALL ARE FATAL hence require URGENT
TREATMENT
•In Anaesthetised patient : Hypotension and uncontrolled
bleeding may be the only signs of severe haemolytic
reaction
•In conscious patient : Signs and symptoms appear within
MINUTES of infusing only 5-10 ml of blood
•Immediately recheck blood pack and patient’s identity
&
If there is any discrepancy, STOP TRANSFUSION
TRANSFUSION REACTION (Cont.)
Type of Reaction Signs Symptoms Possible cause
MILD Urticaria Pruritis Mild
hypersensitivity
Rash
Moderately Flushing Anxiety Severe
hypersensitivity
Severe Urticaria Pruritis Febrile non
haemolytic
Reaction
Rigors Antibodies to
WBC/ Platelet
Rest lessness Mild dyspnea Antibodies to
protein IgA
Tachycardia Headache Contamination
with
pyrogen or
TRANSFUSION REACTION (Cont.)

Type of Reaction Signs Symptoms Possible

cause
Life threatening Rigor, fever Anxiety Haemolysis
Restless Chest pain Bacterial
contamination
Hypotension Loin/ back Anaphylaxis
>20% pain
Tachycardia Resp distress
> 20%
Haemo Headache Over load
-globinuria
Unexplained TRALI
Bleeding
(DIC)
 Management of Transfusion Reactions

Mild (Category I) : Slow transfusion

: Chlorpheniramine 0.5-1 mg/kg IV
(Antihistamininc)
(If no response treat as category II)
Moderately Severe : Stop transfusion
(Category II) : Paracetamol 10 mg/kg oral/ rectal
: IV corticosteroid (Dexamethasone 0.1
mg/kg)
: Bronchodilator
: If improvement – restart transfusion
: If no improvement – Treat as category III
Management of Transfusion Reactions (Contd..)

Life Threatening : Stop Transfusion

(Category III) : Maintain BP (Saline IV 20-30
mL/Kg in 5 mts)
: Maintain Airway give 100% O2
: Adrenaline (1: 1000) 0.01 mg/kg
: Corticosteroid
: Lasix 1mg/kg IV
: If bleeding – 5-6 units of platelets
(DIC) 12 or units of cryoprecipitate or
3 units of FFP
: Dopamine – renal dose
: Dialysis if required
Management of Transfusion Reaction (Contd…)
• Monitor urine output
• If falling or evidence of ARF
(i.e., rising blood K+, urea, creatinine)
(Manage ARF)
• Notify Blood Bank
• Send Blood Sample of the patient
(one clotted, one anticoagulated)
• Fresh urine sample
Investigations in Acute Transfusion Reaction :
•Post transfusion Blood Samples
One clotted, one anticoagulated EDTA
•Full Blood Count
•Coagulation screen
•Direct antiglobin test
•Blood urea, creatinine, electrolytes
•Blood culture
•First specimen of patient’s urine (haemoglobinuria) following
reaction
•After 12 hrs again send blood sample
•After 24 hrs again send blood sample
MASSIVE TRANSFUSION
Defined as :
Replacement of blood loss equivalent or greater than patient’s total blood
volume in less than 24 hrs

COMPLICATIONS
•Acidosis
•Hyper kalaemia
•Citrate toxicity and hypocalcaemia
•Depletion of fibrinogen and coagulation factors
•Depletion of platelets
•Disseminated Intravascular Coagulation (DIC)
•Hypothermia
•Reduced 2-3 DPG (Diphosphoglycerate)
•Microaggregates
 BLOOD CONSERVATION
Blood loss can be significantly reduced by :
1. Meticulous surgical technique
(Surgeon, diathermy, hemostatic park, warm pack)
2. Use of posture (2.5 cms increase from heart vertical height
decrease 2 mm of Hg in BP)
3. Use of vasocontrictor
(1:2 lac or 1:4 lac adrenaline)
4. Use of tourniquets
(100 mm of Hg above sys BP)
5. Anaesthesia techniques
(Regional anaesthesia if possible, hypotensive anaesthesia)
6. Pharmacological therapy
7. Autologous transfusion
8. Future perspectives
 5. Anaesthesia Techniques
Regional – Spinal/ Extradural, Combined GA + Regional
•Deliberate Hypotension
•SNP (Sodium Nitroprusside) •Trimetaphan (Arfonad) ganglion
50 mg in 500 mL (0.01%) blocking drug

Dose 1-10 ug/kg/ mit Dose : 1-4 mg IV in 5-10 mts then

titrate usually about 1 mg/mt
•NTG (Nitroglycerine)
25 mg in 250 mL
Dose 1-10 ug/kg/mt

• Supplemented with B-blockers or with Ca-Channel blockers

Inhalational agent (Halothane, isoflurane)

6. Pharmacological Agents :
•EACA (Epsilon Aminocaproic Acid)
(Inhibitor of plasminogen activation)
Useful in haemophilia
Prostatic surgery
Liver transplantation
Dose : 5 G Loading, 1-2 gms/ Hr
•Aprotinin (Serine protease inhibitor) inhibits trypsin, plasmin
and kallikrein)
Prevents platelet dysfunction
Dose : Initial test dose 10,000 KIU (Kallikrein) inactivating units
For cardiac surgery 2 million KIU for priming
0.5 million / hr IV infusion
Complications: Anaphylactic reactions
Renal toxicity
•6. Pharmacological Agents (Contd…)

•Tranexamic acid (inhibitor of plasminogen activation)

Indications same as that of EACA
Dose : IV 10 mg/kg tds (slowly)
Oral 25 mg/kg tds
Adverse reactions : Nausea, vomiting, diarrhoea occasionally giddiness,
hypotension

Desmopressin (DDAVP)
(1 – desamino-8-d-arginine vasopressin)
Vasopressin analog
Inc. endothelial cell release of
-Von Willibrand’s factor
-Factor VIII
-Plasminogen Activator
Used in – Haemophilia
Uraemic patients
Dose : 0.3 ug/kg IV slowly (rapid dose can cause hypotension)
6.Pharmacological Agents (contd.) :
•Erythropoetin :
•Stimulates proliferation and development of erythroid
precursor cells
•Used in Anaemia of renal origin
•Autologous blood transfusion
•Dose 50-100 IU/Kg 3 times in a week side effects
(Seizures, hypertension)
•Conjugated Oestrogen :
Useful in Uraemic Patients
Dose : IV 0.6 mg/kg/ OD Hormonal side
effects are unusual
Oral 50 mg OD
AUTOLOGOUS BLOOD TRANSFUSION :
Advantages :
(i) Avoidance of complications associated with
allogenic transfusion
(ii)Conservation of blood
Three types are there
I Pre operative blood donation
II ANH (Acute Normovolemic hemodilution
III Intra & postoperative blood salvage
I. PRE OPERATIVE AUTOLOGOUS BLOOD DONATION (PABD)
-Patient’s selection : Hb > 11 gm%, No age or weight limits
-Donations can be scheduled more than once a week
Last donation should be > 72 hrs before surgery
-Has been used in children also
-Erythropoietin stimulates erythropoiesis
Contraindications :
-Bacteremia
-Unstable angina, coronary arterial disease
-CCF, MI within previous 3 months
Complications :
-Vasovagal at the time of donation
Specially in young patients
II. A.N.H. (ACUTE NORMOVOLEMIC HAEMODILUTION)
•Removal of blood before or just after induction and
replacement with crystalloid/ colloid solution and later reinfusion
of the withdrawn blood.
Haematocrit is reduced to 30 to 20%.
HCT 28% Acute limited or moderate normovolemic
haemodilution
HCT 20% Acute extreme normovolemic haemodilution
Augmented acute normovolemic haemodilution (when
oxygen carrying substitute care given with other fluid)
II. A.N.H. (ACUTE NORMOVOLEMIC HAEMODILUTION)
(cont…)
•Apart from reducing the need for allogenic transfusion there
are addition benefits
•Blood is kept in OT hence chances of clerical error are
eliminated
•Does not undergo biochemical alterations (storage lesions)
•Levels of 2-3 DPG are maintained
•Platelet functions is preserved
•Tissue perfusion is improved (dec. viscosity)
•No chance of hypothermia
•Most cost effective than PABD
II. A.N.H. (ACUTE NORMOVOLEMIC HAEMODILUTION)
(cont…)
•Efficacy : 20-90% reduction in the requirement in allogenic
transfusion
•Physiology effects : O2 content dec. but O2 delivery is
unaffected
Inc. cardiac output because of dec. viscosity
Dec. SVR (reflex vasodilatation, release of NO
Inc. coronary and myocardial blood flow
Contraindications :
•Renal disease (diluent fluid may get retained
•Restrictive or obstructive pulmonary disease
•Pre-existing coagulopathics
TECHNIQUE
The amount of blood withdrawn :
V = EBV x (H0-Hf)
----------
Hav
V = volume to be removed
EBV = expected blood volume
Ho = initial Hb
Hf = allowable Hb
Hav = Average of both ( Ho +Hf/ 2)
II. A.N.H. (ACUTE NORMOVOLEMIC HAEMODILUTION)
(contd…)

•Crystalloid and/or colloids are infused

•Blood is withdrawn from large vein or radial art
•Blood can be reused upto 6-8 hrs when kept in OT
at room temperature
•If reinfusion is required after 8 hrs blood should kept
in refrigerator
•Blood is reinfused after major blood loss has
ceased or Hct has gone down to 25-20% (serial Hct
is done)
•Units are reinfused in reverse order of collection
COMPLICATIONS
•Tachycardia and decrease cardiac
output indication of hypovolaemia
•Coagulopathy related to dilution of
clotting factors (inc. bleeding)
•Peripheral oedema (if crystalloid are
used as sole diluent)
III. INTRA AND POST OPERATIVE BLOOD SALVAGE
Recovery or salvage of shed blood
Semicontinuous flow centrifugation devices :
•Double lumen aspiration set
•Incorporate anticoagulant in one line
•Recovered blood mixed with anticoagulant is collected in
disposable reservoir containing a filter
•Centrifuged at 5000 RPM/mt
•Washed with saline and reinfused
•Most of the WBC, platelets, clotting factors and cell
fragments and debris are eliminated
Shed blood can also be collected and filtered in a sterile
disposable single use reservoir for immediate reinfusion
COMPLICATIONS
•Air and fat embolism (1:30,000)
•Pulmonary dysfunctions (infusion of
debris)
•Coagulopathy
•Renal dysfunction
•Sepsis
FUTURE PERSPECTIVES
BLOOD SUBSTITUTES
(i) Perflurocarbons : derived from fluridation of straight chain
hydrocarbons
Ongoing trials :
• Fluosal-DA (Perflurodecaline + perflurotripropylamine)
• Oxygent (Perflurooctyl bromide)
• Oxyfluor (Perfluro dichlorooctane)
• Oncosol (Perfluro phenanthrene)
• Echogen (Do-deca-fluropentane)
Side effects : Shortness of breath, chest tightness and
wheezing
(ii) Haemoglobin Based Oxygen Carrier (HBOC)
(a)Free haemoglobin solutions
(b)LEH (Liposome encapsulated haemoglobin solutions)

(a)Free molecular haemoglobin solutions

• Derived from human RBC which have undergone lysis
Complications : Nephrotoxicity, short half life, a low P50
• Chemically modified haemoglobins (Pyridoxal 5 phosphate
2-nor- 2 formyl pyridoxal – 5 phosphate)
• Bovine haemoglobin (High chloride)
free or polymerized (with glutaraldehyde) less renal toxicity
BLOOD SUBSTITUTES (contd…)
•Recombinant haemoglobin:
Modern biotechnology using recombinant gene
(DNA) technology has made it possible to make
functional human haemoglobin from E. coli and
yeast
A variety of haemoglobins that have custom –
engineered biological characteristics are being
made.
These are under phase I, II and III trials
LEH (Liposome encapsulated haemoglobin
solution)
•It is possible to encapsulate haemoglobin in an artificial non-
antigenic “phospholipid vessicle” or liposome
•Original preparations included egg lecithin, cholestrol and
negatively charged phospholipids
•O2 affinity can be altered by adding 2, 3 DPG
•Cleared by reticuloendothelial system (half life 16-20 hrs)
Side effects :
•Inc. PR, BP leukocytosis, thrombocytopenia
VIVO study done in rats
 “Blood and females are alike. Both
have to play triple role in life.
Female has to act as daughter, wife
and mother whereas blood has to act
as liquid, solid and as an organ”.
Both give life
“Please Respect Both”